Understanding reasons for poor follow-up of HIV positive women and their exposed children in an HIV clinic in Beira, Mozambique: A qualitative study

Background

Mozambique's central region has the highest burden of pediatric HIV nationally. The current PMTCT program has had little success in ensuring continued care of HIV-exposed children due to a high loss to follow-up (LTFU) rate. Little systematic data have been collected from the perspective of both HIV+ women and health workers regarding this topic. We therefore conducted a qualitative exploratory study to determine reasons for poor follow-up of HIV+ women and their HIV-exposed children in HIV care, and to identify barriers for initiating HIV treatment.

Design and Methods

A subset of women/baby pairs from a cohort study of patients in public PMTCT and ART programs were recruited. Focus group discussions (FGD) and in-depth interviews (IDI) were conducted with women, health workers, and study staff. Forty interviews and four FGD were tape-recorded, and transcripts were coded and analyzed using ATLAS.ti. Women with good adherence were compared to those with poor adherence to identify barriers and facilitators for initiating ART in eligible infants.

Results

The main contributors influencing women's decisions to attend scheduled visits and health seeking behavior were: Money-Hungry: Many women struggle on a daily basis to raise money through small businesses, which cannot be abandoned to attend clinics. Although care and treatment are viewed as desperately important, it's still more relevant to procure food for their families. Food aid is also a social problem at health facilities as health workers have to prioritize beneficiaries. Poor health worker communication/performance: Meager information about service availability and long delays at the clinic caused many women to not return for care. Husband's lack of support: The willingness to procure care usually did not depend only on a woman's decision. Women are socially expected to consult their husbands and other relatives before procuring care for themselves and their children. Fear of stigma and domestic violence also prevented utilization of care.

Recommendations

Results uncovered a complex context in which HIV+ women and their children live and operate on a daily basis. Improved communication skills, compassionate care from health workers, food and economic security, and male awareness about treatment are critical issues to address in order to improve health care delivery and utilization of services.