Missed Prevention of Mother-to-Child Transmission of HIV (PMTCT) Visits and Associated Programmatic Predictors: A Pilot Study

Missed Prevention of Mother-to-Child Transmission of HIV (PMTCT) visits have contributed to the delayed achievement of elimination of mother-to-child transmission of HIV. Missed visits promote attrition from prevention of mother-to-child transmission of HIV program and antiretroviral drug resistance. The purpose of the study was to determine the prevalence of missed PMTCT visits and its associated predictors. A descriptive cross sectional survey was carried out at a District Hospital in Goromonzi, Zimbabwe. Fifty-three women completed closed-ended questionnaires pertaining to PMTCT visits and exposure to PMTCT activities. A total of 24.5% missed at least one scheduled PMTCT visit. Statistically significant predictors of not missing a PMTCT visit were satisfaction with family support (β = −0.73, p = 0.029) and level of satisfaction with PMTCT services (β = −0.00076; p = 0.04). The number of days by which scheduled visits were missed were inversely correlated with visit number (β = −2.99, p = 0.04). Enhanced family support and quality improvement to improve patient satisfaction may reduce missed visits. Availing women with a more active role in PMTCT may also reduce the prevalence of missed visits.


Introduction
Prevention of Mother-to-Child Transmission of HIV (PMTCT) is a key strategy in the global AIDS response towards elimination of HIV and AIDS by 2030 [1].
Since the launch of the elimination of mother-to-child transmission of HIV initiative (eMTCT) countries such as Cuba, Armenia, Belarus and Thailand have eliminated mother-to-child transmission of HIV (MTCT) [2] [3]. To achieve elimination breastfeeding, countries need to have MTCT rates 5% or below; non-breastfeeding populations need to sustain MTCT rates of 2% or below [4].
Africa, where the majority of countries are breastfeeding countries, has so far been unable to achieve and maintain an MTCT rate of 5% and below. Zimbabwe has managed to reduce MTCT rate to 6.7%, due to effective PMTCT program.
However, the program is impeded by poor retention rates. A 2012 survey in Zimbabwe found an attrition rate of 43%, along the PMTCT cascade [5]. Attrition in PMTCT is usually due to loss to follow up and death. Both of the two are associated with missed PMTCT appointments.
Countries are aiming to achieve the 90-90-90 targets by 2020. According to the targets, by the year 2020, 90% of people with HIV should know their status and 90% of people diagnosed with HIV infection should be on lifelong antiretroviral therapy. The last 90 in the 90-90-90 strategy aims to have 90% on ART having viral suppression [6]. Missed PMTCT and HIV care visits may stall progress towards elimination of HIV by increasing resistance to antiretroviral medicine and worsening clinical, virologic and immunonologic outcomes. It also increases treatment costs as individuals get managed on relatively expensive second line or third line ARV medicine [7] [8]. About 35% of adults with HIV in Zimbabwe are reported to be on second line ARV drugs.
Many innovative strategies have been used to improve retention in PMTCT, hence reduce the frequency of missed visits. The retention interventions can be health centre based or community-based. In a 2016 systematic review of interventions to improve retention, identified strategies to improve retention in PMTCT included task-shifting to enable nurses to prescribe antiretroviral drugs, integrating PMTCT services in antenatal clinics (ANC), quality improvement at health centres, CD4 testing at health centres, facility-based peer support, encouraging male partner support and using cell phone reminders [9]. Incentives, reinforcement, mobile phone education, laboratory courier for CD4 samples and education of midwives were also proved to improve retention in PMTCT [10].
Despite all these interventions being implemented in most settings, retention remains poor [11]. There is also little documented evidence of missed visits and their correlates in public PMTCT programs, including predictors of missed visits in such settings. More so, the evidence is lacking since the world Health Organization recommended the PMTCT Option B plus and, recently, the test and treat strategy. The purpose of this study was to determine the prevalence of missed PMTCT visits and determine programmatic PMTCT predictors of missed visits. A total of 53 women were selected to participate in the study. The sample size was based on the central limit theorem [12]. The study was then explained, in-

Ethical Considerations
The

Demographic Features
Fifty-three women in PMTCT participated in the study. The age of participants showed a multimodal beta distribution with modal ages of 29, 32 and 33 years (γ = −0.003; SD = 6.7

Current Visit Information
Forty-seven (88.7%) participants the health centre as their usual source of health care and 30 (56.6%) had visited the health centre at least once in the previous year. Only seven (13.2%) spent more than 3 hours coming to the health centre.

Participants' PMTCT Experience at the Site
According to Table 3 which summarizes the participants' PMTCT experience, 39 (73.6%) did not get peer support in PMTCT. Eighteen (34.0%) received community health worker support. Motivation to come for PMTCT visits included cell phone reminders, for 15 (28.3%) participants and cash motivation, for 5 (9.4%). Nobody was referred to another health centre for ARV drugs. While 52 (98.1%) were attended by a female nurse at the PMTCT centre, 27 (50.9%) did not know the nurse by name. Few participants had paid for consultation, medical supplies, laboratory investigations and medication. However, 46 (86.8%) had paid to register their pregnancy at the health centre. Forty-two (79.2%) perceived their health as having improved since they began to take ARV drugs. Ultimately, four (7.5%) had their breastfeeding child having acquired HIV.

Participant Satisfaction
The instrument for participant satisfaction with the PMTCT programme at the hospital yielded a Cronbach's alpha of 0.92. The mean satisfaction score was bimodal with a median of 28 (IQR = 8

Discussion
Findings from this study showed that 24.5% of the women missed a scheduled visit. Satisfaction with the PMTCT programme at the health centre and family support were associated with not missing a PMTCT visit. Not surprisingly, participants who had just been commenced on PMTCT, that is, with few PMTCT visits were more likely to miss a scheduled visit by more days.
In this study 24.5% participants missed the scheduled PMTCT visit. This was a lower figure than in a national survey whereby 43% were lost to follow up by the time of the third drug pick up [5]. However, missing a single PMTCT visit can neither be directly inferred to retention in PMTCT nor to attrition. In this study, peer support and community health worker support were not statistically significant predictors of missed visits. This is not surprising since most community interventions have not been proven to improve retention in PMTCT [13].
For instance, use of community health workers, counselling in the community and HIV disclosure [14] [15]. This may be possible because the interventions tended to give women in PMTCT a passive role in the programme. In this study, participants had not received support: 66% were not members of a PMTCT support group, 73.6% had received no peer support, 90.6% had received no cash  whereby socio-demographics were not predictors of retention in care [18]. A Zimbabwean study also did not find a statistically significant improvement in retention of women after engaging facility-based peer support groups [19]. In the current study, participants may have wanted family acceptance to come for scheduled visits. PMTCT benefits the family, in part, by reducing vertical transmission of HIV to the child. Elsewhere, satisfaction with facility PMTCT services has been shown to improve retention. The coefficient of determination of 11% in the current study implies that there are other predictors responsible for 89% of variance in missed visits.
However, the statistical power in the current study may have been compromised by the small sample size. The study was also done in a single month, which might have produced a selection bias.

Conclusion
Family support and satisfaction with the handling of the PMTCT program may