Uptake and challenges in implementation of early infant diagnosis of HIV in Arua District, Northwest Uganda

Abstract

Background: Human Immunodeficiency Virus (HIV) infected infants have a 35–40% risk of death in the first year of life from HIV related morbidity, if not started on lifelong antiretroviral therapy (ART). The integration of early infant diagnosis (EID) of HIV in the maternal and child health service package has provided definitive diagnosis of HIV in children less than 18 months. While Uganda has a comprehensive HIV strategy in-line with World Health Organisation (WHO) and other policy frameworks, there is limited research reporting on post-implementation perspectives of clients and service providers on the EID program following 2018 revised Uganda National HIV prevention and treatment guidelines, in Arua district. Study objective: To determine the uptake of the first DNA PCR for HIV at 4-6 weeks of age, rate of HIV positivity and the challenges encountered while implementing early infant diagnosis of HIV among exposed infants in Arua district between January 2018 and December 2019. Methodology: This was a sequential explanatory mixed methods study. A retrospective record review of District health information system version 2 (DHIS-2) and health facility record of HIV sero-exposed infants (HEIs) in Arua district from 33 health facilities implementing the EID program after waiver of consent. Data was extracted using data extraction form and thereafter exported to STATA 16.0 for analysis to determine the proportion of infants that tested for HIV at 4-6weeks, and HIV positivity. Six focus group discussions were then conducted with mothers’ /care givers of HEIs; in addition, 8 key informant interviews with service providers of EID program were held. Thematic analysis using open code was used to describe the data. Results: Of the 33 health facilities, 75.8% were public, while 24.2% were Private not for profit (PNFP). HIV test using DNA PCR was offered for 96.7% (1277) of the 1321 HEIs enrolled and 69.3% (865/1249) results were returned within 2 weeks. The proportion of infants who had their test done within 4-6 weeks was 65.2% (861/1321); of these 1.5% tested positive, highest positivity rates were at HCIII (2.24%). On the other hand, 97.1% (838) of the test results were negative and 1.4% (12) were unknown. Only 10.6 % (140/1321) of the enrolled HEIs in the mother–baby care point were home deliveries. Among other EID interventions; 77.7% (859/1106) HEIs were started on cotrimoxazole prophylaxis within 2 months, 88.6% (1171/1321) babies received nevirapine prophylaxis, 88% of infants were exclusively breast fed and 92.5% (1222/1321) mothers were already on ART at the time of infant enrollment. From qualitative data, emerging challenges for xv low EID uptake included; inadequate PMTCT counselling, long distance to the health facility and non-partner disclosure of HIV status, maternal factors; young mothers, home deliveries and low level of education. Health facility factors included; stock out of EID test kits, lack of training and mentorship to staff on EID, poor record management and reporting. Conclusion: Two thirds of HIV-exposed infants accessed the EID service at 4-6 weeks which indicates low uptake. However, the overall proportion of HIV infection at 4-6 weeks was 1.5%, which reflects achievement of the eMTCT target of below 5% in breastfeeding populations. The uptake of EID is lower than international targets probably due to the several caregiver and health system challenges identified in this study. Recommendations: The ministry of health and implementing partners in Arua district need to increase use of EID, improvement in maternal knowledge of EID is needed particularly on the importance of EID, the frequency and schedule during ANC visits; the benefits of HIV sero-status disclosure so as to galvanize social, psychological, and medical support from the spouse, relatives, family members, friends or significant others are needed. This is achievable through health education or routine counseling. In addition, EID programs should recognize maternal age differences as a key factor in use of EID services. Key words: HIV Exposed infant, Early Infant Diagnosis, Mother-To-Child Transmission, PCR