Health workers' views on quality of prevention of mother-to-child transmission and postnatal care for HIV-infected women and their children

Human Resources for Health Health workers' views on quality of prevention of mother-to-child transmission and postnatal care for HIV-infected women and their children Thu Anh Nguyen 2 Pauline Oosterhoff 1 Yen Ngoc Pham 1 Anita Hardon 0 Pamela Wright 1 0 Amsterdam School of Social Science Research, University of Amsterdam , Amsterdam , the Netherlands 1 Medical Committee Netherlands Vietnam , Hanoi , Viet Nam 2 Faculty of Public Health, Hanoi Medical University , Hanoi , Viet Nam Background: Prevention of mother-to-child transmission has been considered as not a simple intervention but a comprehensive set of interventions requiring capable health workers. Viet Nam's extensive health care system reaches the village level, but still HIV-infected mothers and children have received inadequate health care services for prevention of mother-to-child transmission. We report here the health workers' perceptions on factors that lead to their failure to give good quality prevention of mother-to-child transmission services. Methods: Semistructured interviews with 53 health workers and unstructured observations in nine health facilities in Hanoi were conducted. Selection of respondents was based on their function, position and experience in the development or implementation of prevention of mother-to-child transmission policies/programmes. Results: Factors that lead to health workers' failure to give good quality services for prevention of mother-to-child transmission include their own fear of HIV infection; lack of knowledge on HIV and counselling skills; or high workloads and lack of staff; unavailability of HIV testing at commune level; shortage of antiretroviral drugs; and lack of operational guidelines. A negative attitude during counselling and provision of care, treating in a separate area and avoidance of providing service at all were seen by health workers as the result of fear of being infected, as well as distrust towards almost all HIV-infected patients because of the prevailing association with antisocial behaviours. Additionally, the fragmentation of the health care system into specialized vertical pillars, including a vertical programme for HIV/AIDS, is a major obstacle to providing a continuum of care. Conclusion: Many hospital staff were not being able to provide good care or were even unwilling to provide appropriate care for HIV-positive pregnant women The study suggests that the quality of prevention of mother-to-child transmission service could be enhanced by improving communication and other skills of health workers, providing them with greater support and enhancing their motivation. Reduction of workload would also be important. Development of a practical strategy is needed to strengthen and adapt the referral system to meet the needs of patients. - Background Prevention of mother-to-child transmission (PMTCT) has been considered a simple intervention: just giving medication to prevent viral transmission from mother to child. Now, though, PMTCT is recognized as a comprehensive set of interventions requiring capable health workers. It starts with testing pregnant women for HIV, preferably during their first antenatal visit. When giving the test result, health care workers should provide good counselling, including information about PMTCT options. The health system should ensure that HIV-positive women receive the PMTCT services that they choose and should provide postnatal care. All along the timeline from finding out their serostatus to getting treatment for HIVrelated problems, women and their children should be followed closely. The need for comprehensive and longterm care for HIV-infected women has become a challenge for health systems, particularly where lack of coordination among different facilities is common [1,2]. Viet Nam's HIV epidemic is still in a concentrated phase, with the highest seroprevalence among high-risk key populations, including injecting drug users (IDU), female sex workers (FSW) and men who have sex with men (MSM). Hanoi is one of 10 provinces/cities reported to have the highest number of HIV infections per 100 000 inhabitants. After the first case of AIDS was identified, in 1992, the HIV epidemic in Hanoi increased sharply by 1994. The capital has 12 628 persons living with HIV/AIDS (PLHIV), mostly IDU from poor families. Currently, there are 3623 AIDS patients and 2081 who had died of AIDS in the city. Although HIV is predominantly concentrated among IDU and FSW, it is gradually spreading among the general population. In 2007, HIV prevalence among pregnant women attending antenatal care (ANC) clinics in the Hanoi was 0.34% [3]. Hanoi was selected as the study site because comprehensive PMTCT care is theoretically available there. Hanoi had 45 hospitals, 290 surgeries and five international hospitals. The national hospitals in Hanoi serve as referral centres for the northern half of Viet Nam. HIV testing and counselling for pregnant women are offered at health facilities at district or higher level, but often only after the 28th week of gestation. HIV-positive women are referred to provincial or national hospitals for ARV prophylaxis, delivery and postnatal care. Hanoi health services have sufficient supplies of prophylactic ARV to meet the demand. Antiretroviral therapy for adults is available at district level or higher. HIV-exposed infants are offered polymerase chain reaction (PCR) testing and free infant feeding formula for at least six months, while free paediatric ARV is available for children three years of age or older. The extensive health care system in Hanoi reaches the commune level, but multisectoral and cross-programme collaboration to link the pillars of the World Health Organization's (WHO) comprehensive approach to PMTCT are weak [4]. For example, there is little collaboration between the programmes for HIV/AIDS and family planning. Our previous work suggested that a large number of HIV-infected pregnant women remain undetected by the health system [5]. In addition, a number of barriers result in failure to access PMTCT during pregnancy and delivery [6-11]. Among the weak points identified were that HIV-infected women received inadequate information about postnatal care, but even when they had knowledge, many expressed fear of stigma and discrimination that reduced their access to care; HIV testing is not available via health services at commune level, where many pregnant women go for care and delivery; and women feared lack of confidentiality of HIV test results [4,12]. Our previous studies on the experiences and views of women about the provision of PMTCT in Hanoi included criticisms about the quality of services provided by health workers [4]. Other studies in Asia found that health workers were unwilling to provide appropriate care for HIVpositive pregnant women, often because of their own fear or lack of knowledge, or because of high workloads and lack of staff [13,14]. Inadequate health care deli (...truncated)