1.Introduction

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The 2011 United Nations’ political declaration on HIV/AIDS pledged to end the AIDS epidemic, based on 10 targets by 2015. Prevention of mother-to-child transmission of HIV (PMTCT) targets include eliminating new infections among children and substantially reducing the number of women dying from AIDS-related causes and to provide anti-retrovirals (ARVs) to 15 million people [1]. Global coverage of ARVs for PMTCT increased from 57% in 2011 to 63% in 2012. The number of newly HIV-infected children in 2012 was 260 000 in low and middle income counties, showing a 52% decline since 2001. Reportedly, PMTCT services prevented more than 670 000 children from becoming infected with HIV from 2009 to 2012. Nevertheless, in Ethiopia fewer than 50% of HIV-positive pregnant women reportedly used PMTCT services in 2012 [2].

The strategy to eliminate new infections among children comprises [3]: primary prevention of HIV infections, family planning, antiretroviral therapy (ART), as well as care, treatment and regular medical check-ups [4]. This global plan strives to eliminate new HIV infections among children and improve the health of mothers by 2015. In order to accomplish this ideal, new HIV infections among children should be reduced by 90%, the number of women dying from HIV-associated conditions during pregnancy, delivery and postpartum should decrease by 50% and mother-to-child transmission (MTCT) of HIV should be less than 5%. In 2010, 35% of pregnant women in low and middle income countries used voluntary counselling and testing (VCT) services compared to 26% in 2009. In Sub-Saharan Africa (SSA) this coverage increased from 35% to 42%. During 2010 the coverage of PMTCT regimens was 48%. Of the estimated 1.49 million infants born to HIV-infected mothers globally, 42% received ARVs [4].

The HIV prevalence in Ethiopia is 1.5% among adults aged 15-49, 1.0% among men 1.9% among women, but in Addis Ababa it is 5.2%, 4.3% among men and 6.0% among women. The HIV prevalence among antenatal care (ANC) clinic attendees during the preceding three years in the public sector was 1.7% while it was 3.1% outside the public sector [5]. The Federal Ministry of Health (FMoH) of Ethiopia indicated that the number of PMTCT-providing health facilities increased from 32 in 2004 to 1 352 in 2010 and to 1 445 by the end of June 2011. However, in 2011 only 24% of HIV-positive pregnant women used PMTCT services, indicating possible missed opportunities to reduce the impact of HIV/AIDS in Ethiopia [6].

The study aimed to identify factors, reported in published research reports, that influence Ethiopian women’s utilization of PMTCT services.

2.Materials and Methods

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A systematic review was done of reports addressing PMTCT-related issues in Ethiopia. Different themes were selected namely: clients’ satisfaction levels with PMTCT services, voluntary counseling and testing (VCT), infant feeding practices and using ARVs for PMTCT.

A study was included in the literature review when it targeted pregnant women and/or HIV exposed infants; identified barriers affecting the utilization of PMTCT services, evaluated PMTCT services and/or outcomes; and was conducted in Ethiopia.

Information sources included the United States National Library of Medicine Gateway System (PubMed), Google Scholar, the World Health Organization (WHO) and UNAIDS websites to identify studies conducted from 2009 to 2014.

Relevant research reports were grouped according to:

• studies undertaken on factors affecting PMTCT service utilization
• client satisfaction levels with PMTCT services
• studies done on VCT
• infant feeding practices for PMTCT and
• ARVs used for PMTCT.

3.Results and Discussion

3.1.Factors affecting PMTCT service utilization

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A study in the Oromia region of Ethiopia showed that challenges of the PMTCT program included human resource limitations, inadequate coordination between regional and local health services concerning new policies and guidelines, irregular supplies of laboratory test kits and ARVs [7, 19]. A study conducted in the Arba Minch area of Ethiopia [19], reported that out of 74 HIV-positive pregnant women, only 7% gave birth to their babies at health care institutions. HIV stigma prevented HIV-positive women from using health facilities so as not to disclose their HIV status to others. Health care providers were not keen to assist HIV-positive women during the births of their babies. Health facilities’ inadequate monitoring and referral structures and inadequate ARV supplies, cost of accessing the services and poverty prevented some pregnant women from utilizing PMTCT services.

In the Tigray region of Ethiopia [9], researchers found that mothers, whose babies were born at health facilities, were 14 times more likely and their babies were seven times more likely to use PMTCT services compared to those mothers whose babies were born at home. Mothers from urban areas were more likely to use PMTCT services than mothers from rural areas.

3.2.Women’s satisfaction with PMTCT services

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Reportedly 61.6% of pregnant women used prenatal services (including VCT) on the same day that they visited public health facilities in Addis Ababa. On average the women waited at the prenatal clinics for 39.8 minutes and the VCT counselling (pre and post-test sessions) took about 14 minutes. These women acquired more knowledge about HIV and MTCT, the importance of their partners’ HIV testing, living with HIV if HIV-infected, HIV prevention and HIV transmission. Most women were satisfied with counseling rooms’ privacy (82.5%), with the counselors’ services (92.2%) and with the providers’ technical competency (91.5%) [10].

In Adama, in the Oromya region of Ethiopia, interviews conducted with 423 women revealed that they waited for an average 24.5 minutes to see a counsellor, spent 12.8 minutes with their healthcare providers and were satisfied with the PMTCT services (74.7%) [11].

3.3.Factors influencing women’s utilization of VCT services

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In the north western region of Ethiopia, most women did not perceive themselves to be susceptible to HIV because they were reportedly married to faithful husbands. Women who perceived themselves to be susceptible to HIV were three times more likely to accept VCT [12].

Research involving 332 pregnant women in the Gambela region of Ethiopia, indicated that age played no role in VCT utilization as the median age was 23 years for those willing to be tested and 22 years for those who refused testing. Women with lower education levels were more likely to refuse HIV testing services. If the pre-test counseling was rated as being “fair”, then pregnant women were six times more likely to refuse HIV testing than when it was rated as being “very good”. Women who worried about privacy issues during VCT were five times more likely to refuse HIV testing than women who expected privacy during VCT. Pregnant women who had given birth to two or three live infants were more likely to refuse VCT compared to those who had not given birth to a live infant [13].

In Diredawa, Ethiopia, factors influencing 234 women’s acceptance of VCT were studied. Women aged 30 and older, were 78% less likely to accept VCT than women aged 19 or younger. Married women were more likely to accept VCT than single women (OR=22.5). Employed women were four times more likely use VCT services than their unemployed counterparts. Ethnicity, religion, educational status and family size were not associated with acceptance of VCT. Women who were knowledgeable about HIV, MTCT and VCT were 23 times more likely to be tested than those without such knowledge. Women who had used prenatal services 2-3 times were 2.5 times more likely to be tested for HIV than those with fewer or no prenatal clinic visits [14, 20].

3.4.Infant feeding practices

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In northwestern Ethiopia 209 HIV-positive women participated in a study on infant feeding practices and the utilization of PMTCT services. Nurses provided information about infant feeding practices to 58.4% of these women, counselors did so for 55.5% of the respondents. Only 10.5% of these women obtained their infant feeding information from the mass media, 3.8% from their families and 2.9% from their friends and 1.9% had reportedly never been informed about this important aspect of PMTCT. Almost all (92.3%) women knew that HIV could be transmitted to the baby during pregnancy, while being born and during breast feeding. Exclusive breast feeding (EBF) was the only infant feeding option for 39.2% of these women while 10.5% used mixed (breast and formula) feeding. HIV/AIDS stigma and the desire not to make their HIV-positive status known to others, insufficient breast milk and their husbands’ opposition to breast feeding or formula feeding influenced their infant feeding choices [15].

In Addis Ababa, 327 HIV-positive mothers’ infant feeding practices were studied. These findings indicated that 46.8% of these mothers used exclusive replacement (formula) feeding, 30.6% relied on EBF, 15.3% used mixed feeding and 7.3% used EBF for two months and instituted replacement feeding. The most common reasons for mixed feeding included their neighbors’ advice, inadequate supplies of breast milk, the husband’s opposition to breast or formula feeding, illnesses of the mother and/or infant [16].

3.5.Using ARVs for PMTCT

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Out of a cohort of 282 mothers, 232 initiated ARVs during pregnancy, 64% using AZT prophylaxis and 33% lifelong ARVs. Of those on AZT prophylaxis, 68% never missed a dose, 20% missed one dose and 12% missed more than one dose. Of those who initiated ART, 61% never missed a dose, 21% missed one dose and 18% missed more than one dose. Infants born at health facilities were more likely to get ARVs after birth than those born at home [17].

In Northwest Ethiopia, 509 mother-infant pairs were studied. More women were already on ART when enrolled into PMTCT intervention (f=189) as compared to those who received sdNVP+AZT for seven days (f=10), on sdNVP+AZT for four weeks (f=3), none (f=92), sdNVP (f=85) and sdNVP+AZT for seven days+3TC. Likewise 421 infants received ARV prophylaxis at birth, 72 did not receive this prophylaxis and two mothers did not know whether or not their infants had received prophylactic ARVs after birth [18].

Table1

4.Concusion

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Conclusions and recommendations are based on the findings reported in the reviewed literature, relevant to PMTCT facilities, socioeconomic issues, infant feeding options and ARVs.

4.1.Facilities Providing Prevention of Mother-to-Child of HIV transmission

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Collaboration between regional and local Ethiopian health care authorities must be improved and evaluated at regular intervals, especially concerning new policies and procedures, monitoring and evaluation of patients, as well as procedures for patients’ referrals.

Laboratory test kits and adequate supplies of ARVs should always be available at all facilities rendering PMTCT services and internal audits should be conducted regularly.

PMTCT services should have sufficient staff to ensure that HIV-positive pregnant women and their babies receive optimum care. Stigmatization of HIV-positive patients in PMTCT, prenatal and postnatal services and in all health care services should be avoided.

Privacy must be ensured during VCT sessions to enhance patients’ utilization of VCT services. Pregnant women should attend prenatal clinics regularly as from the first trimester so that they can get tested early enabling the optimal utilization of PMTCT services.

4.2.Socioeconomic Issues

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The possibility of subsidizing such women’s travel expenses and/or of providing mobile clinic services in selected areas could help more HIV-positive pregnant women to utilize PMTCT services.

Women with low levels of education were less likely to use VCT services. All women should understand the necessity for VCT and PMTCT. Health education packages should be compiled specifically for women with low levels of education. Knowledge is required for women to evaluate their susceptibility to HIV infection and to understand the need to use VCT services.

Younger, married, employed women who were knowledgeable about HIV, MTCT and VCT were more likely to use VCT services. Thus health education should target older, unmarried and unemployed women to increase the number of women using VCT and PMTCT services.

4.3.Infant Feeding

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Although many Ethiopians reportedly received information about infant feeding from nurses, a minority had never been advised about infant feeding options. Some Ethiopian women practiced EBF or exclusive replacement feeding some also used mixed feeding. Despite costs and efforts, the PMTCT program in Ethiopia could fail to reach its objective, if the mothers do not adhere to the infant feeding recommendations.

Women’s husbands/partners should also receive information about infant feeding options. Support from their husbands/partners might help mothers to persevere with the best possible infant feeding options for their circumstances.

4.4.Anti-retroviral Therapy

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In Ethiopia all HIV-positive women use ARV prophylaxis or lifelong ART for PMTCT. Research reports indicated sub-optimal ART adherence levels among women using PMTCT services [20]. Appropriate health education must be provided at every clinic visit.

Infants born at home were less likely to receive ARVs than those born in hospitals/clinics. Consequently, HIV-positive women should be encouraged to give birth in health care facilities. Babies born at home should be traced and ARVs should be given by health extension workers.

Consistent evaluations of this PMTCT program’s outcomes should be maintained and factors contributing to poor outcomes should be identified and addressed. These measures should enable more babies to be HIV-negative even if their mothers are HIV-positive and to enhance these HIV-positive mothers’ chances of living to raise their children.