Barriers and facilitating factors to the uptake of antiretroviral drugs for prevention of mother-to-child transmission of HIV in sub-Saharan Africa: a systematic review

Abstract

Objectives: To investigate and synthesize reasons for low access, initiation and adherence to antiretroviral drugs by mothers and exposed babies for prevention of mother-to-child transmission (PMTCT) of HIV in sub-Saharan Africa.

Methods: A systematic literature review was conducted. Four databases were searched (Medline, Embase, Global Health and Web of Science) for studies conducted in sub-Saharan Africa from January 2000 to September 2012. Quantitative and qualitative studies were included that met pre-defined criteria. Antiretroviral (ARV) prophylaxis (maternal/infant) and combination antiretroviral therapy (ART) usage/registration at HIV care and treatment during pregnancy were included as outcomes.

Results: Of 574 references identified, 40 met the inclusion criteria. Four references were added after searching reference lists of included articles. Twenty studies were quantitative, 16 were qualitative and eight were mixed methods. Forty-one studies were conducted in Southern and East Africa, two in West Africa, none in Central Africa and one was multi-regional. The majority (n=25) were conducted before combination ART for PMTCT was emphasized in 2006. At the individual-level, poor knowledge of HIV/ART/vertical transmission, lower maternal educational level and psychological issues following HIV diagnosis were the key barriers identified. Stigma and fear of status disclosure to partners, family or community members (community-level factors) were the most frequently cited barriers overall and across time. The extent of partner/community support was another major factor impeding or facilitating the uptake of PMTCT ARVs, while cultural traditions including preferences for traditional healers and birth attendants were also common. Key health-systems issues included poor staff-client interactions, staff shortages, service accessibility and non-facility deliveries.

Conclusions: Long-standing health-systems issues (such as staffing and service accessibility) and community-level factors (particularly stigma, fear of disclosure and lack of partner support) have not changed over time and continue to plague PMTCT programmes more than 10 years after their introduction. The potential of PMTCT programmes to virtually eliminate vertical transmission of HIV will remain elusive unless these barriers are tackled. The prominence of community-level factors in this review points to the importance of community-driven approaches to improve uptake of PMTCT interventions, although packages of solutions addressing barriers at different levels will be important.

Keywords: Africa; HIV; barriers; prevention; review; vertical transmission.

Figure 1

Scope of this review in relation to the PMTCT continuum of care for HIV-positive women and their infants. The narrowing of boxes reflects the attrition in terms of numbers of women and infants through the steps. In different service delivery models, cART or ARV prophylaxis may be received either at the ANC or HIV clinic. ANC=antenatal clinic; ARV=antiretroviral; cART=combination antiretroviral therapy for own health.

Figure 2

Flow diagram of systematic search results.

Figure 3

Factors affecting uptake of ARVs for PMTCT identified in the literature review are populated within a hierarchy of individuals (pregnant women or infants), their community and health systems around them, which are in turn part of the wider health-policy environment. A complex interplay of factors from each level ultimately impacts on PMTCT ARV uptake. This hierarchy is adapted from a socio-ecological model [72]. Possible interventions and policy recommendations addressing barriers at each level are illustrated to the right-hand side. Some interventions may address more than one barrier within a level, or barriers at multiple levels, and may be packaged together. ART=Antiretroviral therapy; ANC=antenatal clinic; CTC=(HIV) Care and treatment clinic; NVP=nevirapine.