Socio-Demographic Profiles of Naive HIV Pregnant Women and Retention to the Prevention of Mother-to-Child Transmission (PMTCT) Interventions in the East Region of Cameroon

Background: At enrolment into antenatal care, socio-demographic data of HIV infected pregnant women and lactating mothers are usually collected with little or no analysis done on them. This study was aimed to describe the so-cio-demographic profiles of naive to antiretroviral therapy (ART) HIV-infected pregnant women in the East region of Cameroon and to link this to retention in order to optimize the implementation of the prevention of mother-to-child transmission (PMTCT) interventions. Methods: A descriptive prospective study that lasted from February 2018 until February 2019 in three catchment health facilities in the East region for the recruitment and follow-up of participants who were consented HIV-infected pregnant women naive to ART. Socio-demographic, treatment compliance and adherence data were obtained by healthcare providers who were trained using a standard questionnaire that was conceived, tested and adapted for the study. Data were analyzed using Graph Prism (Graph pad 6.0, San Diego, USA). The Fisher exact and Chi-squared tests were used to establish the associations and independence between different variables at statistical significance level of p < cantly associated with LTFU at p = 0.01, p < 0.0001 and p = 0.0053, respec-tively. For participants who were retained until study endpoint, having secondary level of education or above and a profession other than housewife had a significant association (p = 0.0063), as well as being a Christian. Conclu-sion: Loss to follow-up in PMTCT program was associated with Muslim religion, primary level of education and the housewife occupation.

cantly associated with LTFU at p = 0.01, p < 0.0001 and p = 0.0053, respectively. For participants who were retained until study endpoint, having secondary level of education or above and a profession other than housewife had a significant association (p = 0.0063), as well as being a Christian. Conclusion: Loss to follow-up in PMTCT program was associated with Muslim religion, primary level of education and the housewife occupation.

Keywords
Pregnant Women, Intervention, Profile, Education, Religion

Background
HIV/AIDS has had a tremendous impact on global morbidity and mortality of women of child-bearing age and children below 15 years of age [1] [2]. Several efforts have been undertaken globally by Governments, non-governmental organizations (NGOs) and other sectors in a bit to curb this tendency and meet the UNAIDS objectives 90, 90, 90 by 2020. Howbeit, in 2018, 4.49% (1.7 million) of the estimated 37.9 million people living with HIV globally were children between the ages 0 -14 years [3]. Over 95% of paediatric HIV infections result from mother-to-child transmission (MTCT) which can occur during pregnancy, labour, delivery or during the postpartum from breastfeeding [4]. The rate of MTCT of HIV varies between 20% to 45%, with 15% to 30% transmission risk in utero or at delivery, and 5% to 20% risk through breastfeeding. The overall transmission risk is approaching 30% to 60% in Low-and Middle-Income Countries (LMIC) [5] [6]. The risk of MTCT can be reduced to lesser than 2% by interventions that include antiretroviral (ARV) prophylaxis or treatment given to women during pregnancy and labour and to the infant in the first weeks of life. Other measures include enhanced delivery techniques, and complete avoidance of breastfeeding [5]. Thus, the survival of the mother is a strong predictor of the child's survival [7] [8].
However, irrespective of the great achievements obtained in the diagnosis and ARV coverage worldwide, in Africa, a disturbing pattern of loss-to-follow-up (LTFU) has emerged at each stage of the PMTCT "treatment cascade." A 2004 study in South Africa showed a loss-to-follow-up rate of 85% at 12 months by HIV-exposed infants [ months for studies reporting ≥ 12 months of follow up [12].
All the LTFU cases have been attributed, in most reports, to a failure in the health system, with none, to the HIV+ woman and/or her lifestyle. Considering the fact that at ART initiation or enrolment, socio-demographic data are being collected. This study was aimed at determining the effect of maternal socio-demographic characteristics on their retention in PMTCT interventions in Eastern Cameroon.

Study Site and Population
This study was carried out at the Bertoua (Mokolo 1 Integrated Health Centre and Bertoua Regional Hospital) and Garoua Boulai (Gado Badzere Integrated Health Centre) Health Districts, in the East Region of Cameroon. The population included naive to highly active antiretroviral therapy (HAART) HIV infected pregnant women who accepted to be initiated on HAART, attending antenatal care (ANC) visits and were to deliver at study sites.

Participant Recruitment and Sampling
This was a prospective observational multi-centric cohort study involving all voluntary ART-naive HIV-infected pregnant women from February 2018 to February 2019 who accepted to be placed on ART, attending ANC visits and was to deliver at their respective catchment sites. Sampling was by convenience of occurrence to minimize issues of stigmatization and discrimination. Sample size of this study was obtained using the formula for calculating sample size for descriptive studies, that is, where Z α = 1.96, p (prevalence of HIV in pregnant women in East region of Cameroon) = 5.6%, α (type I error) = 5% and W (confidence interval) = 0.05.
Participants were recruited after submitting signed informed consent forms.
They were assisted to fill structured questionnaires to obtain socio-demographic data, placed on ART and then follow-up until 6 weeks postpartum (See

Statistical Analysis
Data obtained from the questionnaires were entered and managed using Microsoft Excel spreadsheets then, imported to Graph Prism (Graph pad 6.0, San Diego, USA) prior to analyses. All analyses were stratified into "retained in care" or "lost to follow-up (LTFU)". The mean (±standard deviation) for continuous characteristics (such as age) and the frequency of categorical characteristics (such as marital status) were described for the study participants. The Fisher exact and Chi -square tests were used to evaluate associations and statistical significance of the distribution of the outcome among the different variables. Differences were considered significant when p < 0.05.

Study Participant Characteristics
Seventy women were enrolled into the study with characteristics as detailed in

Retention in Care and Factors Associated
The impact of maternal socio-demographic data and retention in care are as described in Table 2. There was 75.71% retention in care. Religion (Muslim),  educational level (less than secondary level) and profession (housewife) were significantly associated to the Loss to follow-up (LTFU) cases, (p = 0.01, p < 0.0001 and p = 0.0053, respectively). For the retained until study endpoint, having an educational level of secondary level and above and a profession other than a housewife had a significant association (p = 0.0063), as well as being a Christian.

Discussion
Results of this study revealed that the most implicated route of transmission is the sexual route as we observed 73.9% participants being married. This is comparable to that obtained in a Kenyan study where 72.9% of their participants were married [13]. Our study participants were significantly housewives (52.2%) by occupation, attended a conventional educational system (85.5%), of at least a secondary level (53.6%) and of the Christian faith (69.6%) for the urban setting (Bertoua Health District). However, it is worth noting that observing an educational level of at least a secondary level at 53.6% is suboptimal for an urban setting and this is further reflected in the occupation of most participants being  [19].
We had a retention rate of 75.71% six months post ART initiation, giving a cumulative proportion of loss to follow-up at 6 months of 24.29%. This is higher than what was found in a Malawi's study, were 17% of women were lost to follow-up six months after ART initiation [11] and that by Mitiku [21]. Irrespective of the rate observed, it is worth noting that the occurrence of LTFU is more and more frequent with an increasing need for concern.
Taking a critical look at maternal sociodemographic characteristics at enrolment into option B+ PMTCT program in a bit to identify determinants to LTFU, we found out that maternal religion (being a Muslim) was significantly associated. Even though no study has associated maternal religion to PMTCT, we believe it is obvious, as the Muslim culture requires the male partner's approval for female's movement around with seeking for care inclusive. We also obtained as a significant associated factor, maternal educational level and occupation.
Having an educational level of less than secondary level and being a housewife were statistically significant to LTFU. Kweyamba et al. (2018) also made the same observation with majority of their participants being either subsistence farmers (56.5%), housewife (15.6%) or causal labourer (8.7%) as compared to professional (10.1%) and business women (9.1%) [21]. The educational level will not only determine the profession and living standards, but will highly affect the communication skills, understanding, interpretation of instructions and treatment compliance.
Our study did not include the clinical aspects and economic strength of our participants. Being a personally financed study, finance and time was a limiting factor to expand the sample size and follow-up time.

Conclusions
For a successful implementation of PMTCT intervention for the virtual elimination of mother-to-child transmission of HIV, maternal socio-demographic data need more consideration. Maternal socio-demographic data associated with LTFU in the option B+ include being a Muslim, with little or no education and being a housewife in addition to those reported by other authors.