Agnes Mtaja Supervisors : Dr B. Amadi Dr S Wasomwe Department of Pediatrics and Child Health

1. AWARENESS OF REPEAT ANTENATAL HIV TESTING IN MOTHERS AT SIX WEEKS POSTNATAL AT CHILENJE CLINIC, LUSAKA. Agnes Mtaja Supervisors : Dr B. Amadi Dr S Wasomwe Department of Pediatrics and Child Health School of Medicine University of Zambia

2. Introduction Background • Largest source of HIV infection in children ˂ 15 yrs is MTCT (UNAIDS) • High rates of seroconversion rates in pregnancy and early postpartum period in sub Saharan Africa (Kinuthia et al, Moodley et al) • Repeat testing important to identify mothers who seroconvert and facilitate interventions to reduce risk of MTCT

3. Statement of problem • Retesting rates in Lusaka District 10% (ZEPRS) - too low to translate into an effective PMTCT programme • Barriers to uptake of PMTCT services need to be explored. • Could low levels of awareness of the repeat antenatal HIV test contribute to the poor uptake of these services?

4. Objectives Main Objective • To assess the effect of maternal awareness of repeat antenatal HIV testing on actual repeat testing in women attending the 6th week post natal clinic at ChilenjeHealth Centre, Lusaka Specific Objectives • To ascertain the proportion of postnatal mothers that were aware of repeat antenatal HIV testing • To determine the proportion of mothers retested later in pregnancy or labor • To determine the proportion of postnatal mothers who will have seroconverted by the 6th week postnatal visit

5. Research question and Justification • How does awareness affect the uptake of repeat testing? Justification • PMTCT guidelines - all pregnant women to have HIV tests every 3 months • Only 10 % get retested • Women that seroconvert may be missed; ↑ risk of vertical transmission • Study important in identifying some issues related to the non implementation of the guidelines

6. Operational definition and Limitations Aware – women that responded with a ‘yes’ to being asked “In the antenatal counseling you underwent prior to being tested for HIV, were you told that you needed to retest for HIV later in pregnancy?” Limitations • Recall bias • Results not generalizable to other clinics as there may be factors specific to Chilenje clinic

7. Literature review • HIV seroconversion may account for up to 40% of MTCT – Botswana (Lu et al, 2009) • Low retesting rates: - 6% - UTH (Kankasa et al) - 14% - Swaziland (Keiffer et al, 2010) • Barriers to uptake of PMTCT were numerous in various studies. Of note: - lack of discussion by antenatal care providers - lack of awareness of existing services by clients (Bwirire et al, 2008; Gita S et al, 2008)

8. Methodology • Cross sectional study • Convenient sampling – 404 mothers recruited • Eligibility – HIV negative in pregnancy with proof of negativity • Questionnaires - to assess awareness • Repeat test to those eligible

9. Data analysis • Data stored on Epidata v 3.1 and analysed using stata 11. • Frequency tables – socio demographics • Chi square tests - categorical variables with outcome • Multivariate logistic regressions - confounders • Results significant at 95% CI if p<0.05. Effect size was measured using odds ratios

10. Table 1 Characteristics of study participants; n = 404

11. Description of outcomes and association of awareness to repeat testing

12. Adjusting for confounders • Potential confounders – Education, Gestational age at booking, number of ANC visits, number of pregnancies Table 5 Multivariate analysis aw= awareness; ft=first trimester booking; av5=5+ ANC visits

13. Discussion • Major reason for not retesting – not requested for by health care provider, barrier also found in other studies. ? Strain on over-stretched human resource? • Awareness significantly associated with repeat testing. Are women that are aware actively seeking out the test?? • Repeat testing 36% vs 10%. ?? study effect (Keiffer et al al 45% in intervention vs 14% at control sites)

14. Conclusion • Mothers that are aware of repeat antenatal HIV testing have a four fold chance of being retested • Women that book in the first trimester are more than twice likely to be retested than women that book later • Having 5 and more ANC visits increases the chances of being retested threefold

15. Recommendations • Counseling in the antenatal period must be strengthened to ensure that women are empowered to be able to ask for a repeat test when not offered • Strict adherence to PMTCT guidelines, of which repeat antenatal HIV testing is a part, must be emphasised

16. References 1. UNAIDS 2009 2. Prevention of Mother-to-Child transmission of HIV: Expert Panel Report and recommendations to the US. Global AIDS Coordinator January 2010 3. Zambia National Protocol Guidelines for the Integrated Prevention of Mother-to-Child Transmission of HIV, 2010  4. Zambia Electronic Perinatal record system 5. Kieffer M, Hoffman H, Nlabhats B, et al. Repeat HIV testing in labor and delivery as a standard of care increases ARV provision for women who seroconvert during pregnancy. Program and abstracts of the 17th Conference on Retroviruses and Opportunistic Infections (CROI); February 16-19, 2010; San Francisco, California. 6. Bwirire LD, Fitzgerald M, Zachariah R, et al. Reasons for loss to follow up among mothers registered in a Prevention-of-Mother-to-Child Transmission Program in Rural Malawi. Trans R Soc Trop Med Hyg2008; 102: 1195 – 1200 7. Kebaabetswe PM. Barriers to Participation in the prevention of Mother-to-Child HIV transmission Program in Gaborone, Botswana, a qualitative approach. AIDS Care. 2007 Mar: 19 (3): 355 – 60.

17. Acknowledgements • Dr C liu • Dr Ben Chi - CIDRZ • Dr Ben Andrews - UTH • Dr Musonda - CIDRZ • Dr V Mulenga - UTH • Dr C Chabala – UTH • SrSipatonyana – Chilenje clinic • SrChipanda – chilenje clinic