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Implementation and Operational Research: Distance From Household to Clinic and Its Association With the Uptake of Prevention of Mother-to-Child HIV Transmission Regimens in Rural Zambia - PubMed

  • ️Thu Jan 01 2015

Implementation and Operational Research: Distance From Household to Clinic and Its Association With the Uptake of Prevention of Mother-to-Child HIV Transmission Regimens in Rural Zambia

Veronica Escamilla et al. J Acquir Immune Defic Syndr. 2015.

Abstract

Background: In rural settings, HIV-infected pregnant women often live significant distances from facilities that provide prevention of mother-to-child transmission (PMTCT) services.

Methods: We offered universal maternal combination antiretroviral regimens in 4 pilot sites in rural Zambia. To evaluate the impact of services, we conducted a household survey in communities surrounding each facility. We collected information about HIV status and antenatal service utilization from women who delivered in the past 2 years. Using household Global Positioning System coordinates collected in the survey, we measured Euclidean (i.e., straight line) distance between individual households and clinics. Multivariable logistic regression and predicted probabilities were used to determine associations between distance and uptake of PMTCT regimens.

Results: From March to December 2011, 390 HIV-infected mothers were surveyed across four communities. Of these, 254 (65%) had household geographical coordinates documented. One hundred sixty-eight women reported use of a PMTCT regimen during pregnancy including 102 who initiated a combination antiretroviral regimen. The probability of PMTCT regimen initiation was the highest within 1.9 km of the facility and gradually declined. Overall, 103 of 145 (71%) who lived within 1.9 km of the facility initiated PMTCT versus 65 of 109 (60%) who lived farther away. For every kilometer increase, the association with PMTCT regimen uptake (adjusted odds ratio: 0.90, 95% confidence interval: 0.82 to 0.99) and combination antiretroviral regimen uptake (adjusted odds ratio: 0.88, 95% confidence interval: 0.80 to 0.97) decreased.

Conclusions: In this rural African setting, uptake of PMTCT regimens was influenced by distance to health facility. Program models that further decentralize care into remote communities are urgently needed.

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Conflict of interest statement

Conflict of interest statement: None declared.

Figures

Figure 1
Figure 1

Kernel density estimates representing the number of HIV-infected women per km2 who initiated PMTCT regimens. Clusters on the map represent all HIV-infected mothers who participated in the survey. The light peach clusters demarcate areas with zero uptake of PMTCT services, while the light and dark orange clusters represent areas where density of PMTCT uptake ranged from 1 to 10 persons per km2. The dark orange clusters represent uptake of combination antiretroviral regimens only, ranging from 1 to 10 persons per km2. Overall, areas with high density estimates of uptake were located near health centers, and declined in rural areas. The highest density estimates of uptake ranged from 10 to 20 per km2 near Kafue Estates Health Centre and Chipapa Rural Health Centre (demarcated by gray circle).

Figure 2
Figure 2

Predicted probabilities of initiating PMTCT estimated from multivariable logistic regression models. The probability of initiating any PMTCT regimen was highest among participants living within 1.9 km of the facility and declined steadily with distance. Wider confidence intervals are observed at greater distances where few participants reported PMTCT. The probability of initiating a combination antiretroviral regimen had a steeper decline as distance increased due to zero uptake among participants living beyond 15 km.

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