Retention in HIV care and associated factors among young breastfeeding mothers on lifelong antiretroviral therapy in Soroti District, a mixed methods study

doi:10.21203/rs.3.rs-3942852/v1

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Research Article

Retention in HIV care and associated factors among young breastfeeding mothers on lifelong antiretroviral therapy in Soroti District, a mixed methods study

https://doi.org/10.21203/rs.3.rs-3942852/v1

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Introduction: Young women aged 15-24 years living with Human Immunodeficiency Virus (HIV) are less likely to receive the full package of prevention of mother-to-child transmission (PMTCT) interventions compared to older women. While option B-plus policy has led to a reduction in mother-to-child transmission (MTCT) of HIV infections, a sizable proportion of exposed infants (14%) still get HIV infection from their mothers. We aimed to determine the level of retention in HIV care, its barriers, facilitators and associated factors among breastfeeding young mothers on lifelong ART in Soroti district, Uganda.

Methods: We used an explanatory sequential mixed-methods study design to recruit young women from three study sites including Soroti Regional Referral Hospital, TASO-Soroti and Uganda Cares-Soroti, all in Soroti district. In the quantitative study, we selected a cohort of 249 breastfeeding young mothers aged 15-24 years that attended the ART clinics at study health facilities between 1^st January 2017 and 31^st December 2021 using a systematic random sampling of the health records. The main outcome was retention in HIV care measured at each of the Elimination of mother to child transmission of HIV visits in the post-partum phase as recommended by the Ministry of Health. Retention in care was measured as a binary outcome at 6 weeks, 10 weeks, 14 weeks, 5 months, 6 months, 9 months, 12 months, 15 months and 18 months after child birth. The factors associated with retention in HIV care were assessed using a multi-level mixed effects logistic regression in STATA version 14.0. 18 breastfeeding young mothers who were enrolled in PMCTC care between 1^st January 2020 and 31^st December 2021 were invited by phone call to participate in in-depth interviews to explore barriers and facilitators to retention in HIV care. Interviews were conducted between 19^th August and 15^th September 2022 at the respective study sites. Inductive thematic analysis approach was used to analyze qualitative data.

Results; The median age of mothers was 22 years. Majority were married (79.9%), had a treatment supporter and had disclosed their HIV status (88.3%). Retention in care was highest at 6 weeks (83.5%; 95%CI: 78.4-87.7) lowest at 15 months (23.3%; 95%CI: 18.4-29.0) and was (72.7%; 95%CI: 66.8-77.9) at 18 months. Having timely infant PCR done at 6 weeks was associated with retention, OR=0.27(95%CI; 0.15-0.50). The motivators to retention in care were mothers’ attitude towards ART, having disclosed HIV status, support from the health facility, desire to stay alive, friendly health workers and the need to be able to care for their children. The major barrier to retention was transport costs.

Conclusion; Retention among young mothers is below the Ministry of Health (MOH) target of 90%. Interventions specifically targeted at enhancing financial independence among the young mothers are required so as to try and improve retention in care in an effort to meet MOH targets and eventually eradicate HIV in Uganda.

Adolescents

Mothers

HIV

Retention

In 2020, there were approximately 260,000 new HIV infections among adolescent girls and young women globally and 83% of these infections occurred in Sub-Saharan Africa (SSA) (1). Adolescent girls and young women (AGYW) aged 15 to 24 years from Sub-Saharan Africa accounted for 25% of these new infections despite representing 10% of the population(1). In Uganda, there were 38,000 new HIV infections, and adolescent girls and young women were responsible for 29% of all new HIV infections(2) .

Globally, an estimated 1.4 million HIV-infected women give birth, with almost 33,000 babies becoming infected with HIV annually, and about 91% of these reside in SSA (3). Currently in Uganda, mother-to-child transmission (MTCT) accounts for 14% of all new HIV infections (2). Infants born to women living with HIV are at a high risk of acquiring the virus through MTCT any time during pregnancy, childbirth, or while breastfeeding (4).

However, it is possible to reduce MTCT of HIV to less than 5% if HIV-infected women commence antiretroviral therapy (ART) during pregnancy and continue throughout the breastfeeding cycle (5, 6). To this end, the World Health Organization (WHO) in June 2013 recommended the initiation of the Option B-plus strategy. Uganda adopted Option B-plus in 2013 with adherence being a prerequisite for optimum results to be achieved (6).According to PMTCT cascade guidelines, HIV-positive mothers and their infants are required to attend at least 9 visits during the 24 months breastfeeding period for monitoring of maternal and infant health, nutrition, infant development and adherence to medication to reduce the risk of MTCT (7).

Despite the worldwide scale-up, coverage, and benefits associated with PMTCT (Option B-plus) services, retention of mothers in care is still a challenge (8, 9) with 14% of exposed infants getting infected with HIV during breastfeeding, which is still high (4). Adolescents and young mothers are less likely than adults to be tested, access care, and remain in care, and achieve viral suppression (10, 11). This can be attributed to the stigma surrounding adolescent pregnancy and HIV infection, lack of social support, concerns about confidentiality, and negative relationships with health care providers(8). Poor retention in care is one of the leading causes of virologic failure, drug resistance, and MTCT (12).

In Uganda, studies by Kiwanuka et al in Western Uganda, Miller et al in Mbarara district, and Koss et al in Tororo found retention of 87%,73%, and 90% respectively among pregnant and breastfeeding mothers (10, 12, 13). The associated factors included the desire to have HIV free baby, fear of death and opportunistic infections, and support from significant others. However, most of the studies done have included adolescents and young mothers in a broader population of adults yet they have unique challenges. Therefore, this study aimed to determine the level of retention in HIV care, its barriers, facilitators and associated factors among adolescents and young mothers on lifelong ART during the breastfeeding period in Soroti district.

Study design

We used an explanatory sequential mixed methods study design where quantitative data was collected first and then guided the qualitative study. The quantitative study utilized a cohort study design while the qualitative study utilized an exploratory descriptive study design.

Study area and population

This study was carried out at postnatal care clinics at Soroti Regional Referral Hospital, TASO-Soroti and Uganda Cares-Soroti. The study included breastfeeding young mothers aged between 15 to 24 years enrolled on lifelong ART at SRRH, TASO and Uganda cares from 1st January 2017 to 31st Dec 2021and gave informed consent.

Sampling procedure

The sample size for the quantitative aspect of this study was determined using the formula for sample size estimation for proportions in 2 groups that gave N (sample size) = 249 after adjusting for 10% missing data and a design effect of 2.

The records of participants were accessed at the study health facilities. A list of all breastfeeding mothers that fulfilled the eligibility criteria at each of the study sites constituted the sampling frame. Proportionate sampling was used to determine the approximate number of participants to be recruited from each of the three participating health facilities according to availability of patient records. These included 13% from TASO (31 participants), 40% from Uganda cares (100 participants) and 47% from Soroti Regional Referral hospital (118 participants).

Systematic random sampling was used to recruit participants at each site using the available records for the period from 1st January 2017 to 31st December 2021 from each site.

For the in-depth interviews, 18 young mothers who were breastfeeding between 1st January 2020 and 31st December 2021 were purposively sampled from the study health facilities. 9 were among those categorized as having retention and 9 among those categorized as having non-retention.

Data collection

Quantitative data was collected first followed by the qualitative data.

For the quantitative data collection, a standardized abstraction tool was used to record data from participant’s files (including HIV care/ ART cards) at the participating health facilities. Data was collected by two trained research assistants at each site. The data on the abstraction tool was then entered in Epidata using double data entry.

Qualitative data was collected using an interview guide by an experienced qualitative research assistant. The interviews were conducted in either English or Ateso and audio-recorded. The audio records were transcribed on the same day, and later transcripts in Ateso were translated to English.

Variables

Dependent variable

The main outcome was retention in HIV care. A breastfeeding mother was taken to be retained if they had no missed visits more than 14 days from the last scheduled visit date (Font et al., 2020). It was a binary outcome measured at 6 weeks, 10 weeks, 14 weeks, 5 months, 6 months, 9 months, 12 months, 15 months, and 18 months. These time points were synchronized with the child's immunization schedule and recommended attendance following the elimination of mother to child transmission of HIV cascade for breastfeeding mothers and their infants (MOH, 2020).

Independent variables

Data analysis methods.

Quantitative data was analyzed using Stata 14.0. Descriptive statistics for categorical variables were presented in frequency tables while continuous variables were described using means and standard deviations for normally distributed data and median and inter-quartile range for skewed data while adjusting for clustering using the survey methods.

Retention in HIV care was calculated as a proportion of the enrolled young mothers who attended all scheduled visits (greater than 14 days of the scheduled appointment/visit). This was computed at 6 weeks, 10 weeks, 14 weeks, 5 months, 6 months, 12 months, 15 months, and18 months. A logit 95% confidence interval was computed.

We used a multi-level mixed effects logistic regression to determine the factors associated with retention in HIV care. At bivariate analysis, independent variables with a p-value < 0.2 were considered for multivariate analysis.

At multivariate analysis, interaction was assessed by testing parameters for the interaction terms. Backward elimination procedure was used to in model building adjusting for clustering by the site and study subject was done. Confounding was assessed by comparing the crude and adjusted odds ratios. A factor that changed the odds ratio of another independent variable in the multivariate model by a magnitude of 10% or more was considered to be a confounder. A p-value < 0.05 was considered statistically significant in the final model.

For qualitative data, the transcripts were uploaded in open-code version 4.03 software for analysis. Inductive thematic analysis was used to analyze the data. Coding was done by two independent researchers (initials) basing on themes and sub-themes in line with the study objectives using the framework of Andersen and Newman’s Behavioral Model for Healthcare Utilization.

Ethical considerations

Ethical approval was sought from the Makerere University School of Medicine Research and Ethics Committee (SOMREC-2022-379) and TASO Research and Ethics committee. Waiver of consent was sought from SOMREC to allow access to patients' records without individual consent. Administrative clearance was sought from the management of Soroti Regional Referral Hospital, TASO, and Uganda cares. All participant records were handled with confidentiality and privacy.

And additionally for the qualitative study written consent was sought from all participants before the start of the interview and they were informed that their participation was voluntary and they can choose to withdraw from the study at any point and there would be no penalties. Young mothers less than 18 years were considered as emancipated minors according to the Uganda National Council of Science and Technology guidelines.

Table 1
**Socio-demographic characteristics of the 249 study participants from Soroti Regional Referral Hospital (SRRH), TASO-Soroti and Uganda cares-Soroti**.
Variable	Frequency			P-value
	SRRH (n = 118), %	Uganda cares (n = 100), %	TASO (n = 31), %
Median Age (IQR)	22.0(21.0–24.0)	23.0(21.0–24.0)	22.0(20.0–23)	0.182
Mean number of children (SD)	2.1(1.0)	2.2(0.9)	1.6(0.8)	0.048
Median age at ART initiation (IQR)	19.0(18.0–21.0)	19.0(17.0-20.5)	19.0(9.0–21.0)	< 0.001
Marital Status				< 0.001
Single	15(12.7)	10(10.0)	14(45.2)
Married	95(80.5)	87(87.0)	17(54.8)
Divorced	6(5.1)	3(3.0)	0(0.0)
Widowed	2(1.7)	0(0.0)	0(0.0)
Treatment supporter				0.350
Yes	105(89.0)	90(90.0)	25(80.7)
No	13(11.0)	10(10.0)	6(19.3)
Disclosure				0.350
Yes	105(89.0)	90(90.0)	25(80.7)
No	13(11)	10(10.0)	6(19.3)
Distance from H/C				0.001
0-5km	71(60.2)	67(67.0)	13(41.9)
6-10km	30(25.4)	11(11.0)	3(9.7)
11-20km	8(6.8)	11(11.0)	6(19.4)
20-50km	6(5.1)	7(7.0)	8(25.8)
> 50km	3(2.5)	4(4.0)	1(3.2)

Table 2

Baseline clinical characteristics of the 249 participants from SRRH, TASO-Soroti and Uganda cares-Soroti.
Variable	Frequency			P-value
	SRRH(n = 118)	Uganda cares(n = 100)	TASO(n = 31)
Infant HIV status				0.024
Positive	2(1.7)	0(0)	1(3.2)
Negative	116(98.3)	99(99)	28(90.3)
Unknown	0(0)	1	2(6.5)
Mean initial CD4	455.5	528.2	486.1	< 0.001
Viral load at delivery				0.623
Non-suppressed	3(3.1)	1(1.1)	1(3.4)
Suppressed	93(96.9)	86(98.9)	28(96.4)
WHO stage at ART initiation				< 0.001
1	88(74.6)	70(70)	3(9.7)
2	27(22.9)	29(29)	1(90.3)
3	3(2.5)	28	0(0)
WHO stage at delivery				< 0.001
1	90(76.3)	68(68)	4(12.9)
2	28(23.7)	32(32)	27(87.1)
Infant PCR at 6 weeks				0.001
Yes	102(86.4)	88(88)	19(61.3)
No	16(13.6)	12(12)	12(38.7)

Table 3

Retention in care at the different time points for the 249 participants from SRRH, TASO-Soroti and Uganda cares-Soroti
Variable	Frequency(N = 249),%	95%CI
At 6 weeks
Yes	208 (83.5)	78.4–87.7
No	41(16.5)	12.3–21.6
At 10 weeks
Yes	191 (76.7)	71.0-81.6
No	58(23.3)	18.4–29.0
At 14 weeks
Yes	174 (69.9)	63.9–75.3
No	75 (30.1)	24.7–36.1
At 5 months
Yes	139 (55.8)	49.6–61.9
No	110 (44.2)	38.1–50.4
At 6 months
Yes	179 (71.9)	65.9–77.2
No	70 (28.1)	22.8–34.1
At 9 months
Yes	190 (76.3)	70.6–81.2
No	59 (23.7)	18.8–29.4
At 12 months
Yes	125 (50.2)	44.0-56.4
No	124 (49.8)	43.6–56.0
At 15 months
Yes	58 (23.3)	18.4–29.0
No	191 (76.7)	71.0-81.6
At 18 months
Yes	181 (72.7)	66.8–77.9
No	68 (27.3)	22.1–33.2

Table 4

Retention in care by site at the different time points for the 249 participants from SRRH, TASO-Soroti and Uganda cares-Soroti
	SRRH	Uganda Cares	TASO
	n = 118(%)	n = 100(%)	n = 31(%)
At 6 weeks
Yes	102(86.4)	88(88)	18(58.1)
No	16(13.6)	12(12)	13(41.9)
At 10 weeks
Yes	102(86.4)	76(76)	13(41.9)
No	16(13.6)	24(24)	18(58.1)
At 14 weeks
Yes	84(71.2)	72(72)	18(58.1)
No	34(28.8)	28(28)	13(41.9)
At 5 months
Yes	69(58.5)	60(60)	10(32.3)
No	49(41.5)	40(40)	21(67.7)
At 6 months
Yes	99(83.9)	64(64)	16(51.6)
No	19(16.1)	36(36)	15(48.4)
At 9 months
Yes	89(75.4)	78(78)	23(74.2)
No	29(24.6)	22(22)	8(25.8)
At 12 months
Yes	58(49.2)	52(52)	15(48.4)
No	60(50.8)	48(48)	16(51.6)
At 15 months
Yes	32(27.1)	22(22)	4(12.9)
No	86(72.9)	78(78)	27(87.1)
At 18 months
Yes	82(69.5)	83(83)	16(51.6)
No	36(30.5)	17(17)	15(48.4)

Table 5

Bivariate analysis of independent factors associated with retention in care for the 249 participants from Soroti Regional Referral Hospital, TASO and Uganda cares-Soroti.
Variable	Category	cOR, (95%CI)	P-value
Age		1.15 (1.01,1.32)	0.045
CD4 count at initiation		1.00 (1.00,1.00)	0.06
Viral load at delivery	Non suppressed	Ref	Ref
	Suppressed	2.64 (1.50, 4.63)	0.018
Infant PCR at 6 weeks	Yes	Ref	Ref
	No	0.27 (0.15,0.50)	0.011

Table 6

Multivariate analysis of the factors associated with retention in care among the 249 participants from Soroti Regional Referral Hospital, TASO and Uganda cares.
Variable	Category	aOR, (95%CI)	P-value
Infant PCR at 6 weeks	Yes	Ref	Ref
	No	0.27 (0.15, 0.50)	0.011

From Table 8 above, mothers whose infants did not have PCR done at 6 weeks were 0.27 times as likely to be retained in care as those whose infants had PCR done at 6 weeks.

4.3 Qualitative results

Table 7

Characteristics of the 18 participants that were interviewed from Soroti Regional Referral Hospital, TASO and Uganda cares-Soroti
ID	Age	Marital status	Highest level of education	Employment status	Length of stay in care(years)
P01	20	single	diploma	social worker	5
P02	21	single	secondary	peasant	9
P03	24	married	secondary	peasant	4
P04	23	single	secondary	peasant	5
P05	20	married	certificate	lab assistant	3
P06	21	married	diploma	peasant	9
P07	21	married	secondary	peasant	2
P08	22	married	primary	peasant	4
P09	23	married	secondary	teacher	10
P10	24	married	diploma	teacher	2
P11	24	single	certificate	social worker	10
P12	24	married	secondary	peasant	5
P13	21	married	secondary	peasant	3
P14	21	married	primary	peasant	6
P15	22	married	secondary	peasant	2
P16	23	married	certificate	teacher	17
P17	24	married	secondary	peasant	3
P18	20	married	primary	peasant	2

From table 9 above, all participants were above 18 years. Majority were married (77.8%), had at least secondary education (83.3%) and unemployed (72.2%).

Table 8

**a; Predisposing factors associated with retention in care**.
ANBM Characterization	Themes	Sub-themes	Codes
Predisposing factors	Attitude of young mothers towards ART	Knowledge about benefits of retention	husband also become positive and child, stay like people, stay suppressed
		Attitude towards medication	medicine is life, now used to the medicine, would have died without medicine
	Disclosure	support from friends	told a friend of mine, my friends advised me to start medication, my friends is always by my side
		spousal support	husband supports me, husband brings me to facility, husband encourages
		support from family members	my dad counseled me, my father picks my drugs, my sister helps with my son

Table 8

**b: Enabling and Need factors associated with retention in care**.
ANBM Characterization	Themes	Sub-themes	Codes
Enabling factors	Accessibility to health facility	Transport costs	had no transport, borrow money for transport
		Means of transport	transport to facility was difficult, motorcycle was down
		work for transport	do lay work to get transport, taken up by work, no time to come
	Support from health facility	Adequate counseling	counseled properly, counseling until I understood, counseled me again
		Counseling before medication	counseled me and started medication, after counseling I started medication
Need factors	Perceived needs	Desire to stay alive	to live longer, want to live, stay like other people
		Friendly health workers	nurses are happy with me, they serve me well, thank you for loving us, treating us well
		To be able to care for their children	bring up my child, pay my son's school fees, children see me when they grow
	Evaluated needs	intention to remain in care	mark date, remind me of date

Predisposing factors

There were 2 key themes that emerged from the qualitative data that describe predisposing factors to retention in care

Attitude of the young mothers towards ART; most of the young mothers are aware of ART and the benefits of attending ART that informs their retention in care as directed by the clinic as highlighted below;

“My husband is negative and I am positive, if I do not follow the taking of my medication, then my husband will also become positive and my child.” (P5)

“I also want to stay like people; I do not want to fall sick like that. So I have to keep so that I don’t miss because if you miss, you will fall sick then you will not do anything again.” (P11)

Disclosure

Presence of social support; the respondents indicated to have support from spouse, family members or friends they had disclosed to. The support/ help got encouraged and enabled them to stay in care as quoted below;

“Yes, my husband supports me. He gives me money for transport.” (P6)

“My husband brings me to the facility to pick medication; he advises me and encourages me, my parents as well.” (P10)

Enabling factors

The key themes were accessibility of the treatment facility and presence of support from the health facility.

Accessibility of the facility; the major challenge expressed by majority of the young mothers was transport costs that also encompassed difficulty in accessing means for transport especially for the frequent visits that contributed to reduced retention at the different time points as cited below;

“Getting money for transport is the problem. You have to do lay work just. The way of coming to the hospital is very difficult. My husband sometimes he gives you when he has but sometimes not. Like today when I asked, he said he doesn’t have, so I had to look for a way, you have to borrow money for transport to come.” (P14)

“I work in the private sector; last month we were not paid so I did not have transport. Even the motorcycle at home was down, so my husband could not bring me.” (P4)

Presence of support from the treatment facility

Majority of the respondents said they received adequate support especially in the form of ART counseling at initiation and also during consecutive visits that encouraged them to adhere to their visits as cited below;

“I was counseled properly, then after that I started treatment.” (P5)

“I felt like dying, I felt pain, I felt life was over, I felt bad. But since they counseled me and I started medication, I got calm.” (P8)

Need factors

The themes that emerged were the individual’s perceived needs and evaluated needs.

Perceived needs; when asked about their motivation for remaining in care, the following reasons were given

Desire to stay alive as cited below;

“It’s because I want to live a long life and keep my baby and my spouse also from contracting the disease.” (P5)

Friendly health workers; good relationship with the health workers also encouraged the young mothers to always attend their visits as highlighted below;

“The nurses are happy with me. They know me, when I come they just pick my file. If I delay, sometimes I have excess, when they call me, I say am coming.” (P8)

“They are usually friendly and when there are maybe no drugs; they usually get an option for me” (P5)

To be able to care for their children as noted below;

“To maintain my health and to make me strong so that I can bring up my children” (P15)

Evaluated needs; intention to remain in care

Some women responded that they always mark the date of their visit and also some ask their relatives to always remind them of the time to take medication showing their intention to always adhere to care as cited below;

“Before I come, I always check my card to remind me of the date of coming back and I always thank God when I remember I have to mark that date that on such and such a date, I have to go back.” (P1)

Retention in care

The overall retention in care among young breastfeeding mothers on lifelong ART measured at 6 weeks,10 weeks,14 weeks, 5 months, 6 months, 9 months,12 months, 15 months and 18 months was 83.5%, 76.7%, 69.9%,55.8%,71.9%,76.3%,50.2%,23.3% and 72.7% respectively with the lowest retention noted in TASO. This overall retention at 18 months is slightly higher than that reported by a cohort study in Gulu of 410 mother-baby pairs that found retention of 69.5% by 18 months (14). It’s lower than findings from a mixed methods study in 5 health centers in rural western Uganda that reported a retention of 87% (8). The generalized decline in retention with time is similar to that found by a study on 11534 women in Malawi with a cumulative probability of non-retention being 5% and 15% at 6 and 12 months and a retention of 50% at 18 months (9), a nationwide retrospective study in Zimbabwe found an overall retention at 6, 12, 24 and 36 months to be 92.5%, 86.5%, 79.2% and 74.4% (15).

The observed difference in retention between this study and that conducted in rural western Uganda could be due to the difference in the definition of retention. The study in rural western Uganda defined retention as not missing more than 3 consecutive visits while this study defined retention as not attending appointment date within 14 days of the scheduled date which was more stringent. The populations under study could also explain the difference in findings. The outsourcing of antenatal services by TASO could also explain the relatively reduced retention at TASO compared to other sites as studies have shown that integrated care during the antenatal and postpartum period increased retention in HIV care among women aged 18 to 24 years (16). However, there are no similar studies done in Uganda assessing retention in mothers at different time points for comparison with these findings.

A very low retention at 15 months could be explained by the fact that majority of the mothers have HIV negative infants at 9 months and therefore are advised to stop breastfeeding at 12 months and have an infant PCR done 6 weeks after cessation of breastfeeding. This is normally done at around 14 months and therefore by 15 months most mothers don’t see a need to return for a visit especially if they had a refill for 3 months done at 14 months.

However, retention at 18 months is higher than that at 15 months. This could be due to the fact that mothers want their infants’ final HIV test done and then discharged from mother-infant care and return to general clinic.

Despite the sub-optimal retention, the observed HIV transmission rate was low (1.2%) both at 6 weeks and 18 months, which is within the targets for the elimination of mother to child transmission of HIV.

Mothers who didn’t have their infant PCR done at 6 weeks were 0.27 times as likely to be retained in care compared to those who had timely infant PCR done at 6 weeks. These findings are similar to those by a study in Gomba where mothers that didn’t have timely DNA-PCR testing at 6 weeks were more likely not to be retained with an adjusted HR of 4.57(95%CI; 3.15-6.57) (10). This could be explained by the fact that mothers who not adhere to their own care schedules are more likely also to miss those of their infants (14).

Motivators to retention in care among young breastfeeding mothers on lifelong ART at selected sites in Soroti District

Several factors influence retention in HIV care among young breastfeeding mothers in Soroti. Women’s existing attitudes and beliefs about HIV and ART facilitated retention in care. The mentioned benefits for retention in care were improving health and having strength to live a long life. This coupled with the presence of disclosure enabled participants to have support necessary for them to retain in care. These findings are similar to those found by a qualitative study in Nigeria that recruited 24 women to assess factors associated with retention (17). The enabling factors associated with retention were presence of support from the treatment clinic especially in form of ART counseling and the need factors included desire to live, friendly health workers, and being able to care for their children. These findings are similar to those found by a study in Gomba district (10) and those from a mixed methods study in rural western Uganda (8).

Barriers to Retention in care among the young breastfeeding mothers in selected sites in Soroti district.

The major challenges faced by the young mothers were transport costs that affected accessibility to the health facility These findings are also similar to those by the study in Nigeria (17) and the study in Gomba district in Uganda (10).This can be explained by the lack of financial independence as they are mainly dependent on either a spouse or relative and therefore don’t have much control of their ability to make always make it for the scheduled appointments

Limitations of the study

The study was conducted using secondary data and therefore there was a problem of missing data for some variables especially CD4 count at initiation and viral load measurement at 6 months and 18 months which could have affected the findings

Some of the variables we wished to study could not be collected from the available record; that is level of education and income levels as they were not captured.

There was a problem of selection bias most probably due to the use of which did not give an equal chance for everyone to be included in the study.

There could also have been random error due to a small sample size that made it difficult to find significant factors associated with retention in care.

This study showed sub-optimal retention in HIV care which is below the MOH target of 90% (at least 9 out of the 10 recommended visits in the 24 months postpartum) (MOH, 2020) with having timely infant PCR done at 6 weeks as a factor associated in retention in care. The facilitators to retention include attitude of mothers toward ART, disclosure, support from the health facility (inform of counseling), desire to stay alive, friendly health workers and the need to be able to care for their children. The major challenge faced was transport cost and lack of financial independence. These challenges are modifiable to improve retention.

Recommendations

Government through MOH should formulate interventions specifically targeting adolescents and young youths living with HIV to improve retention in HIV care especially in peri-urban areas and hence further continue to reduce transmission rate in an effort to eradicate HIV in Uganda. These interventions should mainly focus on enhancing financial independence among young mothers through creation of income generating activities.

TASO should consider integrating antenatal and immunization services with the general HIV care so as to improve on retention of these young mothers receiving care from their site.

The study was conducted in an urban setting, therefore to enable comparison of findings especially for retention at different time points; it also should be done in a rural setting since the results may not be generalizable.

Funding Declaration: There was no outside funding for the study. The study was self-funded by the first Author Ms. Akello Faith.

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No competing interests reported.

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Retention in HIV care and associated factors among young breastfeeding mothers on lifelong antiretroviral therapy in Soroti District, a mixed methods study

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Abstract

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Introduction

Methods

Study design

Study area and population

Sampling procedure

Data collection

Variables

Ethical considerations

Results

4.3 Qualitative results

Discussion

Conclusion

Declarations

References

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