CERTIFICATION

This is to certify that the research work emitted, Factors influencing the uptake of Prevention of

Mother to Child Transmission of HIV (PMTCT) was carried out by Ngalame Laura Ebude

(HS14A11) and has been read and approved as partial fulfillment of the requirements for the award

of a Bachelors in Nursing Sciences (BSC) degree

Signature----------------------------------------------------------

Date----------------------------------------------------------------

Dr. Palle Ngunde (Head of Department)

Signature----------------------------------------------------------

Date----------------------------------------------------------------

Supervisor (Mme Ebob Bessem)

DEDICATION

1
I dedicate this research to God Almighty and to all HIV positive pregnant women

ACKNOWLEDGEMENTS

I will like to express my special thanks of gratitude to my supervisor (Mme Ebob Bessem) who

assisted me in doing this research project.

2
I am really thankful. Secondly, I would to thank my family and friends who assisted me a lot in

finalizing this research within the limited time frame.

Appreciation to your department in school, study participants????

ABSTRACT

Introduction: In 2010 reports from National AIDS Control Committee (NACC) of Cameroon

showed that about 7300 babies were born HIV positive due to MTCT. Approximately 90% of HIV

3
infection among children is acquired through mother to child transmission of HIV (MTCT). The

risk of MTCT can be reduced to less than 2% with a package of evidenced based interventions.

With an effective Prevention of Mother to Child Prevention (PMTCT) program, the risk can be

reduced to as little as 2%.. Despite the international and national efforts to try to implement such

interventions, some gaps and barriers still exist in many sub-Saharan Africa countries, including

Cameroon, posing a challenge to PMTCT program roll out. This study attempts to identify these

gaps and barriers in the Limbe Regional Hospital

Methodology: A quantitative study was done using semi structured questionnaires. The target

population consisted of health care workers with more than 1year of working experience in PMTCT

Findings and Recommendation: The study participants were very experienced in delivering

PMTCT services and the majority has been working on the program for more than two years. Some

of the challenges identified include home deliveries, lack of male involvement and stigma

surrounding HIV/AIDS and formula feeding. The main reasons associated with these challenges

include illiteracy or ignorance, financial difficulties and trust in traditional birth attendance.

Respondents also felt there is a lack of staff to attend to the high patient load experienced at their

health facilities and that current staff should be retrained more often. It was recommended that

PMTCT program strategies should be improved by putting measures in place to increase awareness

around HIV/AIDS and PMTCT issues identified in this study.

Are u working on challenges of factors????

TABLE OF CONTENT

Title…………………………………………………………………1

Declaration……………………………………………………………2

Abstract…………………………………………………………………3
4
Acknowledgements………………………………………………--------4

Table of Contents…………………………………………………………5

List of figures and tables ___________________________________-6

CHAPTER 1: INTRODUCTION

1.1 Background……………………………………………………………….…..10

1.2 statement of problem………………………………………………12

1.3 justification…………………………………………………………...12

1.4 Research question……………………………………………………………..12

1.5 Aim of study…………………………………………………………...12

1.6 General objectives……………………………………………………...13

1.7 Specific objectives---------------------------------------------------------

1.8. Definition of key concepts------------------------------------------------------

CHAPTER 2: LITERATURE REVIEW

2.1 Introduction……………………………………………………………….…..14

2.2 Prevention of MTCT of HIV…………………………………….……...14

2.3 WHO guidelines on PMTCT…………………………...…………………….14

2.4 Global PMTCT target………………………………………………………...15

2.5. Cameroon country context …………………………………………….….16

2.6. PMTCT care continuum………………………………………….….17

5
2.7. Socio cultural and /or health facility factors influencing PMTCT………...19

CHAPTER 3: RESEARCH METHODOLOGY

3.1 Study design---------------------------------------------------

3.2 Study area……………………………………………………………...22

3.3 Study period…………………………………………….………23

3.4. Target population…………………………………………………….…...23

3.5 Sampling method…………………………………………………….……24

3.6 Data collection…………………………………………………...24

3.7 Data management and analysis……………………………………….………24

3.8. Ethical considerations---------------------------------------------------------------

CHAPTER 4: RESULTS

4.1 Demographic Data

4.2. Sociocultural factors and PMTCT

4.2.1. Home delivery

4.2.2. Male involvement

4.2.3. Compliance to follow up

4.2.4. Compliance to ARVs

4.2.5. Stigma and feeding choices

4.3. Health system and facility factors

6
CHAPTER 5 DISCUSSION, RECCOMENDATION AND CONCLUSION

5.1. Home delivery

5.2. Male involvement

5.3. Compliance to ARVs and appointments

5.4. Stigma and feeding choices

5.5. Drug availability

5.6. Human resources

5.7. Data management

5.8. Available support system from clinic

5.9. Correlations between demographic information and factors influencing PMTCT.

5.10 Recommendations

5.11. Limitations of study

5.12. Conclusion.

References

Appendix 1: Consent form

Appendix 2: questionnaires

Appendix 3: Study approval letters

7
List of Figures and Tables

Figure

Figure 4.2 Compliance to ARVs------------------------------------------

Figure 4.3. ARVs availability-------------------------------------------

Table

Table 4.1 Demographic distribution

Table 4.2 Home delivery

Table4.3 Male involvement

Table 4.4 compliance to follow up visits

Table4.5 Reasons for non-compliance to visits

Table4.6 Reasons for non-compliance to ARVs

Table4.7 Stigma and feeding choices

Table4.8 patient reaction to formula feeding

Table 4.9. Ways to prevent stigma from formula feeding

Table 4.10 support system

Table4.11 Human resources

Table 4.12correlation between working experience and male involvement

Table 4.13correlation between working experience and ARV compliance

8
Table4.14. correlation between clinical levels and reasons for noncompliance to appointments

4.15. Correlation between working experience and reasons for home delivery

FACTORS INFLUENCING THE UPTAKE PREVENTION OF MOTHER TO CHILD

TRANSMISSION OF HIV (PMTCT)

CHAPTER ONE

INTRODUCTION AND OBJECTIVES

1.1 Background of study

Worldwide, approximately 39.5million people are living with HIV/AIDS, including an estimated

17.7million women and 2.3million women and 2.3million children under the age of 15.women

currently represent the population which reflects the fastest increase in HIV infection rate, more

than 60% of all new HIV infections are occurring in women, infants , and young children with 1400
9
children under the age of 15 being infected with HIV, with approximately 90% of these infections

occurring in sub-Saharan Africa. Without appropriate care and treatment, more than 50% of newly

infected children will die before their second birth (WHO, 2017).

Approximately 90% of HIV infection among children is acquired through mother to child

transmission of HIV (MTCT). The risk of MTCT can be reduced to less than 2% with a package of

evidenced based interventions including ARV prophylaxis and treatments combined with elective

caesarean section and avoidance of breastfeeding. Infant feeding patterns are a very important

determinant of MTCT. For mothers using replacement feeding there is obviously no transmission

through breastfeeding (WHO 2017).Breastfeeding during a period of 6 months leads to

approximately 10% extra transmission (from 20% to 30%), while breastfeeding during a period of

18-24 months leads to approximately 17.5% extra transmission (from 20% to37.5%), c0mpared to

no breastfeeding (De cock et al., 2000).

PMTCT is the prevention of mother to child transmission of HIV/AIDS or vertical transmission. In

low and middle income countries PMTCT program coverage remains low with high transmission

rate Msuya{2009},Ekanem{2014}.Cameroon with a population of 24,513,689 as at 2016 faces one

of the most severe HIV epidemics in west and central Africa with 600,000 HIV positive

Cameroonians and a 4.3% prevalence rate with women more affected than men(UNAIDS,2016). In

1986, the government of Cameroon responded to the HIV epidemic by creating the national AIDS

control committee{NACC] with a national goal of virtual elimination of MTCT by 2015 as targeted

in the 2009-2015 national strategic plan and the Cameroon national plan to eliminate new HIV

infections in children and keep mothers alive Ekanem{2014},Gross{2014},Jayasuriyas{2012}. In

2011 a global plan was launched to reduce the number of new infection through PMTCT by 90%

by 2015 {Abou and Grants [2008}, WHO {2013} but this goal hasn’t been met yet. Over the last

four decades the knowledge of HIV/AIDS has increased and so have the number of people affected

10
with close to 90% of pediatric infections occurring in sub Saharan Africa. Worldwide 2.5-3.5

million children die of AIDS related deaths, this causes shortfalls in the achievement of the

sustainable development goals 3 and 4 of sustainable health and education for all but the prevalence

of pediatric HIV continues to be on the rise in spite so much national and international efforts.

In 2010 reports from National AIDS Control Committee(NACC) of Cameroon showed that about

7300 babies were born HIV positive due to MTCT (Ministry of public Health,2010); and without

intervention, more children will be born infected(Newell et al,2004),Hence, targeting pregnant

women is pivotal in the prevention of mother to child transmission (PMTCT) of HIV ,as it will

reduce the incidence of HIV infection, identifying the challenges to the uptake of these services by

HIV pregnant women will go a long way to reduce the incidence of HIV .

The 2010 WHO PMTCT guidelines recommended eliminating the use of single drug regiments,

favoring longer duration of ARVs during pregnancy and breastfeeding, including ARTs for non-

eligible pregnant/breastfeeding women under option B in, resource limited settings. The 2010

guidelines also recommended extending ARV coverage through durations of breastfeeding

exposure, now recommended for at least 12 months. In 2011, UNAIDS and PEPFAR proposed

ambitious new global goals;

1) To reduce the number of new HIV infections in children by 90% from the 2009 baseline

2) To cut HIV related maternal deaths in half .The 2013 WHO guidelines now recommend triple

therapy(either option B or B+) for all pregnant and breastfeeding women(WHO,2013)

By 2015 ,the implementation of option B+ had resulted in 915 0f the 1.1million women receiving

ARVs as part of PMTCT services being offered lifelong ART(UNAIDS,2016)’

According to Health Bridge (2007) and Karia (2008), some of the identified gaps were mainly due

to structural and socio-cultural factors, such as the following:

11
  Inadequate counselling (specifically about breastfeeding) has been noted from some studies

as a cause for dropout at different delivery points in the PMTCT protocol;

 For pregnant women who come for a first visit to antenatal care (ANC), not all are

counseled for HIV;

 Among those that are counseled not all get tested;

 For those who tested, not all receive their test results;

 For those found to be HIV positive some may not being evaluated for HAART or AZT

eligibility and their monitoring;

 Some infants also may not receive the Nevirapine prophylaxis and some also may end up

not being tested for DNA/PCR, as well as receiving Cotrimoxazole prophylaxis;

 Minimal or no involvement of men;

 Programs focus too much on HIV-infected women and not on men;

 Men do not attend ANC;

 Men do not comply with protection measures such as using condoms;

 -Many spouses of HIV-positive women refuse testing;

 Home delivery: Women attend ANC and MCH clinics but many deliver at home and

therefore it is difficult to ensure and establish that drugs provided were taken;

 Compliance and follow-up: Some positive mothers refuse the AZT pill and many HIV-

negative women do not go for a confirmatory test.

The researcher observed that despite the country implementation of PMTCT programs, it

seems that the above mentioned structural and socio-cultural factors are major challenges in

achieving the UNAIDS vision aimed at zero new HIV infections, zero discrimination, and zero

AIDS-related deaths. In order to achieve this vision, more effective PMTCT programs are needed,

and addressing the factors influencing the PMTCT outcomes are of paramount importance – in

12
order to clear the gaps and also for proper prevention of MTCT of HIV. This research project will

therefore focus on exploring the structural and socio-cultural factors that influence PMTCT

outcomes.

1.2 Statement of the problem

Currently a high prevalence of HIV infection amongst girls of reproductive age specifically

pregnant women exist, and as a result the risk of vertical transmission of HIV from infected mother

to their new born is also high (Nambili et al, 2016), despite the struggle to eliminate MTCT so

many challenges are still faced hindering the realization of an HIV free generation, this study is

specific to identifying the structural and/or sociocultural factors that influence the outcome of

PMTCT services. This research aims at identifying factors that contribute to poor delivery of

PMTCT services therefore leading to a decrease in HIV prevalence amongst susceptible children

born of HIV infected mothers.

The vast majority of HIV infections in children have been averted due to the provision of ARVs

worldwide in the years 2010-2015(UNAIDS, 2017).But despite this significant progress, the

number of children becoming newly infected with HIV remain unacceptable. In 2016,24% of

pregnant women living with HIV didn’t have access to ARVs to prevent transmission to their

infants(UNAIDS,2016),An estimated 45% of new HIV infections( vertically ) among children in

2015 occurred in west and central Africa(UNAIDS,2016).

Cameroons mother to child HIV transmission rate is 5.6% at 6weeks (MOH, 2015) AND 25% by

18 months, contributing roughly 7300 of 9500 newly infected children (UNAIDS, 2014). The 2016

NACC annual report revealed some successes in the PMTCT program ,these include an increase in

ANC attendance from 69.5% in 2014 to 78$ in 2016 and up to 635178(97%) of pregnant women

receiving an HIV test with 4.5% identified HIV positive and 19940(69%) positive initiated on ARV

nationwide
13
Although PMTCT programs show significant progress more needs to be done to involve and keep

the HIV positive pregnant woman in care in order to attain virtual Elimination of PMTCT. .

Therefore this study will contribute to the attainment of sustainable development goals 3 and 4 to

provide sustainable health, education in that these factors will be known, and solutions sorted out

and implemented thereby solving the problems responsible for the poor uptake of PMTCT

programs in Cameroon.

1.3 Justification

The result of this study will help improve the quality of PMTCT services provided and received by

the health providers and HIV positive pregnant women respectively, it will enable us understand the

factors that influence PMTCT outcome therefore reducing HIV prevalence amongst babies

1.4 Research Questions

1. What is the demographic profile of nurses working in the PMTCT unit of the Limbe

Regional Hospital?

2. Do sociocultural factors and facility factors influence PMTCT outcome in the Limbe

Regional Hospital?

3. What is the association between demographic characteristics of participants and factors

influencing PMTCT?

1.5 Goal of study

To identify the structural and/or socio- cultural factors that influence the outcome of prevention of

mother to child transmission of HIV (PMTCT), in order to provide guidelines for PMTCT program,

better deal with PMTCT challenges and barriers, and at the end reducing the prevalence of vertical

HIV transmission

1.6 General objective

14
To identify the factors influencing PMTCT (construct a good sentence)

1.7 Specific objectives

1. To describe the demographic characteristics of nurses working in the PMTCT unit of the

Limbe Regional Hospital.

2. To determine the Health facility and socio-cultural factors influencing PMTCT in the Limbe

Regional Hospital

3. To determine the association between demographic characteristics of participants and

factors influencing PMTCT

1.8 OPERATIONAL DEFINITIONS OF KEY CONCEPTS

For the purpose of this study, the following terms were used as defined below:

Human Immuno-deficiency Virus (HIV): It is a retrovirus that causes AIDS by infecting helper T

cells of the immune system. The most common serotype, HIV-1, is distributed worldwide, while

HIV-2 is primarily confined to West Africa. Also, called AIDS virus, human T-cell leukaemia virus

type III, human T-cell lymphotrophic virus type III, lymphadenopathy-associated virus. Mother-to-

child transmission (MTCT) of HIV-2 is rare. This is a virus which an infected pregnant woman has

and can be transmitted from mother to baby either during pregnancy, delivery or breastfeeding.

Acquired Immune Deficiency Syndrome (AIDS): The late symptomatic stage of the chronic

disease caused by HIV infection which progressively impairs the body’s cell mediated immune

responses to infections and cancers system (Bailliere 2005). In this study, it is regarded as the final

stage of HIV infection among HIV positive pregnant women who suffers gross wasting and

diarrhea.

Prevention: To prevent something means to ensure that it does not happen (Oxford Advanced

Learner’s Dictionary 2005:1149). Transmission: Transmission (transfer) is the act or process of

15
passing something from one person, place or thing to another. It is also transmission of the disease

or risk of transmission (Oxford Advanced Learner’s Dictionary 2005:1573).

Prevention of Mother to Child Transmission (PMTCT): Prevention of mother-to-child

transmission entailed interventions that are available and accessible, provided pregnant women to

prevent/reduce the transmission of HIV to their child. Such interventions include counselling and

testing, infant feeding options, use of ART, safe obstetrics practices and replacements feeding,

aimed at reducing MTCT of HIV.

Influencing: To affect people’s judgment or way they do things.

Utilize (Utilization) –The operational definition of service utilization as it relates to PMTCT

services entails point of entry into the services, where services were given and quality of services

received in terms of HCT, Registering for ANC, accessing ARVs, infant feeding counsel as well as

other follow-up services.

Voluntary Counselling and Testing (VCT): In VCT the importance of HIV counselling and

testing are explained to Clients, but the choice to accept the testing or not depends on the client.

Exclusive breastfeeding refers to when an infant receives only breast milk, and no other liquids or

solids, not even water, with the exception of drops or syrups consisting of vitamins, mineral

supplements or medicines

Antenatal Care– This is a form of care, given to a pregnant woman who registered in a health

facility by a health official to help monitor her wellbeing during pregnancy

PMTCT Coverage - Percentage of pregnant women who were counseled and tested and received

HIV test results

16
HIV counseling - is the confidential dialogue between individuals and their health care providers to

help clients examine their risk of acquiring or transmitting HIV infection and to make informed

decisions based on information available to them. Any person talked to by a trained HCT counsellor

before and after testing for HIV is said to have received HIV counselling and testing. Early

Infant Diagnosis (EID) - seeks to identify HIV-infected children during the first few months of life

in order to begin treatment before a child becomes sick. Health and nutritional monitoring of

children using Rapid diagnostic tests, improves EID. Early Infant Diagnosis test is carried out on an

exposed baby (baby born by a HIV positive woman) after six weeks of delivery using PCR. In

places where the machine is not available, samples are transported to another site using Dried Blood

Spot

Skilled Birth Attendant -The WHO (2004:3) defines a skilled birth attendant (SBA) ’’as an

accredited health professional- such as a midwife, doctor or nurse- who has been educated and

trained to proficiency in the skills needed to manage un-complicated pregnancies, childbirth and the

immediate post natal period and in the identification, management and referral of complications in

women or newborns

CHAPTER TWO: LITERATURE REVIEW

2.0 INTRODUCTION
17
Mother to child transmission or vertical transmission of HIV {MTCT} is the transmission of HIV

from an infected mother to her baby (Abou and Grent Kantu, 2008). MTCT can occur during;

pregnancy, delivery, breastfeeding (Graham Stein 2000). Without intervention, approximately 1 in

4 infants born to women living with HIV will acquire HIV in –utero or during delivery and 1 in 8

will acquire HIV during breastfeeding.

Prevention of mother to child transmission (PMTCT) is a term used to describe a package of

services intended to reduce the risk of MTCT, its objective is to improve HIV-free survival for

infants, it entails initiation of lifelong antiretroviral therapy{ART} for pregnant and breastfeeding

women living with HIV. This approach is referred to as the option B+ APPROACH with nurses and

midwives playing a very important role in its implementation. This approach is recommended in the

WHO (2013) consolidated guidelines on the use of antiretroviral drugs for the treatment and

prevention of HIV infection .If realized and performed effectively, this approach will advance the

goal of an AIDS-free generation

PMTCT programs require women and their infants to receive a cascade of interventions including

uptake of antenatal services and HIV testing during pregnancy, use of ART by pregnant women

living with HIV/AIDS, safe child practices and appropriate infant feeding, uptake of infant HIV

testing and other post natal healthcare services, MTCT rate is less than 1% through perinatal

prevention of MTCT in high income countries (Baxter 2010),( Baumann2009).

2.2 Prevention of mother-to-child transmission (PMTCT) of HIV

Prevention of mother-to-child transmission (PMTCT) programs provide antiretroviral treatment

(ART) to HIV-positive pregnant women to stop their infants from acquiring the virus.

18
  PMTCT services should also continue after an infant has been born – although this remains

a major challenge to programs – with early infant diagnosis at four to six weeks after birth

and ART initiation within the first 12 weeks for HIV-exposed infants.

 PMTCT services, where implemented, are effective. Around 1.6 million new HIV infections

among children have been prevented as a result of these programs since 1995

HIV can be transmitted from an HIV-positive woman to her child during pregnancy, childbirth and

breastfeeding. Mother-to-child transmission (MTCT), which is also referred to as ‘vertical

transmission’, accounts for the vast majority of new infections in children.

Prevention of mother-to-child transmission (PMTCT) programs provide antiretroviral treatment

(ART) to HIV-positive pregnant women to stop their infants from acquiring the virus.

Without treatment, the likelihood of HIV passing from mother-to-child is 15% to 45%. However,

ART and other effective PMTCT interventions can reduce this risk to below 5% [WHO, 2016]

Around 1.6 million new HIV infections among children have been prevented since 1995 due to the

implementation of PMTCT services. Of these, 1.3 million are estimated to have been averted in the

five years, between 2010 and 2015. (UNAIDS, 2016)

Despite this significant progress, in 2015 23% of pregnant women living with HIV did not have

access to ARVs and 150,000 children (400 children a day) became infected with HIV (UNAIDS,

2016)

Effective PMTCT programs require women and their infants to have access to - and to take up - a

cascade of interventions including antenatal services and HIV testing during pregnancy; use of

ART by pregnant women living with HIV; safe childbirth practices and appropriate infant feeding;

uptake of infant HIV testing and other post-natal healthcare services. (Padian et al, 2011)

19
The World Health Organization (WHO) promotes a comprehensive approach to PMTCT programs

which includes:

 preventing new HIV infections among women of childbearing age

 preventing unintended pregnancies among women living with HIV

 preventing HIV transmission from a woman living with HIV to her baby

 Providing appropriate treatment, care and support to mothers living with HIV and their

children and families.(WHO,2010)

2.3 World Health Organization PMTCT guidelines

Guidelines for pregnant and breastfeeding women living with HIV

WHO’s 2013 guidelines recommended that a woman living with HIV only continue on ART after

breastfeeding if it would benefit her own health. (WHO, 2015) However, in September 2015 the

WHO released new guidelines recommending that all pregnant women living with HIV be

immediately provided with lifelong treatment, regardless of CD4 count (which indicates the level of

HIV in the body). This approach is called Option B+ (WHO, 2015)

By 2015, the implementation of Option B+ had resulted in 91% of the 1.1 million women receiving

ARVs as part of PMTCT services being offered lifelong ART (UNAIDS, 2016)

In resource-poor settings, when formula feeding is not a viable option, the WHO advises women

living with HIV to exclusively breastfeed (rather than mixed feeding), providing that they are on

ART. This is because, while formula feeding offers the safest option for postnatal HIV prevention,

in resource poor settings it is not always easy for families to afford formula or access things such as

clean water which are needed for it use(UNAIDS, 2013)

2.4 Global PMTCT targets

20
In 2011, a Global Plan was launched to reduce the number of new HIV infections via mother-to-

child transmission by 90% by 2015 (Aidsportal, 2015)

The WHO identified 22 priority countries, with the top 10 (Angola, Botswana, Burundi, Cameroon,

Chad, Côte d’Ivoire, Democratic Republic of the Congo, Ethiopia, Ghana and India) accounting for

75% of the global PMTCT service need. It was estimated that the effective scaling up of

interventions in these countries would prevent over 250,000 new infections annually (WHO, 2013).

In 2016, UNAIDS with PEPFAR among others launched Start Free, Stay Free, AIDS Free – a

framework calling for a worldwide sprint towards “super fast-track targets” to end AIDS among

children, adolescents and young women by 2020.

Targets relating to PMTCT include reducing the number of new HIV infections among children to

fewer than 40,000 by 2018 and fewer than 20,000 by 2020. There is also a commitment to ensure

that 95% of pregnant women living with HIV are receiving lifelong HIV treatment by

2018(UNAIDS, 2016).

Start Free, Stay Free, AIDS Free takes a ‘lifecycle approach’, which means it considers how

different stages of someone’s life impacts on their vulnerability to HIV(UNAIDS, 2016)

2.5 Cameroon country context

Cameroon’s population of 19.9million faces one of the most severe HIV epidemics in west and

central Africa, with an adult HIV prevalence of 4.3 %(DHS Cameroon, 2011) ).HIV prevalence

amongst adults ages 15-49 ranges from 0.8% in the extreme north region to 5% in the north west

region.(Ministry of public Health Yaoundé, 2010) ) approximately 610000 people currently leave

with HIV and 37000 die of AIDS as of 2009 (UNAIDS, 2009 ).Cameroonian women are

disproportionately affected with an HIV prevalence of 5.6% versus 2.9% for men) ), and the

estimated prevalence amongst pregnant women is high (7.3%),(DHS Cameroon, 2011 ).

21
Approximately 54000 children under 14 years of age are affected by HIV while a staggering 33000

children have lost at least one parent as a result of AIDS (UNAIDS, 2009) in 2009, just 37% of

pregnant women received HIV testing and counseling and only 27% of HIV positive pregnant

women and 255 of HIV exposed infants received antiretroviral (ARV) for prevention of mother to

child transmission (PMTCT) (UNICEF, 2012). There are marked regional disparities in access to

services; the first antenatal care (ANC) attendance rate ranges from 20% in the extreme north to

nearly 645 in adamawa with a national average of 385 in 2010( ).maternal mortality is also on the

rise in Cameroon, with a maternal mortality ratio of 690 per 100000 live births in 2010 compared

with 670 in 1990(WHO et al, 2012)

In 1986 the government of Cameroon responded to the HIV epidemic by creating the National

AIDS Committee to Coordinate a national AIDS program .By 2000, the first 5 year National

Strategic Plan for HIV/AIDS was developed and implemented .although such efforts have led to a

rapid expansion of PMTCT services in urban centers of Cameroon, access to PMTCT services and

ART in rural communities where the majority of the population lives, is still limited. To reach the

national goal of virtual elimination of mother to child transmission by 2015 as targeted in the 2009

-2015 National Strategic Plan and the Cameroon National Plan to Eliminate New HIV Infections in

Children and keep Their Mothers Alive, PMTCT services must be extended to rural communities

and access to more efficacious combinations regiments most be improved.

2.6 PMTCT Care Continuum: Pregnant and Breastfeeding Women

PMTCT services are delivered across a care continuum for pregnant and breastfeeding women in

four steps:

1. HIV Testing: Provider-initiated HIV testing and counseling (PITC) is recommended for all

pregnant and breastfeeding women for early identification of HIV infection. (UNICEF, UNAIDS,

WHO 2010)
22
2. ART: Antiretroviral therapy (ART) is recommended for all pregnant and breastfeeding women

infected with HIV to keep mothers healthy and prevent mother to child transmission (Townsend et

al 2000-2011)

3. Adherence & Retention: Counseling, support, and monitoring services should be provided to

ensure the mother does not miss any doses of antiretroviral medications and returns to the health

facility for regular follow-up care and treatment.

4. Linkage to lifelong care: HIV-infected mothers must be referred from maternal and child

healthcare settings to HIV clinics for lifelong care and treatment, to keep mothers healthy and

prevent mother to child transmission in the future.

A breakage in any step of the PMTCT care continuum will lead to poor prevention of the HIV

virus from an infected mother to her child. The HIV positive pregnant woman’s role in PMTCT is

to adhere to the above guidelines.

2.7 STRUCTURAL AND SOCIO-CULTURAL FACTORS THAT INFLUENCE PMTCT

SERVICES

Home Delivery

Some studies done showed that many women attend antenatal (ANC) and also MCH clinics during

pregnancies but still many deliver at home and so is difficult to ensure that drugs provided were

really taken. Health Bridge (2007) has been analyzing the challenges in the prevention of Mother to

child transmission of HIV in Africa. Its report documented some findings from Cameroon which

showed that the ANC prevalence of HIV was 22% but that of the delivery room was only 8.7%

indicating that a large number of deliveries have been conducted at home with many HIV-positive

women not delivering at the hospital. With home deliveries mothers missed out on their drugs
23
which are supposed to be taken during labor and after delivery, children are brought late or

completely miss the Nevirapine (NVP) prophylaxis syrup, which is recommended 72 hours post-

delivery (Health Bridge, 2007).

A study done in rural Malawi by Kasenga (2007) which investigated the home deliveries and

consequent implications for adherence to Nevirapine in a PMTCT program. The study was

following the women in a PMTCT program till delivery for adherence assessment to NVP

prophylaxis tablets and syrup. The study found that 75 HIV positive women were registered in the

PMTCT programs, 40 women (53%) delivered in the hospital and 35 (47%) did not – 27 (77.2%) of

them were traced to their homes. This study showed that all women who delivered at a hospital had

taken their NVP tablets

And their babies had received NVP syrup – except one baby who died soon after delivery. Of those

who delivered at home and were traced 16 (59.3%) had access to NVP and had taken their tablets

during labour but none of their babies was taken back to health facilities for NVP syrup. Common

reasons for not delivering in a hospital were lack of money (66.6%), distance (45%) and illness

(22.2%).

Koye (2013) conducted a study which investigated predictors of mother to child transmission of

HIV among HIV-exposed infants at a PMTCT Clinic in North West Ethiopia. The study came up

with findings which showed home delivery as one of the predictors for mother to child HIV

transmission. Other factors were absence of maternal PMTCT interventions, mixed infant feeding,

rural residency and late enrolment of exposed infants to a clinic.

Shah, et al (2007) conducted a study in Pakistan. The study investigated the home deliveries,

reasons and adverse outcomes in women presenting to a tertiary care hospital. Findings of the study

showed that 65 % of deliveries were conducted at home. The most frequent reason stated by 57% of

24
women for not delivering in a facility, was the belief that it was not necessary. The next most

common reason stated by 38% of women was that it costs too much.

Involvement of males

Generally, research has highlighted the beneficial impact of male involvement in PMTCT programs

to tackle new infections among infants (Kalembo et al, 2013)

Health Bridge (2007) reported that many health facilities implementing PMTCT programs do not

focus on involving men in these activities. This has led to poor communication between spouses as

far as disclosure of HIV status is concerned. The lack of male involvement in Antenatal Care

(ANC) services and the fact that they do not receive counselling on HIV has been found to be one

of the reasons why men do not comply with protection measures (such as condoms) and many

refuse HIV testing.

Averting HIV and AIDS or Avert (undated) from its report on PMTCT in practice, documented

findings from a study done in Kenya by Irin (2009) who investigated whether men accompanying

their partners had any significant influence on attendance levels. The study showed that when

women are supported and accompanied by their spouses, it improved their clinic attendance levels.

Reports by WHO, UNAIDS & UNICEF (2011) related to HIV/AIDS epidemic updates and the

health sector’s progress towards universal access, show that if couples are attending ANC and

PMTCT services and have been counseled and tested together, there is less potential for blame and

discrimination among themselves.

Another study conducted in Kenya by Aluisio, et al (2011) which investigated if male antenatal

attendance and HIV testing were associated with decreased infant HIV infection and increased

infant survival without HIV infection found that when the man has been involved in the PMTCT

programs the risk of vertical transmission was decreased by 40%.

25
Nuwagaba et al (2007) conducted a study on the challenges faced by health workers in

implementing the Prevention of Mother to Child HIV Transmission (PMTCT) programs in Uganda

and found that women were facing certain difficulties in disclosing their HIV status to their

partners. The study further noted that the finding was due to lack of male partner involvement in

the PMTCT activities. The non-disclosure of the HIV status to the partner created a services

problem in family planning, and also in some instances one partner had started ARV’s without

informing the other. The result of women not disclosing their HIV status to their spouses leads to

loss of follow-up, as they do not wish to be traced to their houses and their community.

Secka (2010) conducted a study in Gambia which investigated male involvement in care and

support during pregnancy and childbirth. The study showed that there are certain reasons why men

don’t escort their partners to a clinic. Some of the reasons were due to men’s job responsibilities,

long waiting times at the clinic, the large age difference between husband and wife – in many

instances old men marry younger girls and then feel ashamed to escort them to the clinic.

Compliances and follow-up

UNICEF (2009), in a briefing paper about scaling up early infant diagnosis and linkages to care and

treatment state, found that compliances to medications and clinic follow-up can prevent/avoid

postpartum HIV transmission and improve the overall infant outcomes. The follow-up of HIV

exposed children is important for early diagnosis of HIV infection and timely enrolling in care and

initiation of ARV’s medications being administered to infected children.

Another important benefit of compliances and PMTCT follow-up is to ensure a referral to

community based psychosocial support and home based care services. Perez et al, (2004)

highlighted this benefit in the report on the implementation of a rural program of prevention of

mother to child transmission of HIV in Zimbabwe at the first 18 months of experience.

26
Braun et al (2011) checked if inadequate coordination of maternal and infant HIV services could

detrimentally affect early infant diagnosis outcomes in Malawi, and Stringer et al (2008)

investigated the monitoring effectiveness of programs to prevent mother to child HIV transmission

in lower income countries. Their study findings showed that failure to comply with ARV’s

medications and prophylaxis as well as follow-up to clinic visits for medication resupply and other

PMTCT and MCH (Maternal and Child Health) services disrupt the interventions in eliminating

pediatric HIV. They explained that this barrier results in eliminating the opportunity to prevent

early HIV transmission during labor and delivery as well as late transmission (through

breastfeeding). Also it disrupts early HIV diagnosis in infants and thus prevents associated

morbidity and mortality.

Also a study done in Nigeria by Rawizza, Meloni, Oyebode et al (2012) on their evaluation of loss

to follow-up within the prevention of mother to child transmission care cascade in a large ART

program, showed that among 19,303 women entering PMTCT care during the antenatal period only

10 078 (52%) completed the entire cascade of services, including prenatal care, delivery and at least

one infant’s follow-up visit. The study showed that the greatest loss in the PMTCT care cascade

occurred before infant follow-up with 31% of women lost to follow-up after receiving delivery care.

Also amongst the mothers who received some antenatal care, infant outcomes were unknown for

45%.

Kalembo & Zgambo (2012) in their study investigated the loss to follow-up and they found it to be

a major challenge to successful implementation of prevention of mother to child Transmission of

HIV-1 programs in sub-Saharan Africa. In this study they also found that the high attrition within

PMTCT programs are likely to be more lost to follow-up (LTFU) than mortality. The cumulative

loss to follow-up in sub-Saharan Africa PMTCT programs are estimated between 20-28% during

antenatal care, up to 70% after four months after delivery and close to 81% at six months after

27
delivery. These findings were also documented in their reports by UNAIDS (2010) and WHO

(2011).

Another study which documented similar findings was done by Painter, et al (2005) – this study

investigated the socio-demographic factors associated with participation by HIV positive pregnant

women in an intervention to prevent mother to child transmission of HIV in Côte d'Ivoir. The study

showed that a large number of patients was lost to follow-up.

Also another study conducted by Badri, et al (2001) which investigated initiating cotrimoxazole

prophylaxis in HIV-infected patients in Africa, showed the importance of compliance to follow-up.

Pregnant mothers who comply with their follow-up appointments also received counselling for

exclusive breastfeeding for 6 months or making use of bottle feeding, provision of prophylaxis, e.g.

cotrimoxazole for mother and her infant(s).

The study which was done in South Africa by Miller, et al (2010) investigated the reasons for loss

of follow-up for antiretroviral patients. Study findings showed that there were certain serious

barriers which put treatment out of reach. Treatment barriers included transportation costs, time

needed for taking of medications and logistical problems. Other less influential barriers were found

to be HIV/AIDS related stigma and medication side effects.

Stigma and Feeding Choices

Health Bridge (2007) analyzed the challenges in the prevention of Mother to child transmission of

HIV in Africa and in its report documented some findings from Malawi. It showed that stigma and

discrimination is still high in the community and many viewed ones with HIV/AIDS as having

received a death sentence. It was pointed out that some women who can afford formula feeding still

decided to continue breastfeeding so as to avoid being stigmatized. As a result the rate of

28
acceptance of formula feed is very low (<30%) amongst women who received PMTCT treatment in

Malawi.

Nuwagaba, et al (2007) in their study which investigated the challenges faced by health workers in

implementing the Prevention of Mother to Child HIV Transmission (PMTCT) programs in Uganda;

found that the major challenge in dealing with the women was advice on breastfeeding. The

researcher noted that it is not only the mother who can decide and choose the mode of infant

feeding but the entire family has to have a say. Due to non-disclosure of HIV status and fear of

stigmatization women tend to breastfeed their children much longer than recommended.

It was also noted from other studies done by Doherty, et al (2006) while investigating the effect of

the HIV epidemic on infant feeding in South Africa, and Sprague, et al (2011) who investigated if

the health system weakness constrained access to PMTCT and maternal HIV services in South

Africa – their findings showed that tins used for formula feeding were associated with stigma. The

interviewed women were hiding their HIV status by stating that their babies did not like breast milk

or they placed formula milk in other containers which were not of their origins

Drug Availability

Rujumba, et al (2012) conducted a study in Eastern Uganda aimed at listening to health workers

and gaining lessons for strengthening the program for the prevention of mother to child

transmission of HIV. They noticed that there was no consistency of drugs supply to the facilities

and hence another challenge for running the PMTCT program had cropped up. As a consequence

some of the study sites reported running out of test kits and nevirapine for mothers and babies.

Other sites even decided to refer the needy mothers to the larger centers and hospitals where drugs

were more readily available. Generally the whole process of going to one clinic and then being

referred to another large center or hospital became very costly for women and their families.

29
Human Resources and PMTCT Data Management

Findings from the study done in Eastern Uganda by Rujumba, et al (2012) – while listening to the

health workers on ways of strengthening the PMTCT program – showed that many health workers

interviewed mentioned the need of more training on PMTCT to update their own knowledge and

skills. The participants emphasized the importance of continuous skill development and up-dating

of health workers on the latest developments and knowledge in PMTCT and HIV/AIDS fields as

vital measures for effectively managing PMTCT programs. The same study indicated the need for

adequate numbers of health workers to minimize the ever expanding heavy load in order to

strengthen the PMTCT program.

The study done in South Africa by Sprague, et al (2011) investigated if health system weakness

constrained access to PMTCT and maternal HIV services. The study findings showed that there was

poor data management in PMTCT programs. Some participating sites where there was no computer

the information was recorded manually, and after comparing the recorded indicators and the actual

tallied figures the result reflected only a portion of PMTCT and ART activity, and generally the

data collected was of poor quality.

The Need for further Research

To summarize, studies presented here found that PMTCT programs face numerous challenges for

successful implementation:

Home delivery was found to be a barrier for PMTCT programs as mothers and new born babies

miss the opportunity to receive medications necessary for prevention of HIV to the new born.

Lack of male involvement in the PMTCT program results in poor support to the pregnant mothers,

as well as development of stigma in the family. Failure to comply with the given clinic

30
appointment date as well as not taking medications as prescribed by health care workers was found

to be another challenge for the programs as pregnant mothers and small children would not be able

to adhere to their medications. Stigma surrounding HIV/AIDS and stigma associated with formula

could lead to mothers not giving formula feed to their babies as they were scared of being branded

as HIV positive. Other places reported experiencing shortages of ARV’s drugs and ended up

referring patients to other clinics, heath canters or hospitals for medications’ refill. Some patients

were not able to reach this destination and subsequently returned home without receiving their

ARV’s medications and hence hindering the PMTCT program. Some health facilities experience

problems with the shortage of health care workers as those who are available have been facing

numerous challenges such as heavy work load, lack of adequate PMTCT training and re-training, as

well as poor handling of PMTCT and antiretroviral medications data.

Based on the evidence presented here, PMTCT programs, if implemented correctly, are an

effective way of reducing vertical HIV transmission. However, the structural and socio-cultural

factors identified here could impede successful roll-out of such programs. As far as could be

ascertained, no specific study has been done in Cameroon to investigate these factors impairing

PMTCT programs and will therefore be investigated in this study

31
 CHAPTER 3: RESEARCH METHODOLOGY

3.1 STUDY DESIGN

This study was a hospital based descriptive cross sectional study.

3.2 STUDY AREA

This study was conducted in the mile 1 Regional Hospital Limbe located in the Limbe 1 subdivision

,a 200 bed hospital and one of the main referral hospital in the south west region of Cameroon .It

was founded in 1940 and is the oldest hospital in Limbe this hospital serves as a reference hospital

to all health facilities in the Limbe health district, the hospital offers units for radiology, surgery,

gynecology and obstetrics, dental surgery, ophalmology, pediatrics, physiotherapy, maternity and

general medicine. What’s your choice of study area?

3.3 STUDY PERIOD

This study was conducted from October 2017 to June 2018 at the Limbe Regional Hospital

3.4 TARGET POPULATION

The study population consisted of nurses working in the ANC, UPEC, PMTCT (option B+ unit)

and maternity of the Limbe mile 1 Regional Hospital and any nurse that has ever worked in the

above mentioned units.

3.4.1. Inclusion criteria;

- All nurses working in the ANC, UPEC, and Maternity

-All nurses that have worked for more than a year in the above mentioned units.

- All nurses who were willing to participate in the study.

32
3.4.2. Exclusion criteria;

- Nurses that have never worked in the ANC, UPEC, maternity

-Nurses that have worked for less than a year

- Nurses who weren’t willing to participate

3.5 SAMPLING METHOD

This study employed a convenient sampling technique, which is a non-probability sampling

technique where subjects are selected because of their convenient accessibility and proximity to the

researcher.

SAMPLE SIZE

The sample size (n) was calculated using the Cochran’s formula

2 2
No = Z PQ/e

Where; n = desired sample size (for a sample size of less than 100)

Z = Standard normal deviation and the required confidence level usually set at 1.96.(gotten from a

Z table)

P = the estimated proportion of the population which has the attribute in question (proportion of

nurses in the limbe mile 1 regional hospital that have had any formal training and experience on

PMTCT). 95% (0.95)

q =1-P

e = is the desired level of precision (i.e. the margin of error)

Thus the sample size will be calculated as follows;

33
n = (1.96)2 × (0.95) × (0.05) / (0.05)2

n = 72.9 therefore 73

Given that the population being studied is small

n= n0/ (1 + (n0 -1)/N))

Here n0 is cochran’s sample size recommendation

N is the population size (60 nurses) and n is the new adjusted sample size

Therefore n = 73/ (1+ (73-1)/60)) = 33

3.6 DATA COLLECTION TOOL

A semi structured questionnaire was used to collect data. The questionnaires were shared to

participants and consent was gotten, the researcher was present to explain any worries from

participants. Pretesting????

METHOD OF DATA COLLECTION

3.7 DATA MANAGEMENT AND ANALYSIS

3.7.1 DATA MANAGEMENT

The data was stored in two different computers and a USB flash drive. The information obtained

by means of the questionnaires were coded into a computer using Microsoft Excel 2013 and back

up done daily.

3.7.2 DATA ANALYSIS

34
Data was analyzed using EPI info version 7.0 .Frequencies and percentages were calculated and

results presented in tables and figures.

3.8 ETHICAL CONSIDERATION

The purpose and nature of this study was explained to the participants. Every participant was

informed that participating in the research was voluntary. Written consent was obtained from all

participants. Confidentiality of both participant and information was observed, the questionnaires

were coded. Ethical clearance was obtained from the South West Regional Delegation of Public

Health.

ADMINISTRTATIVE PROCEDURE???

35
 CHAPTER FOUR

RESULTS

4.1. Demographic data

The table below shows the demographic information of the study participants. out of the 30
participants 26 with 4 males ages ranged from 20-45years, workers years of experience ranged from
1-10years(consider grammar, the grammar is not clear)

Table 4.1: Demographic distribution of Nurses at the Limbe Regional Hospital, 2018.

Characteristic Frequency Percentage

Sex
Male 4 13.33
Female 26 86.67

Age (years)
20-25 7 23.33
26-30 4 13.33
31-35 8 26.68
36-45 11 36.66

Clinical Level
Bsc 7 23.33
MIDWIFE 4 13.33
OTHERS(HND and NA) 9 30.00
SRN 10 33.34

Experience with PMTCT

(years)
1 to 3 11 36.67
4 to 6 11 36.67
7 to 10 8 26.67
36
PMTCT training
Yes 4 13.33
No 26 86.67

Desire more training

Yes 30 100

4.2 Socio-cultural factors and PMTCT outcome

4.2.1. Home delivery

Out of the 30 participants, 27(90%) said yes they received children delivered at home while 3(10%)

don’t receive children born at home

Table 4.2: Distribution of participants

use one digit in numbering table. Eg table 4 and not table 4.2

NORMALLY RECIEVING BABIES? Frequency Percent Cum. Percent

NO 3 10.00 % 10.00 %

YES 27 90.00 % 100.00 %

TOTAL 30 100.00 % 100.00 %

Distribution of participant’s response on reasons for home delivery

Out of 30 participants 13(43.33%) said illiteracy (ignorance) as a cause for home delivery,

7(23.33%) said birth attendance, 7(23.33) said financial reasons while 3(10%) said others (unaware

of EDD, beliefs and culture, failure to attend ANC) .

37
Always relate your comments to the accompanying table or figure to guide your reader

Figure 4.1; distribution of participant’s response on reasons for home delivery

4.2.2. Male involvement

Table 4.3: distribution of participant’s response on whether men are escorting their pregnant

partners during ANC visits

ARE MEN ESCORTING? Frequency Percent Cum. Percent

NO 18 60.00 % 60.00 %

YES 12 40.00 % 100.00 %

TOTAL 30 100.00 % 100.00 %

38
From table 4.3 above Out of 30 participants 18(60%) said no men do not escort their wives, while

12(40%) said yes men escort their wives.

Use one system of comment throughout your work. Either comment above or

below or not both

4.2.3. Compliance to follow up visits

Table 4.4: Distribution of participant’s response on women coming regularly for their appointments

COMING FOR APPOINTMENTS Frequency Percent Cum. Percent

NO 11 36.67 % 36.67 %

YES 19 63.33 % 100.00 %

TOTAL 30 100.00 % 100.00 %

From table 4.4 above, Out of the 30 participants 11(36.67%) said NO mothers on HAART or ARV

do not come regularly for appointments while the other 19(63.33%) say yes the appointments are

respected

Table 4.5: distribution of participant’s response with respect to reasons for not respecting

appointments

IF NOT WHAT ARE THE REASONS? Frequency Percent Cum. Percent

DEPRESSION 5 16.67 % 16.67 %

FORGETTING 4 13.33 % 30.00 %

STIGMA 21 70.00 % 100.00 %

39
TOTAL 30 100.00 % 100.00 %

According to the table 4.5 above, it can be seen that 5(16.67%) said depression as a cause for

mothers not to come for their appointments, 4(13.33%) said forgetting as a reason while

21(70.00%) said stigma as a reason.

4.2.3. Compliance to ARVS

Figure 4.2: Distribution of participants with respect to compliance to ARVS

From figure 4.2 above, out of the 30 participants 21(70%) said YES mothers do take their ARVS as

prescribed while 9(30%) said NO mothers do not take ARVS as prescribed

40
Table 4.6: Distribution of participant’s response with respect to reasons for non-compliance

to ARVS

WHY NOT RECIEVING HAART? Frequency Percent Cum. Percent

DEPRESSION 4 13.33 % 13.33 %

FORGETTING 3 10.00 % 23.33 %

STIGMA 22 73.33 % 96.67 %

ILLITRACY 1 3.33 % 100.00 %

TOTAL 30 100.00 % 100.00 %

From table 4.6 above, Out of the 30 participants the majority 22(73.33%) gave stigma as a reason

why mothers don’t take their medications, 4(13.33%) gave depression as a reason, 3(10%) gave

forgetting as a reason and 1(3.33%) gave illiteracy as a reason.

4.2.4. STIGMA AND FEEDING CHOICES

Table 4.7: Distribution of participant’s response to whether stigma affects mothers not

coming for HIV counseling

DO YOU THINK STIGMA? Frequency Percent Cum. Percent

NO 6 20.00 % 20.00 %

YES 24 80.00 % 100.00 %

TOTAL 30 100.00 % 100.00 %

41
From Table 4.7 above, out of 30 responses 6(20.00%) said NO stigma is disappearing now our

days and HIV patients are not discriminated upon, however the majority 24(80%) said yes stigma is

still a big challenge

Table 4.8: distribution of participant’s response on mother’s reaction to formula feeding

HOW DO PATIENTS
Frequency Percent Cum. Percent
REACT?

ANGRY 1 3.33 % 3.33 %

ACCEPTANCE 1 3.33 % 6.67 %

DEPRESSED 3 10.00 % 16.67 %

DISAPPOINTED 1 3.33 % 20.00 %

NO REACTION 1 3.33 % 23.33 %

ANXIOUS 23 76.67 % 100.00 %

TOTAL 30 100.00 % 100.00 %

From table 4.8: above, most of the participants 23(76.67%) reacted with anxiety, angry 1(3.33%),

acceptance 1(3.33%), depressed 3(10%), disappointed 1(3.33%) and 1(3.33%) said no reaction

Table 4.9: Distribution of participant’s response on ways mothers use to prevent stigma from

formula feeding

FROM YOUR EXP Frequency Percent Cum. Percent

BREASTFEED 1 3.33 % 3.33 %

DO NOT WANT TO BREASTFEED 1 3.33 % 6.67 %

42
DON’T KNOW 1 3.33 % 10.00 %

DOCTORS ADVICE 1 3.33 % 13.33 %

MIX FEEDING 24 80.00 % 93.33 %

CANNOT PRODUCE BREAST MILK 1 3.33 % 96.67 %

TOO BUSY 1 3.33 % 100.00 %

TOTAL 30 100.00 % 100.00 %

From table 4.9 above, Majority of respondent 24(80%) said mothers mix feed in order to prevent

stigma from formula feeding, other participants 1(3.33%) each said mothers breastfeed, some say

they do not like breastfeeding, it’s the doctor’s advice, I cannot produce milk, too busy to

breastfeed and some participants didn’t have a response

Table 4.10: Distribution of participant’s response with respect to availability of adequate

support from the clinic which helps protects patients from the above stigma.

IS THERE ANY AVIALABLE SUPPORT? Frequency Percent Cum. Percent

NO 2 6.67 % 6.67 %

YES 28 93.33 % 100.00 %

TOTAL 30 100.00 % 100.00 %

From table 4.10 above, out of 30 participants 2(6.67%) said NO, while 28(93.33%) said YES

43
4.3. HEALTH WORKERS AND THE FACILITY FACTORS

Table 4.11: Distribution of participant’s response on whether there are more patients than the

health workers can handle

DO YOU BELIEVE THAT THERE ARE MORE Cum.

Frequency Percent
PATIENTS Percent

NO 4 13.33 % 13.33 %

YES 26 86.67 % 100.00 %

100.00
TOTAL 30 100.00 %
%

From table 4.11 above, 26(86.67%) said YES staff-patient ratio is high while 4(13.33%) said NO

44
Figure 4.3: Distribution of participant’s response on ARV availability

The pie chart above shows that all 30 participants agreed that ARVS are always available in the

clinics

5.9. Correlation between demographic characteristics and factors influencing PMTCT

Table 4.12. Correlation between nurses working experience and participants response on if

men are escorting their wives for PMTCT visits

WORKINGEXPERIENCE * MALE INVOLVEMENT

WORKINGEXPERIENCE NO YES TOTAL

1-3 5 5 10

45
4-6 12 7 19

7-10 1 0 1

TOTAL 18 12 30

Chi-square df Probability

1.1623 2 0.5593

An expected value is < 5. Chi-squared may not be a valid

From table 4.12. Above showed that majority of the nurses who said men do not escort their female

partners for clinic visits had 4-6 years of working experience in PMTCT.

Table 4.13. Correlation between working experience and nurse’s response on ARV

compliance by HIV positive mothers

WORKINGEXPERIENCE * ARVs COMPLIANCE

WORKINGEXPERIENCE NO YES TOTAL

1-3 2 8 10

4-6 8 11 19

7-10 1 0 1

TOTAL 11 19 30

Chi-square Df Probability

3.1654 2 0.2054

An expected value is < 5. Chi-squared may not be a valid test

46
From table 4.13. Above, 11 of the nurses with 4-6 years of working experience in PMTCT said

YES HIV positive mothers take their ARVS as prescribed and 8nurses with the same years of

experience in PMTCT said NO mothers do not take ARVs as prescribed.

Table 4.14. Correlation between clinical levels and participants response on reasons for non-

compliance to appointments

CLINICALLEVEL * REASONS FOR NONCOMPLIANCE TO

APPOINTMENTS

CLINICAL
DEPRESSION FORGETTING Stigma TOTAL
LEVEL

BSC 3 0 3 1

MIDWIFE 1 0 3 4

OTHERS(HN 1 1 7 9

47
 D AND

NURSING

AID)

SRN 0 3 7 10

TOTAL 5 4 21 30

Chi-square Df Probability

10.3135 8 0.2437

An expected value is < 5. Chi-squared may not be a valid test.

Out of the 30 participants 7 SRNs and 7 HNDS and NA said stigma was a reason for non-

compliance to appointments, and 3 SRNs said forgetting as a reason

Table 4.15. Correlation between working experience of nurses and reasons for home delivery

WORKINGEXPERIENCE * REASONSFORHOMEDELIVERY

OTHERS(not
TRADITIONAL
knowing
WORKINGEXPERIENCE FINANCIAL ILLITRACY BIRTH TOTAL
EDD, culture
ATTEND
and beliefs)

1-3 4 4 1 1 10

48
4-6 3 8 2 6 19

7-10 0 1 0 0 1

TOTAL 7 13 3 7 30

Chi-square Df Probability

4.3146 6 0.6342

An expected value is < 5. Chi-squared may not be a valid test.

Table 4.14. Above shows that 8 nurses with 4-6years of experience said illiteracy as a cause for

home delivery and 6 nurses with 4-6years of experience said traditional birth attendance as a cause

for home delivery, one nurse with 7-10years of PMTCT experience said illiteracy as a cause for

home delivery

CHAPTER FIVE

DISCUSSION, RECOMMENDATIONS AND CONCLUSION

5.1 DISCUSSION

Home deliveries

The study showed that home deliveries still remain one of the major challenges facing the

successful implementation of PMTCT programs. All participants acknowledged that they still

receive babies who are born at home. Despite sufficient availability of hospitals and clinics a

number of children are still not delivered at the health facilities. Findings from this study about

49
home deliveries correlates with the findings from Uganda documented by Irin (2008). The latter

study showed that home delivery was a huge challenge to PMTCT programs. Despite the majority

of HIV positive pregnant women having access to available PMTCT services, still about 60% to 70

% of pregnant mothers gave birth at their homes hence making implementation of PMTCT

programs impossible as ARV’S prophylaxis medications can’t be administered to prevent vertical

transmission of HIV from mothers to their new-borne.

Also findings from this study shows how home deliveries can impair the PMTCT program

correlates with another study done in Ethiopia by Koye (2013). The latter study showed that home

deliveries are one of the predictors for mother to child transmission of HIV. Other factors which

were mentioned by Koye as predictors for mother to child transmission of HIV but are not amongst

the findings of this study, are village/rural residence, absence of PMTCT intervention regarding the

mother, and infant mixed feeding.

This study found that one of the main reasons for home deliveries is illiteracy and ignorance ,some

women are unaware of their expected date of delivery(EDD) and do not know the importance of

ANC visits during pregnancy .all of these are possible reasons for home delivery .Respondents also

stated that communities are already well accustomed to the traditional way of living and for many,

many years traditional midwives have been conducting deliveries and people have been seeing

mothers and children surviving in a similar to those in the hospitals and clinics. This poses a

challenge in convincing them that there are advantages and safety in hospital delivery and those

communities should avoid home deliveries. Other reasons found for home deliveries in this study

where financial, trust in traditional birth attendants, and other reasons like culture and beliefs

Findings from this study about reasons for home deliveries correlate with other studies done in

Pakistan by Shah, et al (2007). Results of the Pakistan study showed that the main reasons for home

50
deliveries were family tradition, lack of affordability to enter hospital, insufficient time in which to

reach a hospital and inaccessibility to maternity/hospital services.

Kasenga (2007) from his study in Malawi (discussed earlier) found that a lack of money, distance to

the health facility and being ill, constituted the major reasons for home deliveries. Lack of money

and distance to the health facility also correlates with findings of this study.

Involvement of men

Study findings showed that there was no – or minimal – male involvement in the PMTCT program

the majority of the study participants – 18 out of 30(60%) said that the PMTCT program lacked

involvement of males and as a result impaired its implementation.

Possible reasons for the lack of involvement by males may mainly be a lack of knowledge , men

don’t realize the importance of escorting their partners to the clinic and they don’t consider that this

could be beneficial to them. Other reasons for lack of involvement by men includes stigma, fear

cause they may perceive themselves to be at risk of HIV ,the Africans view of pregnancy being a

woman’s affair, clinics/hospitals not being friendly to them during ANC visits, especially the first

one; someone could be obliged to spend more than six hours just waiting for services to be

rendered. Other reasons given for lack of male involvement include; working long distances from

home and being extremely busy at work.

Findings of this study correlates with the UNAIDS (2012) report which showed that when men are

involved in the PMTCT program the outcomes of such a program proves to be more favorable. The

health care workers can counsel, test and talk to the couples together, and they can subsequently

then abide by different ways of protecting their new born from becoming HIV infected.

The findings of this study on the importance of male involvement in the PMTCT program

correlates with the findings of a study done by Aluisio, et al (2011) which showed that infant

51
mortality was reduced by more than 40% compared to when there had been no involvement by

males.

Compliance and follow-up

Compliance in taking HAART or ARV’s prophylaxis and also regularly keeping appointments are

also one of the key measures for prevention of maternal transmission of HIV infection, as well as an

effective PMTCT program. Not all pregnant mothers regularly keep their clinic appointments 11

out of 30 participants said mothers do not keep to appointments and not all take their medications as

prescribed by health care workers. The main reason for poor compliance to follow-up procedures

and taking of medication from this study was stigma, the patients are afraid to be seen going to the

hospital regularly or to be seen taking medications regularly, this stigma is not just from the public

but also from the health workers

Other reasons for non-compliance to follow up and ARVS is depression due to the diseased state

loosing hope and not believing that one can survive the disease or the many side effects the ARVs

have may also cause this depression also forgetting to come for the appointments or forgetting to

take medications given that it’s a lifelong commitment.

These findings correlated with a study on factors influencing adherence to ARVS by Sharada P et al

in 2012 who found that embarrassment about taking medications was a key reason for non-

compliance to ARVS

Stigma and feeding choices

With the increasing knowledge on HIV/AIDS from the internet and other sources the public is well

educated on the use of formula to prevent HIV transmission through breast milk, this causes stigma

amongst HIV positive mothers who have to formula feed to protect their babies

52
Respondents felt that there was much stigma surrounding HIV/AIDS and bottle feeding in the

community. Usually the community had marked mothers who were feeding their babies with bottle

milk stating that they were HIV – this fact would then prompt most mothers not to formula feed

and sometimes even decide to practice mixed feeding 24 0ut of the 30 participants said mixed

feeding was a way to counteract this stigma. Those who are able to continue formula feeding

always try to concoct other reasons for this practice in order for them to hide their HIV status like

saying it was the doctor’s orders to formula feed, they are too busy to breastfeed and other reasons.

The majority of health care workers said that stigma in the community provided a serious hindrance

to HIV counselling and testing. Poor education on the difference and between exclusive

breastfeeding and mixed feeding to counteract this stigma and also confusion over the fact that they

were thought at ANC on the importance of breastfeeding but know are asked to formula feed.

The findings of this study concerning stigma associated with bottle feeding correlates with a study

done by Doherty et al (2006). Findings of this study showed that as a way of preventing stigma

associated with bottle feeding, some mothers decided to move the formula milk and place it in other

containers which were not of its origin.

Drug availability

All the 30 participants in this research indicated that ARV medications are always available in the

health facility, this may be due to staff commitment to regular checking of necessary medications,

as well as proper ordering. . Therefore drug availability isn’t a barrier or a factor to effective

PMTCT services

Human Resources

26(86.67) out of the 30 participants indicated a disproportional relationship between the number of

health care workers and the number of patients who come to seek care at the health facility. The

53
health care workers have been facing heavy workloads due to a high patient load and also because

they are obliged to implement a multiple program at the health facility and hence end up doing

multiple activities.

A reason for this problem may be that one or two staff members are delegated to run the PMTCT

services and also the fact that particular days are delegated for this services, making so much work

to be accumulated on a few staff members within a short period of time though this approach

ensures that there is someone who is very skilled, experienced and comfortable in running the

PMTCT services and is always up to date with the National guidelines and normally receives much

PMTCT training. He/she also acts as a focal person for the program at the facility. This ensures the

smooth running of a program. But the problem here is when the responsible person is not at work;

possibly he/she was on vacation, sick leave, or attending training, or a meeting or could even have

resigned from work. Should this occur there would then be no one at the facility competent and

comfortable enough to run the program and clients could be referred back until the focal person

returns?

Using an approach were all staff members are involved in PMTCT services, there usually is in-

service training where experienced and skilled health care workers teach the others how to run the

PMTCT program. The program will be managed by the entire facility staff and at any time all staff

members are able to render service to needy patients even if they don’t have the extensive

knowledge of a focal person. They are, however, afforded the chance of learning, asking and

delivering services to patients.

A study done by Rujumba et al (2012) complemented the above findings of this study to the effect

that for proper running of the PMTCT program not only the number of health care workers have to

be adequate to run the services, but also as long as they have been involved in delivering services

they must obtain adequate training in order to update their knowledge and skills

54
Available support from the clinic and health facilities.

28(93.33%) of the participants said there is a support system to help the patient counteract stigma

by rendering support to patients and helping them overcome various PMTCT barriers. Clinics and

health facilities in totality are providing health education, linking patients with other support

groups, promoting couple counselling and follow-up, conducting outreach services and tracing

defaulters.

Though 2 out of the 30 participants indicated a lack of this support system this may be due to the

absence of the necessary services and supports at the health facility; for instance they may not have

a program for tracing defaulters and no program which links patients to the support groups.

There is a need for health facilities to ensure that they implement and provide the adequate

supports to their clients. In doing so they will play a major part in trying to minimize PMTCT

barriers associated with socio-cultural factors.

CORRELATION BETWEEN DEMOGRAPHIC CHARACTERISTICS AND FACTORS

INFLUENCING PMTCT

Associating participants years of experience in PMTCT and if men escort their female partners

for PMTCT visits, the researcher found that majority of participants who said men do not escort

their wives for PMTCT visits had 4-6years of working experience. This may be due to the fact that

they have more experience and have seen many more cases than those with 1-3years of experience.

Though we expected the nurses with 7-10 years of working experience to have witnessed more

couples coming together for visits this wasn’t the case, this could be because these nurses worked

more in urban areas where men were too busy to escort their wives for clinic visits.

The association between working experience in PMTCT and if mothers take their ARVs as

prescribed showed that majority(11 out of 30) of the respondents with 4-6years of experience said

55
mothers do receive their ARVs as prescribed whereas those with 7-10years of experience thing

otherwise with zero participants in that group saying mothers take ARVs on time.

This may be because the different group of respondents have worked in different environments,

maybe the nurses with 4-6years had that experience in areas where the patients are less exposed to

stigma than, while the nurses with 7-10years of PMTCT experience have worked in areas of high

stigma preventing mothers from coming for medications therefore not taking as prescribed

In associating clinical level of nurses with reasons for non-compliance to PMTCT appointments

we find out that the state registered nurses and the HND and Nursing aids gave stigma as the main

reason for missed appointments, this reason may be due to their constant exposure to the patients

given that they are closest to the patients than the nurse with a BSC. The nurses with a BSC do

agree on stigma too as a reason for non-compliance but also say forgetting was one of the reasons

this may be cause they are better trained on this topic so could identify forgetting as one of their

clients problems .forgetting here may be due to the fact that they are feeling well after haven taken

ARVs so don’t feel the need to visit the clinic, or are too busy with other activities they deem more

important, or even not believing in the treatment

Correlating working experience with home delivery we discover that nurses with 4-6 years of

working experience said illiteracy was one of the major causes of home delivery from their

experience

56
5.2 Conclusion (conclusion comes before recommendations)

5.3 Recommendations

 Findings of this study have shown that PMTCT programs still face some sociocultural

and structural barriers. The common challenges found by this study are stated below:

 Home delivery is one of the barriers to PMTCT programs. Factors associated with

home deliveries are illiteracy and ignorance, financial difficulties, culture and beliefs in

traditional birth attendants, ignorance regarding the expected date of delivery, failure

to attend antenatal care services during pregnancy.

 Lack of male involvement severely hampers the PMTCT program. Reasons for

minimal or no male involvement include lack of knowledge/illiteracy, stigma and fear

of disclosing their HIV status, long waiting hours at the clinics and being at work or

working outside the town.

 Some pregnant mothers and mothers of new borne don’t comply with their clinic

appointment as well as taking of medications as prescribed and as a result introduce

negative consequences to the PMTCT program. Reasons for poor compliance to

follow-up and taking of medications were: lack of knowledge, distance from the clinic,

poverty, illiteracy and stigma associated with HIV/AIDS.

 Stigma associated with HIV/AIDS and stigma towards formula feeding are the other

challenges to PMTCT. Pregnant mothers won’t go to the clinic for HIV counselling

and testing due to fear of stigma. Mothers feared to give their babies the bottle milk

because it has been associated with HIV status – so they fear to be stigmatized. Some

mothers, in order to overcome stigma which is associated with bottle feeding, decided

57
 to come up with a hiding mechanism so that they can bottle feed their babies without

being stigmatized.

 Poor PMTCT and ARV’s data control and monitoring are other structural factors

which were identified by the study and they represent a setback to the PMTCT

program. (not Necessary) remove all the above in red ink. No need to state

challenges again. Just go straight to recommendations

From the above mentioned study findings; in order to improve the PMTCT outcomes and

achieve the target of zero new HIV infections, zero HIV/AIDS related deaths and zero

stigmatization, the researcher wishes to recommend the following to the policy makers and all

stake holders of the PMTCT and HIV/AIDS program;

 Increase awareness of HIV/AIDS and PMTCT programs.

 Health education has to be provided by all key stakeholders and not only the hospital or

health facilities.

 Dissemination of information has to be done at schools, churches, all gatherings, using

media such as TV, radio, newspapers, etc.

 Programs should be multi-sectorial: have to involve not only health care workers but also

committed politicians, village headmen, traditional herbalists and also traditional birth

attendants.

 Clinics have to conduct outreach services to ensure they cover all pregnant mothers and to

ensure that they are all registered for ANC services.

 Clinics have to motivate about male involvement and have to create an environment where

men will feel a clinic is friendly towards them, e.g. creating a space for men and also, if

necessary in order to motivate them, their couple has to be seen first. Men themselves have

to be committed and feel proud to be part of the program.

58
 The most important intervention to motivate involvement of men is through health

education and raising awareness on the importance of escorting their partners to attend ANC

services, for HIV counselling and testing and to follow-up. Cultural belief that it is a sign of

weakness if a man is also attending and escorting his partner to the clinic should be cleared

up.

 Issues concerning HIV and stigma, as well as stigma associated with formula feeding, have

to be cleared up through health education and disclosure. Much information is needed in

order to combat stigma and also to empower people sufficiently to disclose their status to

close family members. This will prevent unnecessary queries, e.g.” why you are using the

bottle milk instead of breast milk in feeding your child?” Disclosure of HIV status will

enable mothers to have full control of their infant feeding options as there will be no need to

seek reasons to hide their HIV status due to bottle feeding.

 Recruitment of adequate staff members to the clinics for running of PMTCT services.

 All nurses have to be trained regarding PMTCT – due to the nature of their work they

usually deal with PMTCT clients on a daily basis.

 For proper data management and for smooth running of the program the sites need to have

at least a computer if full computerization of all consulting rooms at the health facility is not

possible. Also sites need a data clerk who will be responsible for controlling and managing

data; data input, data output and the generating of reports Health facilities have to ensure

that there are no PMTCT medications missing as far as they are available and being

provided by the government. This can be achieved through the proper management and

regular checking and ordering of medications.

(Too many unrealistic recommendations. Base your recommendations

according to your objectives and ensure they are attainable)

59
5.4 Limitations of the study

The use of health care workers may not explain well about various PMTCT barriers which patients

themselves are facing. The study interviewed health care workers on the basis of their experience

and their views about various factors such as PMTCT barriers. The study could produce better

findings if patients themselves (pregnant mothers, mothers of new born or any mother who was

managed by a PMTCT program) could be involved and hear their views about how programs could

be improved, as well as challenges they are facing or those which they faced while on PMTCT

program.

Other limitations????

5.12. CONCLUSION

In conclusion the study has found that both socio-cultural and structural factors play a role as

barriers to the PMTCT program and hence its outcomes.

The study has found that home deliveries are still common practice and as a consequence impair the

PMTCT program. Lack of male involvement is another hindrance faced by the program and men

and the health facility have to find some measures to bring more men on board – as ANC is not just

a women thing. Recruitment of new staff, review of current staff establishment and sending more

health care workers for training and re-training, are important measures for the program as currently

health facilities are facing a s shortage of human resources and heavy patients load.

Health facilities still need a better way of monitoring their data as they rely only on manual data

entries which in most cases are likely to generate data of poor quality. Computerization of sites and

employment of data clerks are needed for a proper data management.

60
some activities which would help to minimize and clear PMTCT barriers have to be implemented,

e.g. health education to clear the myths of stigma and stigma associated with breastfeeding,

encouragement of male involvement and disclosure, as well as the importance of attending early to

ANC services.

Other services such as linking of patients to support groups, defaulter tracing and conducting

outreach activities to cater for patients who live far from the health facilities need to be more

emphasized and strengthened.

Each of your objectives should have a conclusive point

REFERENCES

1) Aluisio, A., Richardson, B.A., Bosire, R., John-Stewart, A., Mbori-Nqacha, D., &

Farquhar, C. (2011). Male antenatal attendance and HIV testing are associated with

decreased infant HIV infection and increased HIV- free survival

2) Avert HIV (undated). Preventing mother to Child Transmission (PMTCT) in practice.

Retrieved from the web on 20/04/2013 from www.avert.org/pmtct-hiv.htm

61
3) Badri, M., Ehrlich, R., Wood, R., & Maartens, G. (2001). “Initiating co-trimoxazole

prophylaxis in HIV-infected patients in Africa: An evaluation of the provisional

WHO/UNAIDS recommendations,” AIDS, vol. 15, no. 9, pp. 1143–1148.

4) Braun, M., Kabue, M.M.,& McCollum, ED. (2011). Inadequate coordination of maternal

and infant HIV services detrimentally affects early infant diagnosis outcomes in Lilongwe,

Malawi. J Acquir Immune Defic Syndr. 56:e122-e128. Abstract

5) De Cock,K.M., Fowler, M.G., Mercier, E., Vincenzi,I., Saba, J., Alnwick, D.J., Rogers, M

., & Shaffer,N. (2000). Prevention of Mother-to-Child HIV Transmission in ResourcePoor

6) Countries: Translating Research into Policy and Practice.

7) Doherty, T., Chopra, M., Nkonki, L., & Jackson, D. (2006). Effect of the HIV epidemic on

infant feeding in South Africa: “when they see me coming with the tins they laugh at me”

Bulletin of the world Health Organization.

8) Farquhar, C. (2004). "Antenatal couple counseling increases uptake of interventions to

prevent HIV-1 transmission", JAIDS 37(5)

9) Health Bridge (2007). Challenges in the prevention of Mother to child transmission of HIV

in Africa.

10) Irin (2012). Humanitarian news and analysis. Kenya: The downside of male involvement in

PMTCT

11) Irin (2008). Humanitarian news and analysis. Uganda: Home births hamper PMTCT

program, Retrieved from the web on 11/01/2014 from

www.Irinnews.org/report/80002/uganda-homebirths-hamper-pmtct-programme

12) Karia, J.M. (2007-8). Factors affecting access and utilization of PMTCT services in Nairobi

province, Kenya. International course in Health Development (ICHD).

62
13) Kalembo, W., & Zgambo, M. (2012). Loss to follow up: A major challenge to successful

implementation of prevention of mother to child Transmission of HIV-1 programs in

subsaharan Africa.

14) Kasenga, F. (2007). Home Deliveries: Implications for adherence to Nevirapine in a

PMTCT programme in rural Malawi.

15) Koye , D.N. (2013). Mother to child transmission of HIV and its predictors among HIV-

exposed infants at a PMTCT Clinic in North West Ethiopia

16) Nuwagaba, H. (2007). Challenges faced by Health Workers in implementing the prevention

of mother to Child HIV Transmission (PMTCT) programs in Uganda.

17) Painter,T.M., Diaby, K.L., & Matia, D. (2005). “Sociodemographic factors associated with

participation by HIV-1-positive pregnant women in an intervention to prevent mother-to-

child transmission of HIV in Côte d'Ivoire,” International Journal of STD and AIDS, vol.

16, no. 3, pp. 237–24

18) Rujumba, J., James, K., Tummine, Thorkild,T., Stella, N., & Harald, K. H. (2012).

Listening to Health workers: Lessons from Eastern Uganda for strengthening the program

for the Prevention of Mother to Child Transmission of HIV.

19) Secka, E. (2010). Men’s involvement in care and support during pregnancy and childbirth:

A qualitative study conducted in Gambia.

20) Sprague, C., Mathew, F., & Black, V. (2011). Health System weakness constrain access to

PMTCT and maternal HIV services in South Africa: A qualitative enquiry.

21) Stringer, E.M., & Chintu, N. (2008). Monitoring effectiveness of programs to prevent

mother-to-child HIV transmission in lower-income countries. Bull World Health Organ.

2008;86:57-62. Abstract

63
22) UNAIDS (2010). Towards universal access of PMTCT; Presentation to Funders Concerned

about AIDS.

23) UNAIDS (2010). Report on the global AIDS Epidemic. Retrieved from the web on

20/04/2013 from http://www.unaids.org/globalreport/global_report.htm.

24) UNICEF (2009). Briefing Paper: “Scaling up early infant diagnosis and linkages to care and

treatment. Retrieved from the web on 20/04/2013 from

http://www.unicef.org/aids/files/EIDWorkingPaperJune02.pdf.

25) WHO (2007). Department of HIV/ AIDS: Prevention of Mother to child Transmission of

HIV (PMTCT); Briefing note.

26) WHO (2011). Prevention of Mother-to-child transmission of HIV-1. Retrieved from the web

on 20/04/2013 from http://www.who.int/HIV-1/topics/mtct/en/nm.

27) WHO/UNAIDS/UNICEF (2011) .Global HIV/AIDS Response: Epidemic update World

Health Organization (WHO) 'Mother-to-child transmission of HIV' [accessed 23 May 2016]

28) .UNAIDS (2016) 'Prevention Gap Report'[pdf]

29) . UNAIDS (2016) ‘Children and HIV fact sheet’[pdf]

30) World Health Organization (2010) 'PMTCT strategic vision 2010-2015: Preventing mother-

to-child transmission of HIV to reach the UNGASS and Millennium Development

Goals'[pdf]

31) . World Health Organization (WHO) (2015) 'Guideline on when to start antiretroviral

therapy and on pre-exposure prophylaxis for HIV'[pdf]

64
32) World Health Organization (WHO) (2015) 'Guideline on when to start antiretroviral therapy

and on pre-exposure prophylaxis for HIV'[pdf]

33) UNAIDS (2016) 'Prevention Gap Report'[pdf]

34) UNAIDS (2013) 'Global Report: UNAIDS Report on the Global AIDS Epidemic 2013'[pdf]

35) UNAIDS (2014) 'The Gap Report'[pdf]

36) UNAIDS (2016) ‘Children and HIV fact sheet’[pdf]

37) . World Health Organization (WHO) (2015) 'Guideline on when to start antiretroviral

therapy and on pre-exposure prophylaxis for HIV'[pdf]

38) World Health Organization (WHO) (2015) 'Guideline on when to start antiretroviral therapy

and on pre-exposure prophylaxis for HIV'[pdf]

39) . aidsportal (2015, 25 June) 'Wide political support for eliminating 90 per cent of new HIV

infections in children is yielding impressive results'

40) . World Health Organization (WHO) (2013) 'Global Report 2013'[pdf]

41) UNAIDS (2016) 'On the Fast-Track to an AIDS-free generation’[pdf]

42) UNAIDS (2016) 'On the Fast-Track to an AIDS-free generation’[pdf]

43) World Health Organization (WHO) (2016, 8 June) 'WHO validates countries’ elimination of

mother-to-child transmission of HIV and syphilis'

44) . World Health Organization (WHO) (2015, 30 June) 'WHO validates elimination of

mother-to-child transmission of HIV and syphilis in Cuba'

45) . The Observer, M.Mugalu (accessed 28/11/2016) 'Unique approach boosts fight against

HIV in newborns'

46) . UNAIDS (2016) 'On the Fast-Track to an AIDS-free generation’[pdf]

47) UNAIDS (2016) 'On the Fast-Track to an AIDS-free generation’[pdf]

48) UNAIDS (2014) 'The Gap Report'[pdf]

49) UNAIDS (2016) 'Prevention Gap Report'[pdf]

65
50) UNAIDS (2016) 'On the Fast-Track to an AIDS-free generation’[pdf]

51) . UNAIDS (2016) 'Prevention Gap Report'[pdf]

52) . UNAIDS (2013) 'Global Report: UNAIDS Report on the Global AIDS Epidemic

2013'[pdf]

53) . Rahangdale, L. et al (2010) 'Stigma as experienced by women accessing prevention of

parent-to-child transmission of HIV services in Karnataka, India' AIDS Care 22(7):836-842'

54) . Kalembo, F.W. (2013) 'Association between Male Partner Involvement and the Uptake of

Prevention of Mother-to Child Transmission of HIV (PMTCT) Interventions in Mwanza

District, Malawi: A Retrospective Cohort Study

55) 'Shah,N., Rohra, D.K., Shams, H., & Khan, N.H. (2007). Home deliveries: reasons and

adverse outcomes in women presenting to a tertiary care hospital. Department of

Gynaecology & Obstetrics, Unit III, Dow Medical College and Civil Hospital, Karachi,

Pakistan.1,3,4]

56) Padian, N.S. et al (2011) 'HIV prevention transformed: the new prevention research agenda'

Lancet 378(9787):269-278

57) Townsend CL, Byrne L, Cortina-Borja M, Thorne C, de Ruiter A, Lyall H, et al. Earlier

initiation of ART and further decline in mother to child HIV transmission rates,2000

58) Ekanem Okwi, (2014). MTCT; assessing the factors influencing mother to child

transmission of Abou and Grent Kantu (2008) “Counting on Mother’s Love: The Global

66
 Politics of Prevention of mother to Child Transmission of HIV in Eastern Africa”. In Hahn

R, Inhorn N. Anthropology and Public Health: bridging differences in Culture and Society.

Oxford University Press page 449

59) HIV/AIDS in Enugu Nigeria.

60) 1 measure DHS, Cameroon: DHS 2011—Preliminary Report, 2011.

http://measuredhs.com/publication-rss-page .cfm , accessed July 15, 2012.

61) ministry of public Heath and national aids Control Committee, Rapport Annuel des

Activités du Programme National de Lutte Contre le SIDA, 2010. 2010, Yaoundé.

62) Joint United Nations program on HIV/AIDS (Unaids), Cameroon epidemiological fact sheet

on HIV and aids, 2009.

63) Measure DHS, Cameroon: DHS 2011—Preliminary Report.

64) Unaids, Cameroon epidemiological factsheet on HIV and aids, 2009. 2009.

www.unaids.org, accessed July 15, 2012.

65) UNICEF, State of the World’s Children 2011—Adolescence: An Age of Opportunity,

February 2011. www.unicef.org/sowc2011/, accessed July 15, 2012.

66) World health organization (Who), Unaids, and UNICEF, Towards Universal Access Report

2010, 2010. http://www.who.int/hiv/pub/2010progressreport/en/, accessed July 15, 2012.

67) Who, UNICEF, United Nations population fund (UNPF), and World Bank, Trends in

Maternal Mortality: 1990 to 2010. WHO, UNICEF, UNFPA and The World Bank

Estimates, http://africa.unfpa.org/public/pid/10773, accessed July 22, 2012.

Do not use numbering in APA reference system. Just arrange in

alphabetical order.

All your in text citations should be found in the reference page and vice versa

67
Do not forget to include your appendices eg questionnaire, consent form,

authorization from school and delegation

68