Accessibility of HIV diagnostic services by exposed under five-year children in Muheza district in North-East Tanzania

Abstract

Introduction: Early diagnosis of HIV (Human Immunodeficiency Virus) among exposed infants gives an opportunity for early access to HIV care and treatment with potential for increased survival. Despite global efforts to scale up early infant diagnosis (EID) services, in resource-limited, high HIV burden countries including Tanzania, the coverage is still lower than the recommended levels. The study was carried out to determine HIV prevalence and factors associated with accessibility of EID among HIV exposed under five-year children in Muheza district, Tanzania. Methods: A concurrent mixed methods design comprising of cross sectional survey, health facility survey and case study design was conducted among mother/guardian-child pairs of HIV exposed child and health care providers at Muheza health facilities between June 2015 to June 2016. Information on HIV status, socio-demographic and other relevant data was collected using structured questionnaires, interview guides and health facility checklist. Multiple regression analyses were done by using STATA version 13.0 to examine the factors associated with accessibility to EID. Thematic generation and analysis were done using Nvivo version 10. Results: A total of 576 HIV exposed children with their respective mothers/guardians were recruited. Of the 576 mothers/guardians, 549 (95.3%) were the biological mothers with a median age of 34 years (inter-quartile range (IQR):30 to 38 years). The median age of the 576 children was 15 months (IQR: 8.5 to 38.0 months). A total of 251 (43.6%) children were born to mothers with unknown HIV status at conception. Only 329 (57.1%) children accessed EID between four and six weeks of age. In the district, EID testing sites were only available in 61% of health facilities. Children born to mothers with unknown HIV status at conception (AOR=0.6, 95% CI 0.4-0.8) and those with ages 13-59 months (AOR=0.4, 95% CI 0.2-0.6) were the significant factors of missed opportunity to access EID. Children living with the head of household with at least a high education level had higher odds of accessing EID (AOR= 1.8, 95% CI 1.1-3.3). Their likelihood of accessing EID services was three-fold higher among mothers/guardians with good knowledge of HIV infection prevention of mother to child transmission (PMTCT) (AOR=3.2, 95% CI 2.0-5.2) than those with poor knowledge. Mothers/guardians living in rural areas had poorer knowledge of PMTCT (AOR=0.6, 95% CI 0.4-0.9) than those living in urban areas. According to qualitative interviews, barriers identified to influence EID access at individual level included inadequate vii knowledge regarding EID and PMTCT, lack of transport cost to go to health facility, poverty, HIV stigma, culture, traditional and religious beliefs, geographical relocation, lack of psychosocial support, lack of paternal permission, poor patient-health care provider interaction and low satisfaction with health care services. Laboratory materials out of stock, weak health care infrastructures, lack of skilled health care providers, inadequate health care providers and delay of HIV results were an additional challenges to health care system that affect access to EID services. In addition, health care providers were not satisfied with their job due to high workload, lack of motivation, communication and transport allowances. Furthermore, the HIV prevalence among 576 under five children was 10.6% (95% CI 8.1-13.1%). The burden of HIV infection was observed among older children aged 25-59 months (AOR= 5.6, 95% CI 1.6-19.1) and those born to mothers with unknown HIV status at conception (AOR=3.9, 95%CI 1.6-9.3). The odds of HIV infection was higher among children who were delivered at home (AOR=2.6, 95% CI 1.0-6.6), received mixed feeding (AOR=2.4, 95% CI 1.1-4.9), and those living far from health facility (AOR 2.5, 95% CI 1.1-5.4). The odds of HIV infection was low among children with head of household who had at least attained high education level (AOR= 0.3, 95% CI 0.1-0.9). Conclusion: Accessibility of EID services among HIV exposed under five-year children in Muheza district is low and the HIV prevalence among this population is high. This does not show just limitations in testing efforts in the past, but it suggests a reshaping of current HIV testing for women and men so that pre-pregnancy HIV knowledge of status is prioritized. Further, these findings stress the need for continued HIV education and outreach services, particularly in rural areas in order to target reaching out to hard to reach and predominantly poor mothers and their children. Noting that there still exists many gaps in the EID system, creating a functioning surveillance system with strategy to generate context specific information for programming, should also be prioritized for improved PMTCT and EID programming.