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ABSTRACT Adherence to antiretroviral therapy (ART) remains sub-optimal among pregnant and postpartum women with HIV (PPWH) in high HIV prevalence low resource settings with few effective behavioral interventions. A large body of qualitative literature has established general barriers and facilitators to ART adherence in PPWH at various levels (individual, interpersonal, structural). However, research exploring the underlying behavioral mechanisms of ART adherence in PPWH with objectively verified adherence biomarkers is extremely limited. We conducted 24 in-depth interviews with postpartum women in western Kenya who had linked ART drug concentrations obtained from three dried blood spot samples across the peripartum period. Among PPWH with a low drug concentration ( n  = 13) compared to those with continuously high drug concentrations ( n  = 11), distinct themes emerged related to HIV status disclosure, social support, interactions with the health system, and health beliefs. By combining ART biomarkers with patient reported challenges, there is the potential for real-time interventions to support sustained ART adherence among PPWH and improve maternal and infant health outcomes.

When male partners of pregnant women living with HIV do not participate in antenatal care, it decreases the uptake of prevention of mother-to-child transmission interventions, which increases the risk of HIV transmission to newborns. We evaluated the association of male partner involvement and vertical HIV transmission at 6 weeks along 4 constructs: antenatal clinic accompaniment, mother's awareness of partner HIV status, disclosure of mother's HIV status to partner, and couple testing. Thirty-three HIV-exposed infants with positive 6-week polymerase chain reaction (PCR) results were compared with 144 HIV-exposed infants with a negative PCR. Mothers of PCR-negative infants were 14 times more likely to have disclosed their HIV status to their partners (odds ratio [OR] = 14.1 [5.0-39.4]), to be aware of partner HIV status (OR = 0.2 [0.1-0.96]), and to have been accompanied by their male partners to the antenatal clinic (OR = 0.6 [0.5-0.9]). There is a need for male engagement in prevention of mother-to-child transmission programs.

Background: Childbirth at health facilities is an important strategy to reduce maternal morbidity and mortality, improve fetal outcomes, and reduce mother-to-child transmission of HIV. Although access to antenatal care in Kenya is high (>90%), less than half of births occur at health facilities. This analysis aims to assess correlates of facility delivery among recently pregnant HIV-infected women participating in a community-based survey, and to determine whether these correlates were unique when compared to HIV-uninfected women from the same region., Methods: Women residing in the Kenya Medical Research Institute/Centers for Disease Control and Prevention Health and Demographic Surveillance System, and who had delivered an infant in the previous year were visited at home in 2011. Consenting mothers answered a questionnaire assessing demographics, place of delivery, utilization of prevention of mother-to-child HIV transmission (PMTCT) services, and stigma indicators. Known HIV-positive women were purposively oversampled. Chi-square tests of proportions and multivariate logistic regression, stratified by HIV status, were performed to assess correlates of facility delivery., Results: Overall, 101 (46.8%) HIV-infected and 127 (39.9%) HIV-uninfected women delivered at health facilities. Among HIV-infected women, cost (42.8%), distance (18.8%) and fear of harsh treatment (15.2%) were primary disincentives for facility delivery; 2.9% noted fear of HIV testing was a disincentive. HIV-infected women who delivered at facilities had higher education (p = 0.04) and socioeconomic status (p < 0.005), initiated antenatal care (ANC) earlier (4.9 vs. 5.4 months, p = 0.016), were more likely to know partner's HIV status (p = 0.016), report satisfaction with delivery care (p = 0.001) and use antiretrovirals (87.1% vs. 77.4%, p = 0.063) compared to those with non-facility delivery. Stigma indicators were not associated with delivery location. Similar cofactors of facility delivery were noted among uninfected women., Conclusions: Utilization of facility delivery remains low in Kenya and poses a challenge to elimination of infant HIV and reduction of peripartum mortality. Cost, distance, and harsh treatment were cited as barriers and these need to be addressed programmatically. HIV-infected women with lower socioeconomic status and those who present late to ANC should be prioritized for interventions to increase facility delivery. Partner involvement may increase use of maternity services and could be enhanced by couples counseling.

This study aimed to document whether food insecurity was associated with beliefs and attitudes towards exclusive breastfeeding (EBF) among urban Kenyan women. We conducted structured interviews with 75 human immunodeficiency virus (HIV)-affected and 75 HIV-status unknown, low-income women who were either pregnant or with a child ≤24 months and residing in Nakuru, Kenya to generate categorical and open-ended responses on knowledge, attitudes and beliefs towards EBF and food insecurity. We facilitated six focus group discussions (FGD) with HIV-affected and HIV-status unknown mothers (n = 50 women) to assess barriers and facilitators to EBF. Of 148 women with complete interview data, 77% were moderately or severely food insecure (FIS). Women in FIS households had significantly greater odds of believing that breast milk would be insufficient for 6 months [odds ratio (OR), 2.6; 95% confidence interval (95% CI), 1.0, 6.8], that women who EBF for 6 months would experience health or social problems (OR, 2.7; 95% CI, 1.0, 7.3), that women need adequate food to support EBF for 6 months (OR, 2.6; 95% CI, 1.0, 6.7) and that they themselves would be unable to follow a counsellor's advice to EBF for 6 months (OR, 3.2; 95% CI, 1.3, 8.3). Qualitative analysis of interview and FGD transcripts indicated that the maternal experience of hunger contributes to perceived milk insufficiency, anxiety about infant hunger and a perception that access to adequate food is necessary for successful breastfeeding. The lived experience of food insecurity among a sample of low-income, commonly FIS, urban Kenyan women reduces their capacity to implement at least one key recommended infant feeding practices, that of EBF for 6 months., (© 2010 Blackwell Publishing Ltd.)

Pregnant women who fear or experience HIV-related stigma may not get care for their own health or medications to reduce perinatal transmission of HIV. This study examined factors associated with anticipating and experiencing HIV-related stigma among 1777 pregnant women attending antenatal care clinics in rural Kenya. Women were interviewed at baseline, offered HIV testing and care, and a sub-set was re-interviewed at 4-8 weeks postpartum. Women who were older, had less education, whose husbands had other wives, and who perceived community discrimination against people with HIV had significantly greater adjusted odds of anticipating HIV stigma. Over half of the HIV-positive women interviewed postpartum reported having experienced stigma, much of which was self-stigma. Women experiencing minor depression, and those whose family knew of their HIV status had significantly greater adjusted odds of experiencing stigma. Lack of women's empowerment, as well as depression, may be important risk factors for HIV-related stigma and discrimination.

HIV/AIDS stigma is a common thread in the narratives of pregnant women affected by HIV/AIDS globally and may be associated with refusal of HIV testing. We conducted a cross-sectional study of women attending antenatal clinics in Kenya (N = 1525). Women completed an interview with measures of HIV/AIDS stigma and subsequently information on their acceptance of HIV testing was obtained from medical records. Associations of stigma measures with HIV testing refusal were examined using multivariate logistic regression. Rates of anticipated HIV/AIDS stigma were high-32% anticipated break-up of their relationship, and 45% anticipated losing their friends. Women who anticipated male partner stigma were more than twice as likely to refuse HIV testing, after adjusting for other individual-level predictors (OR = 2.10, 95% CI: 1.15-3.85). This study demonstrated quantitatively that anticipations of HIV/AIDS stigma can be barriers to acceptance of HIV testing by pregnant women and highlights the need to develop interventions that address pregnant women's fears of HIV/AIDS stigma and violence from male partners.

Background: The African Medical Research Foundation antiretroviral therapy program at the community health centre in Kibera counsels women to wait with pregnancy until they reach the acceptable level of 350 cells/ml CD4 count and to discuss their pregnancy intentions with their health care providers. A 2007 internal assessment showed that women were becoming pregnant before attaining the 350 cells/ml CD4 count and without consulting health care providers. This qualitative study explored experiences of intentionally becoming pregnant among women receiving highly active antiretroviral therapy (HAART)., Methods: Nine pregnant women, six newly delivered mothers and five women wanting to get pregnant were purposefully selected for in-depth interviews. Content analysis was used to organize and interpret the women's experiences of becoming pregnant., Results: Women's choices for pregnancy could be categorized into one overarching theme 'strive for motherhood' consisting of three sub-themes. A child is thought of as a prerequisite for a fulfilled and happy life. The women accepted that good health was required to bear a pregnancy and thought that feeling well, taking their antiretroviral treatment and eating nutritious food was enough. Consulting health care providers was perceived as interfering with the women's decisions to get pregnant. Becoming pregnant as an HIV-infected woman was, however, complicated by the dilemmas related to disclosing HIV infection and discussing pregnancy intentions with their partners., Conclusions: Motherhood is important to women on antiretroviral treatment. But they seemed to lack understanding of the relationship between a high CD4 cell count and a low chance of transmission of HIV to offspring. Better education about the relationship of perceived good physical health, low CD4 cell count and the risk of mother to child transmission is required. Women want to control the domain of childbearing but need enough information to make healthy choices without risking transmission.

Objective: Malaria is a major cause of morbidity and mortality in tropical and subtropical regions, affecting mostly the impoverished sections of the population. Pregnant women living in malaria-endemic areas are at higher risk of malaria infection with higher density of parasitaemia than non-pregnant women. The aim of this study was to assess factors affecting the uptake of IPT among women attending antenatal clinics at Bondo District Hospital, Western Kenya., Methods: This study was a hospital-based cross-sectional survey among pregnant women attending clinics. Malaria is endemic in Bondo district. Both women from Bondo town (urban) and greater Bondo District (rural) who had been pregnant for at least 35 weeks or had delivered not more than 6 weeks prior to the survey), and had ANC cards were included in the study. The main outcomes were ANC attendance, IPT doses received and client and provider factors., Results: Results showed that women's knowledge on ANC and IPT was high. The uptake of IPT was low among pregnant women with those from urban areas more likely to make more ANC visits and to get more IPT doses than women from the rural areas. ANC attendance was hampered by the fear of being tested for HIV at the clinic. Perceived side effects associated with IPT-SP hindered IPT uptake and were linked to HIV-related symptoms. Negative attitude among health workers towards pregnant women also adversely impacted IPT uptake. Women suggested that IPT drugs be distributed through community health workers instead of the health facility for improved uptake., Conclusions: Retraining of health workers on the administration of IPT, harmonization of health messages, and assessment of alternative community-based IPT distribution channels ought to be urgently considered. More evidence on the influence of HIV pandemic on perceptions and attitudes toward and uptake of other health interventions is urgently needed.

Objectives: To quantify the use of elective Caesarean section (ECS) for prevention of mother-to-child transmission of HIV (PMTCT) at an urban Kenyan maternity hospital, to describe mode of delivery decision making among HIV positive women, and to understand patient knowledge and attitudes regarding ECS for PMTCT., Design: Descriptive cross-sectional study., Setting: Pumwani Maternity Hospital, Nairobi, Kenya., Subjects: Two hundred and fifty postpartum HIV-infected women., Main Outcome Measures: ECS delivery rate, correlates of mode of delivery decisions and ECS for PMTCT knowledge and attitudes, Results: The rate of delivery by ECS for PMTCT was 4.0% (10/250), though 13.6% (34/250) planned this mode of delivery. Patient education regarding ECS for PMTCT was limited, and 64% (160/250) of participants had never heard of ECS. Planning ECS for PMTCT was positively correlated with attending clinic at PMH (OR=9.12, 95% CI: 2.94-28.28, p<0.001), knowledge of ECS (OR=27.22, 95% CI: 5.04-148.20, p<0.001) and having a history of abdominal surgery (OR=30.96, 95% CI: 6.32-205.02, p<0.001). Delivering by ECS was associated with planning this mode of delivery (OR=19.52, 95% CI: 3.69-103.23, p<0.001). Planning but not delivering by ECS was mostly due to labour before scheduled ECS (55.6%, 15/27) or poor patient understanding of the intervention (29.6%,8/27). After education on ECS for PMTCT, 48.0% (120/250) of participants would consider elective Caesarean section if offered, though cost represented a significant barrier to acceptability., Conclusions: Knowledge and utilisation of ECS for PMTCT are limited and varied in this patient population. ECS may be an acceptable mode of delivery for some Kenyan women, especially if the burden of cost is removed. A clear policy on ECS counselling and utilisation is urgently needed to ensure consistent and appropriate use of this PMTCT intervention in Kenya.

Objectives: To evaluate risk factors for treatment denial and loss to follow-up in an antiretroviral treatment (ART) cohort in a rural African setting in western Kenya., Method: Sociodemographic and clinical data of patients enrolled in an ART cohort were collected within 18 months of an observational longitudinal study and analysed by logistic and Cox regression models., Results: Of 159 patients with treatment indication 35 (22%) never started ART. Pregnancy [adjusted odds ratio (AOR) 3.60, 95% confidence interval (CI) 1.10-11.8; P = 0.035] and lower level of education (AOR 3.80, 95% CI 1.14-12.7; P = 0.03) were independently associated with treatment denial. The incidence of total loss of patients under therapy was 43.2 per 100 person years (pys) (mortality rate 19.2 per 100 pys plus drop out rate 24 per 100 pys). Older age [adjusted hazard ratio (AHR) 1.06, 95% CI 1.01-1.12; P = 0.04], AIDS before starting treatment (AHR 5.83, 95% CI 1.15-29.5; P = 0.03) and incomplete adherence to treatment (AHR 1.05, 95% CI 1.03-1.07; P < 0.001) were independent risk factors for death. Incomplete adherence also independently predicted drop out because of other reasons (AHR 1.06, 95% CI 1.04-1.09; P < 0.001)., Conclusion: Pregnancy and lower level of education, higher age, advanced AIDS stage and impaired compliance to ART were identified as risk factors for treatment denial and death, respectively. Adequate counselling strategies for patients with these characteristics could help to improve adherence and outcome of treatment programmes in resource-limited settings.

Chloroquine prophylaxis for malaria was available free of charge to pregnant women in Saradidi, Kenya. The drug was supplied by village health helpers (VHH's). However, only 29.1% of 357 pregnant women seen in antenatal clinics from 1983 to 1984 were on chemoprophylaxis. One hundred and seven pregnant women not using antimalarial chemoprophylaxis from 22 villages were interviewed in June 1984 to determine the reasons. Age (mean 26.9 years), parity (mean 4.5 children), occupation (96.3% subsistence farmers and housewives) and education (median five to seven years) of the 107 respondents were similar to other women in the area. Previous pregnancies had occurred in 92 women; for 15 this was the first pregnancy. The last pregnancy had resulted in a live birth for 81 (88.0%), a stillbirth for nine (9.8%) and a miscarriage for two (2.2%); 21 (22.8%) of the 92 had experienced a miscarriage or stillbirth at some time (15 once, five twice and one woman four times). Malaria was the most frequent mentioned (28.6% of 21 women) cause of the last stillbirth or abortion. The major reason for not taking chemoprophylaxis was lack of awareness that the service was available (53.3% of 107 women). Other reasons were fear of chloroquine-induced itching (10.3%), the VHH had no drug (8.4%), the VHH had not advised her to take drug (8.4%), the woman was 'not sick' (7.5%), the woman was 'lazy' (6.5%), she had not been advised by clinic so was afraid to mix medicines (3.7%) and chloroquine was 'bad for pregnancy' (1.9%).(ABSTRACT TRUNCATED AT 250 WORDS)