For the Health of the Baby:
Motivations and Barriers to
Early HIV Testing and Counseling
Among Pregnant Women in Vietnam
PSI Vietnam
March 2008
Outline
Acknowledgements
Abbreviations
Introduction
Study Background and Objectives
Data Collection Methods Used
Findings
Annexes
Acknowledgements
The study on Barriers to and Motivations for accessing PMTCT Serviceswas funded by President’s Emergency Plan for AIDS Relief (PEPFAR) through USAID & PACT/Vietnam. It was conducted by Population Services International (PSI) Vietnam with the collaboration of Consultation of Investment in Health Promotion (CIHP).
PSI Vietnam would like to thank to the many people who contributed to this study. First and foremost, sincere thanks go to the women and men women who participated in the focus group discussions (FGDs) and In-Depth Interviews (IDIs) and provided the foundation of this project.
We take this opportunity to express our sincere appreciation to CDC and the LIFE-GAP project for their collaboration and cooperation with the study and our research agency. In addition, the research has been successfully completed with the tenacious efforts of all research team members from CIHP.
We would also like to convey our thanks to all PAC and LIFE-GAP project leaders in three research provinces for their enthusiastic and effective cooperation and support extended to the research team to complete their on-site research works.
We could not conduct the discussions without the support of health providers in health stations at district and communal/ward level and National hospital of OB/GY at the research sites who have helped us to recruit the participants and arranged the interviews and group discussions.
Research strategy and questionnaires were designed by Mr. Vu Ngoc Khanh, Ms. Le Thi Linh Chi, Dr. Trinh Thu Hang and Ms. Yasmin Madan at PSI/Vietnam, with support from Kathryn O’Connell, PSI Regional Researcher for Asia. CHIP conducted the data collection, transcription, coding, and primary analysis. PSI Vietnam would like to thank Vu Song Ha, Nguyen Truong Nam and all of CIHP team who worked on this project, for their invaluable work. Finally, Ms. Nathalie Likhite, a consultant did the final analysis for the research findings and wrote the final draft for the study.
Abbreviations
ANC Antenatal Care
ARV Antiretroviral Therapy
BCC Behavior Change Communication
CSW Commercial Sex Worker
CT HIV Counseling and Testing
FGD Focus Group Discussion
GOV Government of Vietnam
IDI In-depth Interview
IDU Injecting Drug User
IPC Interpersonal Communications
IMPACT Implementing AIDS Prevention and Care Project
LIFE-GAP Leadership Investment in Fighting the Epidemic Global AIDS Program
MoH Ministry of Health
MARP Most At-Risk Populations
MTCT Mother to Child Transmission
NGO Non-Governmental Organization
PAC Provincial AIDS Committees
PEPFAR President’s Emergency Plan for AIDS Relief
PHD Provincial Health Department
PLWHA Persons Living with HIV
PMTCT Prevention of Mother-To-Child Transmission
PSI Population Services International
STI Sexually Transmitted Infection
SW Sex Worker
USAID United States Agency for International Development
VCT Voluntary Counseling and HIV Testing
WHO World Health Organization
Introduction
Prevention of Mother to Child Transmission of HIV (PMTCT) is a priority area of concern for the treatment of HIV infected people in Vietnam. Due to limited resources, many countries, including the Government of Vietnam (GOV), have been unable to implement universal drug treatment programs, and have taken a more targeted, affordable approach to treat pregnant women at the time of their delivery for PMTCT. By 2010, the GOV expects to provide HIV testing and counseling services to 90% of all pregnant women and Antiretroviral (ARV) therapy to all pregnant women testing HIV Positive (+).
Building on the efforts of PMTCT programs in Vietnam, such as the MOH/LIFE-GAP projects, PSI received PEPFAR funding through Pact/Vietnam to develop and implement a social marketing program to support CDC and LIFE-GAP. PSI will develop a communication campaign to increase the demand for PMTCT services by pregnant women in three (3) PEPFAR priority provinces.
PSI will leverage Vietnam’s social communications infrastructure and public health system to implement a comprehensive communications program. This intervention will be based on collaborative work with the MoH/LIFE-GAP project, established NGOs, Provincial Health Departments (PHD), and civil society groups working with pregnant women. The goals of the project will be to 1) increase knowledge of and demand for voluntary counseling and HIV testing (VCT) services among pregnant women accessing ANC services, 2) reduce the stigma associated with the use of HIV testing services, and 3) improve general understanding of PMTCT.
HIV in Vietnam
At the end of 2002, the official estimate of HIV prevalence among adult men and women in Vietnam was 0.28%. In 2005, the National HIV prevalence rate amongst pregnant women was 0.37%.
As of November 2004, a cumulative total of 88,393 people had been reported as HIV (+) and 13,952 people were diagnosed with full-blown AIDS.[1] HIV infection in Vietnam is predominantly transmitted among injecting drug users (IDU) and sex workers (SW), with approximately 65 % of transmission through IDU. The highest prevalence rates are found in border provinces, large urban and industrial centers, and tourist areas. Many SW are also IDU, compounding the problem. Studies indicate prevalence rates among IDUs and SWs varies significantly by province, but up to 75% of IDUs in Ho Chi Minh City and Hai Phong, and 26% in Hanoi are HIV(+), while nearly 20% of SWs were found to be HIV(+) in Hanoi.
Mother to Child Transmission of HIV[2]
Mother to child HIV transmission (MTCT), or vertical transmission, is the most common source of HIV infection in children under the age of 15 years. At least 90% of all HIV infections in children are a result of vertical transmission. Transmission of HIV from mother to child can occur in utero, during labour and delivery and during lactation. During pregnancy, about 5 to 10% of the fetuses of HIV-infected mothers become infected before labor by transmission across the placenta. Labour and delivery pose the greatest risk for transmission with 10 to 20% of exposed infants infected at this time. Breastfeeding also exposes infants to HIV, and with prolonged breastfeeding for 18 to 24 months, another 10 to 15% of infants become infected. Thus, in non-breastfeeding populations without ARV treatment, approximately 15-30% will become infected; with prolonged breastfeeding, infection rates of 25 to 45% are seen.
PMTCT consists of a four-pronged approach. The four-pronged PMTCT approach recommends that mothers and children should be targeted to receive comprehensive and continuous intervention, and advocates targeting different levels of society, including individuals, communities and institutions. The four prongs include: (1) primary prevention of HIV; (2) prevention of unwanted pregnancy in HIV (+) women; (3) prevention of HIV transmission from HIV (+) mothers to children; and (4) care and support for HIV (+) mothers and their children and families.[3]
Vietnam was one of the first countries in the South East Asian region to introduce Nevirapine for PMTCT. Supervised by a sub-committee on PMTCT created under the National Committee for AIDS, Drug and Prostitution Prevention, PMTCT activities remained limited in Vietnam until 2002. At that time, the National Obstetrics and Gynecology Hospital in Hanoi was responsible for administering Vietnam’s first PMTCT program. Two years later, UNICEF and CDC joined the GOV in its efforts to reduce vertical transmission of HIV by providing technical and financial assistance. Simultaneously, additional financial support was obtained from the GFATM and other organizations.
In March 2004, the Prime Minister of Vietnam officially approved the National Strategy on HIV Prevention and Control until 2010 with a vision for 2020. The National Strategy identifies PMTCT as one of nine action areas that need to be addressed in order to achieve its overall objective, which is to keep HIV prevalence in the general population Vietnam under 0.3% by 2010. Based on the National Strategy, in 2005, the Minister of Health mandated the Department of Reproductive Health to develop a National Plan of Action (NPoA) on PMTCT for 2006-2010. The overall objective of the NPoA for PMTCT is to control the MTCT to below 10% by the year 2010. The aim is to offer VCT services to 90% of all pregnant women, and provide prophylactic interventions to 100% of those testing HIV (+) by 2010.
Assessment of PMTCT Programs in Vietnam
The GOV’s PMTCT program consists of several pilot projects that use differing intervention models. In early 2006, the GOV commissioned a team of consultants to conduct an assessment of the different models. The objectives of the assessment were to 1) explore the strengths and weaknesses of the existing PMTCT models and 2) provide the GOV with evidence-based recommendations for a national PMTCT model and guidelines that could be widely applied in Vietnam, given the current prevalence level and limited resources.
The report of the rapid assessment revealed that all women delivering at the hospital were tested for HIV. Between 50 to 75% of HIV (+) women were diagnosed at the time of labour excluding them from multiple ARV therapy. Single Dose Nevirapine administration during labour varied from 12.5 to 50%, and close to 100% of infants born to HIV (+) mothers received prophylactic therapy for 7 days. When HIV (+) diagnosis occurred during pregnancy, nearly all expecting mothers received multiple ARV prophylactic treatment.
Among primary health care facilities, most project sites appeared to offer free “opt-out” HIV testing with little pre-test counseling. Data on the provision of services was unclear, but results suggested that there were difficulties in maintaining the confidentiality of HIV (+) test results, which may have limited the uptake of these services in early pregnancy. While replacement feeding was recommended to all HIV (+) mothers, the distribution channels were ineffective and counseling was limited. Moreover, HIV care and treatment services were still under development and referral procedures were not well established.
As identified by the report, when it comes to implementation of PMTCT, the main challenge for the GOV is to establish cost-effective and confidential ways to identify HIV (+) women early in their pregnancies, and to establish working referral mechanisms for timely comprehensive treatment and care. The assessment team recommended that well qualified HIV counselors operate from the district level and provide ambulant VCT services to all Commune Health Centres and hospitals in the district. Women diagnosed HIV (+) would be assisted by a counselor, ‘her case manager’, at the district level, who is responsible for referring her to specialized HIV care sites where HIV related pre, intra, post-partum and follow-up care for women and infants would be provided.
I. Study Background and Objectives
PSI began its social marketing operations in Vietnam in early 2005. With PEPFAR funding from USAID through PACT/Vietnam, PSI implements a comprehensive social marketing program for the HIV prevention among most at-risk population groups (MARP), including promotion of VCT, targeted condom social marketing program, PMTCT communications and an outreach intervention for SW who are IDUs. PSI works in close collaboration with the MoH/LIFE-GAP Program Office, the CDC and other providers, as well as PHDs and Provincial AIDS Committees (PAC) in the all PEPFAR priority provinces.
Implementing the recommendations of the assessment of PMTCT services in Vietnam, PSI plans to develop and implement a behavior change communications campaign to increase awareness of and demand for early uptake of VCT during pregnancy. The increase in early VCT among expecting mothers will contribute to the GOV’s goal to provide universal access to early ARV therapy to pregnant women, thus significantly reducing chances of HIV transmission from mother to child. The objective of the present study is to identify key determinants i.e. understand motivations for and barriers to the use of VCT services during pregnancy using PSI’s behavior change framework.
The overall aim of this study is to gain an in-depth understanding of the barriers to and motivations for accessing VCT services as part of routine antenatal care (ANC) among pregnant women, women who had recently delivered a baby, and their male partners in 3 provinces: Hanoi, Hai Phong and Quang Ninh. To better understand the service provision at the district and provincial hospitals, the study also included in-depth interview with ANC service providers in 3 provinces.
Specifically, the study explored
· perceptions towards HIV and personal risk regarding HIV transmission as well as knowledge of MTCT and available modes of protection;
· experiences with HIV testing and counseling during pregnancy, including barriers to and motivational triggers for accessing this service; and
· the role of the male partner in women’s uptake of HIV testing and counseling during pregnancy.
Qualitative research methods, including in-depth interviews (IDIs) and focus group discussions (FGDs), were used for data collection. A short quantitative questionnaire was also employed among the FGD participants to assemble more detailed information from each participant. In total, 158 respondents participated in this study through 22 FGDs (18 FGDs with women and 4 FGDs with men), and 3 IDIs conducted with ANC service providers.
Twenty eight (28) male partners in Hai Phong and over 127 women in the three study locations completed the quantitative questionnaire.
The results of the study will be used to develop targeted communications messages to increase informed demand for PMTCT services available in Vietnam, particularly in the 3 priority provinces of Ha Noi, Hai Phong and Quang Ninh. The study will also assist PSI Vietnam in identifying the most appropriate communication channels for the campaign.
Study Location and Sample
The study was conducted from December 2007 to January 2008 in three locations: Hanoi, Hai Phong and Quang Ninh, Vietnam. These provinces were selected by PSI and CDC because they have a high prevalence of HIV/AIDS and are able to provide the most comprehensive coverage of PMTCT services in the northern part of Vietnam. Identified as PEPFAR priority provinces, there is a strong need to increase awareness of the PMTCT services through communications support in these three provinces.
Study participants were selected from three target groups: women who were currently pregnant or had recently had a baby (6 months old or younger), the husbands of women who were pregnant or had recently had a baby, and ANC service providers in district or provincial hospitals. Initially, study participants were categorized according to whether or not they had accessed VCT services. VCT non-users were defined as women who were currently or recently pregnant and had not accessed VCT services (but could have been tested for HIV late in their pregnancy or during labor). VCT users were women who were currently or recently pregnant and who had accessed VCT as part of ANC.