Background: Kenya has made a commitment to virtually eliminate mother to child
transmission of HIV (MTCT) by 2015. To achieve virtual elimination, the prevention of
MTCT (PMTCT) programs must achieve high coverage and retain HIV-positive women
throughout the PMTCT continuum of care.
Methods: A mixed methods study was conducted in three health facilities in Kenya. To
quantify retention along the PMTCT care continuum, a retrospective chart review was
conducted on HIV positive pregnant or recently-delivered women 18 or older presenting
for antenatal care or delivery between January 2012 and May 2013. The primary
outcome was retention at individual and facility levels through 18 months postpartum.
Logistic regression analysis was performed to determine predictors of retention. Semistructured
in-depth interviews were conducted with HIV positive women and male
partners to understand barriers and facilitators of retention in PMTCT care. A failure
mode and effect analysis was conducted to identify potential failures along the PMTCT
cascade.
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Results: Across the study sites, only 9%, 10% and 16% of the cohort was fully retained.
The retention decreased significantly along the PMTCT cascade from antenatal to the
postnatal phase. Gestational age at first antenatal visit (p= 0.043) and the number of
antenatal visits attended (p=0.036) were identified as significant predictors of nonretention
in PMTCT care. The facilitators of retention included acceptance of HIV
positive status, supportive male partners, disclosure of HIV status to male partners and
family, peer counseling and psychosocial support, and positive experiences with
healthcare providers. Identified barriers were the inverse of the facilitators and were
reinforced by stigma, financial pressure, and stress. The failure modes identified along
the cascade included: missed opportunities for HIV testing and delivery of PMTCT
interventions at antenatal, poor quality of data, loss of infant’s HIV test results, long wait
times, and poor linkage between health facilities.
Conclusion: Retention along the PMTCT continuum of care was low at the study
facilities. The facilitators and barriers of retention comprised an interaction of personal,
societal and structural dynamics operating simultaneously. The results provide the needed
context and important considerations in the improvement of PMTCT implementation
strategies as Kenya transitions to provide lifelong ART.