By Esther Nakkazi
– Uganda –
The number of pregnant women in Uganda accessing Nevirapine, the drug that stops mothers from passing HIV to their newborn babies, is rapidly growing with all districts in the country now offering the service.
Health officials say by the end of last year all 74 districts in the country were offering Prevention of Mother-To-Child HIV Transmission (PMTCT) services at III and IV level Health Centre (HC) facilities, compared to only 50 districts that were offering them in 2005.
Dr. Saul Onyango, national coordinator of PMTCT Ministry of Health, said some districts like Rakai, Tororo, near the Kenyan border, and Jinja, in the east, have achieved about 80 percent coverage where their HC III facilities provide services. The districts have 18, 16 and 14 Health Centre III facilities, respectively.
To improve access to health services at the local level, the government is building these facilities and has so far upgraded 169 Health Centre IV outlets and 180 Health Centre III outlets in the country.
The centers are equipped with wards, operating theaters, staff housing and equipment, improving access to health services where at least 72 percent of the population is within 5 kilometers of a health facility.
Dr. Onyango says in some areas, like Mayuge, in eastern Uganda, that has 4 HC III facilities, and the Kaabong HC III in Pader, located in northern Uganda, the response is remarkable with 100 percentage coverage of the parishes.
Approach change and trend observed
He says at least 60-70 percent of all the pregnant HIV-positive women in Uganda access the PMTCT services, a success he attributes to a change of approach. At least 1.2 million women get pregnant every year and Uganda remains one the countries with the highest rates globally with a fertility rate of 7.1 percent and an annual population growth of 3.3 percent.
Uganda was among the first countries in sub-Saharan Africa to initiate clinical PMTCT programs. The country initiated a pilot program in 2000 and PMTCT was given as a routine service to consenting HIV-positive women at delivery.
“We have changed the approach, educating the women that this is a benefit to them and their children,” said Dr. Onyango. This is a diversion to the earlier approach where PMTCT services were a part of the birth delivery package, given as a routine offer for those who tested HIV positive during prenatal clinic visits.
The change in approach has also meant that the demand for the services has increased substantially. While women appreciate the benefits, the increased demand poses a challenge for the ministry which lacks experienced health workers to administer it.
Health officials say there are two noticeable trends among women who are educated about PMTCT services. The middle class women (educated and working class) do not agree easily to take the HIV test when they are pregnant.
Most of these middle class women want to consult their husbands before testing and if found positive, the decision has to be made by the couple. The women also demand protection of their rights, to both HIV treatments and privacy, said Dr. Onyango.
On the other hand medical workers have observed that the illiterate, rural women accept to be tested and agree to embrace PMTCT services without hesitation. This mostly happens among communities that are ‘assertive’ like Kaabong in the Pader district. Women from these communities are typically the ‘bread winners’ for their families. They care for their children, feed their families and provide shelter while their husbands prove less resourceful by spending more time drinking than providing for their families. While these women have disproportionate responsibilities to care for their families, they enjoy the advantage of making their own decisions, from health care to all manner of important issues.
These women immediately consent to the PMTCT services because the burden of sickness is ultimately theirs. So they agree to be tested fully and if they are positive, agree to take Nevirapine, said Onyango.
These women depend more on their husbands for survival than their educated counterparts, and yet they make this important decision independently. To the medical workers who treat them it seems they do not disclose the HIV test results to their husbands, many of whom are polygamous.
In the past women shied away from determining their HIV status for fear of losing their husbands. And although more women are agreeing to be tested when they are pregnant, many fear the outcome. Not wanting to be the first partner to know their HIV status, some choose to avoid testing altogether.
HIV positive mothers receive a single dose of Neverapine at the onset of labor. A single dose of syrup is given to the baby within 72 hours of delivery.
But Elizabeth Madraa, the AIDS control country programme manager says there is still a lot to be done. Only 20 percent of babies delivered nationwide are birthed in a health facility.
“We get 90 percent of women coming to the hospitals when they are pregnant, but 40 percent of these come for delivery. Mothers who deliver under normal circumstances often leave immediately,” says Madraa.
Uganda has one of the highest maternal mortality rates at 505 to 1,000 and child mortality rate of about 140 per 1,000. Although the country has tried to achieve the HIV/AIDS Millenium Development Goals, it is still lagging behind in maternal and child mortality achievement.
Medical officials say at least 6.5 percent of the 200,000 children born in health centers everyday are HIV-positive. And it is only after 6-10 weeks that children who aren’t born in health centers get tested, and even this is done when parents have brought the babies for immunization and have no choice but to accept to be tested.
Health officials say challenges to the PMTCT programme are still enormous; greatest among them is the lack of trained health workers to run the programme in the different centers now that there is nationwide coverage.
Dr. Addy Kekitiinwa, executive director at Mulago PIDC children’s ward, said women do not agree to breast feed, even if they are advised that exclusive breast feeding is the only chance of keeping their babies’ HIV negative status constant.
The country cannot afford free formulas for the babies born to HIV mothers, although it is true that formula feeding reduces transmission from breastfeeding by a third.
“The challenge is that once you tell them that they are HIV positive they refuse to breast feed saying they will infect their babies. But at least 95 percent can not afford replacement feeding so they have to breastfeed,” she said. Health officials also complained of the low male involvement in the PMTCT programme.