Manuscript title: Facilitators and barriers to cotrimoxazole prophylaxis among HIV exposed babies: a qualitative study from Harare, Zimbabwe

BMC Public Health, Aug 2015

Background Implementation of cotrimoxazole prophylaxis (CTX-p) among HIV-exposed infants (HEI) is poor in southern Africa. We conducted a study to investigate barriers to delivery of CTX-p to HEI in Zimbabwe at each step of the care cascade. Here we report findings of the qualitative component designed to investigate issues related to adherence conducted among women identified as HIV positive whose babies were started on CTX-p postnatally. Of note, Zimbabwe also provided nevirapine prophylaxis for HIV exposed babies, so the majority were giving nevirapine and CTX-p to their babies. Methods Between Feb–Dec 2011, the first 20 HIV infected mothers identified were invited for in-depth interview 4–5months postnatally. Interviews were recorded, transcribed, translated and analysed thematically. Results All women desired their baby’s health above all else, and were determined to do all they could to ensure their wellbeing. They did not report problems remembering to give drugs. The baby’s apparent good health was a huge motivator for continued adherence. However, most women reported that their husbands were less engaged in HIV care, refusing to be HIV tested and in some cases stealing drugs prescribed for their wives for themselves. In two instances the man stopped the woman from giving CTX-p to the baby either because of fear of side effects or not appreciating its importance. Stigma continues to be an important issue. Mothers reported being reluctant to disclose their HIV status to other people so found it difficult to collect prescription refills from the HIV clinic for fear of being seen by friends/relatives. Some women reported that it was hard to administer the drugs if there were people around at home. Other challenges faced were stock-outs of CTX-p at the clinic, which occurred three times in 2011. The baby would then go without CTX-p if the woman could not afford buying at a private pharmacy. Conclusions The study highlights that adherence knowledge and desire alone is insufficient to overcome the familial and structural barriers to maintaining CTX-p. Improving adherence to CTX-p among HEI will require interventions to improve male involvement, reduce HIV stigma in communities and ensure adequate supply of drugs.

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Manuscript title: Facilitators and barriers to cotrimoxazole prophylaxis among HIV exposed babies: a qualitative study from Harare, Zimbabwe

Sibanda et al. BMC Public Health Manuscript title: Facilitators and barriers to cotrimoxazole prophylaxis among HIV exposed babies: a qualitative study from Harare, Zimbabwe Euphemia L. Sibanda 0 Sarah Bernays 2 Ian V. D. Weller 1 James G. Hakim 3 Frances M. Cowan 0 1 0 Centre for Sexual Health and HIV/AIDS Research, (CeSHHAR) Zimbabwe , 9 Monmouth Rd, Avondale West, Harare , Zimbabwe 1 Department of Infection and Population Health, University College London Medical School , London , UK 2 Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine , London , UK 3 Department of Medicine, University of Zimbabwe College of Health Sciences , Harare , Zimbabwe Background: Implementation of cotrimoxazole prophylaxis (CTX-p) among HIV-exposed infants (HEI) is poor in southern Africa. We conducted a study to investigate barriers to delivery of CTX-p to HEI in Zimbabwe at each step of the care cascade. Here we report findings of the qualitative component designed to investigate issues related to adherence conducted among women identified as HIV positive whose babies were started on CTX-p postnatally. Of note, Zimbabwe also provided nevirapine prophylaxis for HIV exposed babies, so the majority were giving nevirapine and CTX-p to their babies. Methods: Between Feb-Dec 2011, the first 20 HIV infected mothers identified were invited for in-depth interview 4-5months postnatally. Interviews were recorded, transcribed, translated and analysed thematically. Results: All women desired their baby's health above all else, and were determined to do all they could to ensure their wellbeing. They did not report problems remembering to give drugs. The baby's apparent good health was a huge motivator for continued adherence. However, most women reported that their husbands were less engaged in HIV care, refusing to be HIV tested and in some cases stealing drugs prescribed for their wives for themselves. In two instances the man stopped the woman from giving CTX-p to the baby either because of fear of side effects or not appreciating its importance. Stigma continues to be an important issue. Mothers reported being reluctant to disclose their HIV status to other people so found it difficult to collect prescription refills from the HIV clinic for fear of being seen by friends/relatives. Some women reported that it was hard to administer the drugs if there were people around at home. Other challenges faced were stock-outs of CTX-p at the clinic, which occurred three times in 2011. The baby would then go without CTX-p if the woman could not afford buying at a private pharmacy. Conclusions: The study highlights that adherence knowledge and desire alone is insufficient to overcome the familial and structural barriers to maintaining CTX-p. Improving adherence to CTX-p among HEI will require interventions to improve male involvement, reduce HIV stigma in communities and ensure adequate supply of drugs. - Background Infants born to HIV infected mothers (HIV-exposed infants, HEI) are at risk of mother-to-child transmission of HIV during pregnancy, delivery and breastfeeding. There is also evidence that HEI suffer more morbidity and mortality than infants born to HIV negative mothers likely due to 1) greater exposure to infection agents, 2) poor nutrition and care as a result of the mother’s illness or death [1–3]; and 3) altered innate immunity which could be mediated by exposure to HIV in utero and early in life or exposure to maternal antiretroviral drugs during prevention of mother to child transmission (PMTCT) [4, 5]. Many interventions have been introduced to prevent mother-to-child transmission of HIV and/or opportunistic infections among both HIV-infected and uninfected HEI. These include ARV prophylaxis and/ or treatment regimens for the mother and infant that are given for various lengths of time depending on the infant feeding method and the WHO guideline that the PMTCT programme has adopted. Those programmes adopting Option B/B+ guidelines advise HEI to take ARV prophylaxis for the first 4–6 weeks of life, but those adopting Option A recommend that infants continue on nevirapine prophylaxis until one week after cessation of breastfeeding [6, 7]. In addition, all HEI in generalised HIV epidemics should take cotrimoxazole prophylaxis (CTX-p) from the first 4–6 weeks of life and continue until HIV infection can be excluded [8]. This means mothers and carers need to devote attention and care in ensuring adherence to these life-saving pharmacological interventions. Unfortunately, current literature shows an unacceptable loss to follow up of infants along the PMTCT cascade [9, 10]. A recent systematic review estimated that 34 % of infants in Sub-Saharan Africa are lost to follow up from real-life PMTCT programs by three months of age, and 45 % are lost after HIV testing [11]. In Zimbabwe, retention of HEI has been a challenge since inception of PMTCT services. In 2007, only 11 % of infants who (...truncated)


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Euphemia Sibanda, Sarah Bernays, Ian Weller, James Hakim, Frances Cowan. Manuscript title: Facilitators and barriers to cotrimoxazole prophylaxis among HIV exposed babies: a qualitative study from Harare, Zimbabwe, BMC Public Health, 2015, pp. 784, 15, DOI: 10.1186/s12889-015-2136-0