Open Access
Research
Retention of children under 18 months testing HIV positive in care
in Swaziland: a retrospective study
Nomvuselelo Sikhondze1, Ozayr Haroon Mahomed1,&
1
Discipline of Public Health Medicine, University of KwaZulu Natal, Durban, South Africa
&
Corresponding author: Ozayr Haroon Mahomed, Discipline of Public Health Medicine, University of KwaZulu Natal, Durban, South Africa
Key words: Retention into care, antiretroviral treatment, Swaziland
Received: 11/09/2017 - Accepted: 06/10/2017 - Published: 26/12/2017
Abstract
Introduction: Significant progress has been made with respect to the initiation of children on antiretroviral therapy (ART) in Southern Africa
including Swaziland, however retention of these children in care poses a major challenge. The aim of the study was to assess retention to care in
children testing HIV positive taking into account the number of return child welfare care (CWC) visits the child made. Methods: A retrospective
cross sectional study and was conducted at 4 facilities in Swaziland. All children who were HIV infected from 0 to 18 months were identified using
the child welfare register (CWC). Infant characteristics were obtained from the child welfare register and early infant diagnosis logbooks.
Proportion of patients retained in care were calculated at three, six, nine and twelve months. Results: Of the 32 HIV positive children identified
tested between December 2014 up to July 2016, sixty eight percent (n = 22) of the children that tested HIV positive were retained at three
months, 40.6% at six months, 18.8% at nine months and 12.5% at twelve months. Children that resided in urban areas, more male than female
children, children from mothers who were on antiretroviral treatment, children initiated on antiretroviral treatment, mothers on antiretroviral
treatment for more than one year and children who received Infant Nevirapine were more likely to be retained. Conclusion: Facilities are
performing well in terms of identifying HIV positive children within the first two months of life and linking them into care. However, as time
progresses the retention of children in care declines. Innovative strategies need to be developed to enhance patient retention.
Pan African Medical Journal. 2017; 28:316 doi:10.11604/pamj.2017.28.316.13857
This article is available online at: http://www.panafrican-med-journal.com/content/article/28/316/full/
© Nomvuselelo Sikhondze et al. The Pan African Medical Journal - ISSN 1937-8688. This is an Open Access article distributed under the terms of the Creative
Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the
original work is properly cited.
Pan African Medical Journal – ISSN: 1937- 8688 (www.panafrican-med-journal.com)
Published in partnership with the African Field Epidemiology Network (AFENET). (www.afenet.net)
Page number not for citation purposes
1
Introduction
Human Immune Deficiency Virus (HIV) continues to be a major
global public health issue. In 2015, there were 36.7 million (30.8
million-42.9 million) people living with HIV globally, including 2.1
million (1.7 million-2.6 million) children (< 15 years) [1]. East and
Southern Africa were the most affected region with 960,000 new
HIV infections, representing 46% of the global burden [2]. About
150 000 (110 000-190 000) children became infected with HIV in
2015 [3]. Swaziland, a small landlocked country in southern Africa,
has the highest HIV prevalence in the world, with 28.8% of their
adult population living with HIV. The epidemic is generalised
affecting all regions. The HIV prevalence in 2016 was 27% in
Hhohho, 30% in Manzini, 28% in Shiselweni and 30% in Lubombo
[4]. In 2015, 11,000 people were newly infected with HIV and 3,800
people died of an AIDS-related illness [5]. The HIV incidence trends
amongst adults between the age of 15 and 49 years has declined
steadily from 2, 23 per 100 person years in 2011 to 1, 85 per 100
patient years in 2016 [6] as a result of the concerted effort of the
Swaziland Government to curb the HIV epidemic. Approximately
144,412 (64%) of people living with HIV were on anti-retroviral
treatment (ART) in 2016 [7]. Pregnant women are a high risk group
for the acquisition and transmission of HIV. More than 97% of
antenatal attendees in Swaziland were aware of their HIV status,
with approximately 35% of all pregnant women (10560) testing HIV
positive in 2014. Ninety percent (9,491) of eligible pregnant women
received ART in 2014 [8], with 99% of the exposed infants receiving
Cotrimoxzole prophylaxix. In terms of the Swaziland integrated HIV
management guidelines (2015) [1], all HIV exposed infants should
be provided with Nevirapine and Cotrimoxazole prophylaxis for 6
weeks and the first HIV DNA PCR test should be conducted. If the
infant is HIV positive then linkages for ART should be established.
However, if the infant is negative, the infant should be continued
with Cotrimoxazole until breastfeeding has been stopped and HIV
has been excluded. The purpose of this study was to determine the
proportion of children less than 18 months that tested HIV positive
who were retained in care. Retention in care was defined as the
patient attending the prescribed follow up child welfare visit (3
months (14 weeks), 6 months, 9 months, 12 months, 15 months
and 18 months) as defined by the Swaziland integrated HIV
management guidelines (2015) [1] post-natal care schedule.
Methods
Study design and setting: A retrospective study and was
conducted in 4 facilities in the country namely Mbabane Public
Health Unit, Lobamba clinic, Ezulwini Satellite clinic and Hhukwini
clinic. Mbabane PHU is a Primary health care facility situated in
Mbabane City next to Mbabane Hospital in the Hhohho region. The
facility serves a catchment population of an average of 4,700 per
year and an average of 45 exposed children at first child welfare
visit i.e. at 6 to 8 weeks visit, per month. Lobamba and Ezulwini
satellite clinics are situated in the semi urban community and serves
a catchment population of 12,000. On average these facilities see
25 exposed children per month at first child welfare care visit.
Hhukwini is situated in the rural area and serves a catchment
population of 5,718 and sees and average of 4 exposed children per
month at first child welfare care visit.
Infant and maternal characteristics were obtained from the CWC
Register and early infant diagnosis logbooks. Data on the number of
child welfare visits and the duration between testing and initiation of
ART were obtained from the patients clinical records. Reasons for
not initiating ART were obtained from the CWC registers. Proportion
of patients that were retained in care at three months, six months,
nine months and twelve months that were HIV exposed were
calculated.
Ethics: The study was approved by the Bio Medical Research Ethics
Committee of the University of KwaZulu Natal (BE 385/16).
Permission to conduct the study was obtained from the Swaziland
Ministry of Health. Patients name and addresses were omitted from
the data extraction tool to maintain patient confidentiality and
privacy.
Results
Demographic characteristics of respondents: Thirty two HIV
positive children identified from four health facilities in Swaziland,
with 75% from two facilities (Mbabane Public Health Unit (n = 12)
and Lobamba Clinic (n = 12)). Seventy eight percent (n = 25) of the
children resided in rural areas with most of the HIV positive children
were male (56.3%; n = 18) (Table 1).
Characteristics of mothers: Seventy eight percent (n = 25) of
the children who tested positive were born from mothers already on
antiretroviral treatment with (92%, n = 23) of the women initiating
antiretroviral treatment during pregnancy at ANC and 8% (n = 2)
initiated after pregnancy at post-natal care. More than half (52%) of
the women initiated antiretroviral treatment in 2015 (52%, n = 13)
whilst about 40% (n = 10) initiated before 2015 (Table 2).
Early infant diagnosis for HIV: All 32 children received a
confirmatory HIV test, with 94% (n = 30) receiving their HIV test
results. Seventy two percent (n = 23) were diagnosed within the
recommended 6 to 8 weeks and were referred for ART. Of all the
children, more than half of the children (62%, n = 20) were
initiated on ART whilst 38% (n = 12) were not initiated. Of the 32
children identified to be HIV positive 81% (n = 26) were on Infant
Nevaripine prophylaxis (I-NVP) for the first 6 weeks of life and 19%
(n = 6) were not initiated on INVP (Table 3). The main reason for
the children not been initiated on ART was that the patients did not
return for child welfare visits (83%, n = 10) and 17% (n = 2) had
died before initiation 8.3% (n = 1) (Table 3).
Retention in HIV care and treatment: Sixty eight percent (n =
22) of the children that tested HIV positive were retained at 3
months, 40.6% (n = 13) at 6 months, 18.8% (n = 6) at 9 months
and 12.5% (n = 4) at 12 months (Figure 1).
Retention in HIV Care and treatment at 3 months:Of the 22
children 100% of urban children and 60% (n = 15; N = 25) of the
children that came from rural areas were retained at 3 months.
Seventy one percent (n = 10; N = 14) of male children compared to
66.7 % (n = 12; N = 18) of female children, 80% (n = 20; N = 25)
of children from mothers who were on ART, 80% (16) of children
who were initiated on ART and 73% (19) of the children that
received Nevirapine prophylaxis were retained at 3 months (Table 4)
Study population: The study population included all HIV positive
children testing positive who were below 18 months during the
course of the data collection.
Discussion
Data collection: All children who were HIV infected from 0 to 18
months were identified using the child welfare register (CWC).
The findings from this study, despite the small number of patient's
highlights strengths and programmatic weaknesses within the
Page number not for citation purposes
2
PMTCT programme in Swaziland. The strengths of the PMTCT
programme demonstrated through the results of the study include
amongst others is that there was adherence to the World Health
Organisation recommendations that infants exposed to HIV should
be tested at 4-6 weeks of age, using a virological test Dried blood
spot to polymerase chain reaction testing and ART should be started
as soon as the infants are found to be HIV-positive, regardless of
clinical and immune status [9]. In this study all children received a
confirmatory HIV test within 6 weeks, 72% (n = 22) were
diagnosed within the recommended 1.5 to 2 months and (62%, n =
20) being initiated on ART. This represents an improvement in 2010
only 47 per cent of HIV-exposed infants received an HIV test at six
to eight weeks of age; 78 per cent of exposed infants received cotrimoxazole; only 28 per cent of HIV-infected infants received ART;
and exclusive breastfeeding rates are at 44 per cent for infants less
than six months old [10]. Loss to follow up (83%) and infant death
(17%) were the main reason for non-initiation of infants on ART.
Amongst the contributing factors to the loss to follow up was the lag
in time between HIV testing and the parents/caregivers receiving
results (1.2 months) and the time from receiving results to initiating
the children on ART was 2 months. The quality of care provided to
HIV exposed infants was sub-optimal as 19% (6) of the infants
were not initiated on Infant Nevirapine, which was inconsistent with
the WHO HIV management guidelines that requires all children born
to HIV positive mothers should be prescribed Infant Nevirapine
(INVP) for the first six weeks of life as prophylaxis to strengthen
prevention of mother to child transmission of HIV (MTCT) [11]. The
proportion of patients retained in care declined from 68.8% at three
months to 12.5% after 12 months of care. These findings are much
lower than the findings a study conducted in Fort Portal, Western
Uganda, to assess adherence to Option B+ until 18 months
postpartum that showed 82.1% retention at six months and 71.6%
retention at 12 months [12]. Furthermore, the findings of the
current study are contrary to the findings from a systematic review
that included 31877 children, all from African countries which
showed a total of 5,558 (19%) children were not retained: 4082
(73%) were reported loss to follow up and 1476 (27%) died [13].
Amongst the African countries that have reported on paediatric
patient retention, Rwanda has the highest retention (95%) [14] and
the lowest retention is in a West African cohort (71%) [15].
In Swaziland the drop in patient retention on the programme could
be attributed to stigma and discrimination driven by community
norms, myths and misconceptions that do not support HIV
prevention efforts. Furthermore, health worker attitudes towards
HIV-positive mothers, especially at labour and delivery and early
post-natal care serve to enhance the myths resulting in patients
withdrawing from care [10]. Patients that withdraw from care or are
not adherent to medication are not followed up due to the weak
linkages and referral mechanisms between community and facility
based services [10]. The characteristics of the patients retained at
three months suggest that children that that resided in urban areas,
more male than female children, children from mothers who were
on ART, children initiated on ART, mothers on ART treatment for
more than one year and children who received Infant Nevirapine
were more likely to be retained. These findings suggest that loss to
follow up depend on the child's caregivers and are impacted by
social determinants of health such as level of education, income
level, availability of transportation, access to health services and
living conditions [13]. Of concern, in this study seventy eight
percent (n = 25) of the children who tested positive were born from
mothers already on antiretroviral treatment with (92%, n = 23) of
the women initiating antiretroviral treatment during pregnancy at
antenatal care. This is an indication of probably the late initiation of
antenatal care and ART uptake. According to the PMTCT guidelines,
the ARV regimen should be initiated as early as possible after 14
weeks, which is only possible if the pregnant woman visits antenatal
care within the first trimester [1]. Secondly, this could be due to the
poor adherence to treatment of patients on ART- as the maternal,
child health programme have poor capability for tracking clients and
ensuring that all services are received and women adhere to their
drug regimens throughout their pregnancy [10].
Study Limitations: The study was affected by the limited number
of patients enrolled within the study over the period of the study.
Data for the children beyond twelve months was not available.
Conclusion
Attrition from paediatric care and treatment programs has severe
consequences on morbidity and mortality. The findings of this study
indicate that children who are identified to be HIV positive are
linked to care, however retention in care is a major challenge. There
is a need to harmonize the information system in terms of improving
the documentation in the child welfare registers and also improving
the referral and linkages between the facility and outreach teams.
Innovative mobile technology should be utilised for health
promotion and reminder messages.
What is known about this topic
Pregnant women are a high risk group for the acquisition
and transmission of HIV;
More than 97% of antenatal attendees in Swaziland were
aware of their HIV status, with approximately 35% of all
pregnant women testing HIV positive in 2014;
Ninety percent of eligible pregnant women received ART
in 2014, with 99% of the exposed infants receiving
Cotrimoxazole prophylaxis.
What this study adds
Retention in care in Swaziland has declined over the
observation periods;
Provides a baseline for further studies to investigate
factors associated with poor retention in care.
Competing interests
The authors declare no competing interests.
Authors’ contributions
Nomvuselelo Sikhondze: provided substantial contributions to
conception and design, acquisition of data, or analysis and
interpretation of data; drafting the article and final approval of the
version to be published. Ozayr Haroon Mahomed: provided
substantial contributions to conception and design, acquisition of
data, or analysis and interpretation of data; revised the article
critically for important intellectual content; and provided final
approval of the version to be published.
Acknowledgments
We would like to express our gratitude to the Hhohho south regional
management for allowing me to have access to the facilities.
Page number not for citation purposes
3
Lobamba, Ezulwini Satellite, Hhukwini and Mbabane Public Health
Unit nurses who were furnishing with the relevant information
needed.
Tables and figures
Table 1: Frequency table of the demographic characteristics of the
study population (2015)
Table 2: Frequency table of the characteristics of mothers
Table 3: HIV testing and ART Initiation
Table 4: Profile of patients retained at three months
Figure 1: Proportion of HIV positive children retained in HIV care
and treatment between three and eight months
References
1.
Swaziland Ministry of Health. Swaziland Integrated HIV
Guidelines-2015. Mababane: Swaziland Ministry of Health.
2015.
2.
(UNAIDS) Joint United Nations Programme on HIV/AIDS.
Global AIDS Update 2016. Geneva: UNAIDS. 2016.
3.
Joint United Nations Programme on HIV/AIDS. Children and
HIV (Fact Sheet). Geneva: UNAIDS, 2016.
4.
Swaziland Government-The National Emergency Response
Council on HIV and AIDS. Swaziland HIV Estimates and
Projections Report 2015. Mbabane: Swaziland Government.
2015.
5.
(UNAIDS) Joint United Nations Programme on HIV/AIDS.
Prevention Gap Report. Geneva: UNAIDS. 2016.
6.
Swaziland Ministry of Health. Swaziland HIV Incidence
Measurement Survey (SHIMS). Mbabane: Swaziland Ministry of
Health. 2011.
7.
Swaziland Ministry of Health. Swaziland Country Operational
Plan. Mbabane: Swziland Ministry of Health. 2016.
8.
Swaziland Ministry of Health. Annual HIV Programme Report
2014. Mbabane: Swaziland Ministry of Health. 2015.
9.
Organization WH. Global update on HIV treatment 2013:
results, impact and opportunities. WHO. 2013.
10. Health SMo. Elimination of new HIV infections among children
by 2015 and keeping their mothers alive- National Strategic
Framework for Accelerated Action 2011-2015. Mbabane:
Ministry of Health. 2011.
11. (MOH) MOH. Early Infant Diagnosis in Swaziland. Standard
Operating Procedure and Training Manual. 2015.
12. Decker S, Rempis E, Schnack A, Braun V, Rubaihayo J,
Busingye P et al. Prevention of mother-to-child transmission of
HIV: postpartum adherence to option B+ until 18 months in
Western
Uganda.
PLoS
One.
2017;
12(6):
e0179448. PubMed | Google Scholar
13. Abuogi LL, Smith C, McFarland EJ. Retention of HIV-Infected
children in the first 12 Months of anti-retroviral therapy and
predictors of attrition in resource limited settings: a systematic
review. PLoS One. 2016; 11(6): e0156506. PubMed | Google
Scholar
14. Van Griensven J, De Naeyer L, Uwera J, Asiimwe A, Gazille C,
Reid T. Success with antiretroviral treatment for children in
Kigali, Rwanda: experience with health center/nurse-based
care. BMC Pediatr. 2008 Oct 02; 8: 39. PubMed | Google
Scholar
15. Ekouevi DK, Azondekon A, Dicko F, Malateste K, Toure P,
Eboua FT et al. 12-month mortality and loss-to-program in
antiretroviral-treated children: the IeDEA pediatric West African
Database to evaluate AIDS (pWADA), 2000-2008. BMC Public
Health. 2011 Jun 30; 11: 519. PubMed | Google Scholar
Table 1: Frequency table of the demographic characteristics of the study population (2015)
Health Facility Name
Residence
Gender
Ezulwini Satellite Clinic
Hhukwini Clinic
Lobamba Clinic
Mbabane PHU
Rural
Urban
Female
Male
n
6
2
12
12
25
7
14
18
%
18.8
6.3
37.5
37.5
78.1
21.9
43.8
56.3
Page number not for citation purposes
4
Table 2: Frequency table of the characteristics of mothers of infants
Mother initiated on ART
n
7
25
23
2
10
13
2
No
Yes
ANC
Post-natal
Before 2015
2015
2016
Place initiated
Year initiated
%
21.9
78.1
92.0
8.0
40.0
52.0
8.0
Table 3: HIV testing and ART Initiation
Received a confirmatory Test
DNA or PCR
Received HIV test result
Referred for ART
Initiated on ART
Reason for not initiating on ART
n
%
Yes
32
100
No
Yes
No
Yes
Missing
No
Yes
Loss to follow up
Died before
initiation
2
30
8
23
1
12
20
10
6.3
93.8
25
71.9
3.1
37.5
62.5
83%
2
17%
Table 4: Frequency table of profile of children retained at three months
n
%
Residence- Rural
15 (25)
60%
Residence - Urban
7 (7)
100%
Male
10 (14)
71%
Female
12 (18)
67%
Mother initiated ART
20 (25)
80%
Year mother initiated ART
Before 2015
10
100%
2015
10
77%
2016
0
0%
Child referred for ART
16 (20)
80%
Child Initiated on ART
16 (20)
80%
Received INVP Prophylaxis
19 (25)
73%
Page number not for citation purposes
5
Figure 1: Proportion of HIV positive children retained in HIV care and treatment between three and eight months
Page number not for citation purposes
6