Awareness and knowledge of mother to child transmission of HIV and preventive measures in western Uganda

Awareness and knowledge of mother to child transmission of HIV and preventive measures in western Uganda

Table of contents 1. SUMMARY 4 2. BACKGROUND 5 3. METHODS 6 4. RESULTS 7 4.1 Interviews with female and male clients of health units and with villagers 7 4.1.1 Description of the surveyed population 7 4.1.1.1 Educational level 7 4.1.1.2 Occupation 7 4.1.2 Knowledge of health unit clients and villagers about HIV transmission 8 4.1.2.1 Active knowledge about HIV transmission of health unit clients and villagers 8 4.1.2.2 Passive knowledge about HIV transmission of health unit clients and villagers 9 4.1.3 Knowledge about HIV preventive measures of female health unit clients and villagers 10 4.1.4 Acceptance of HIV-testing in health unit clients and villagers 11 4.1.4.1 Knowledge about HIV testing and testing facilities 11 4.1.4.2 Acceptance of HIV-testing 11 4.1.5 Attitude of male health unit clients and villagers towards PMTCT measures 12 4.1.5.1 Attitude of male clients towards antiretroviral drug treatment during pregnancy 12 4.1.5.2 Attitude of male health unit clients and villagers towards replacement feeding 12 4.1.6 Infant feeding practices of female clients of health units 12 4.1.6.1 Water supply 14 4.2 Interviews with health workers 14 4.2.1 Description of surveyed health worker population 15 4.2.2 Health workers knowledge about mother to child transmission of HIV 15 4.2.2.1 Estimated rates of HIV transmission 15 4.2.2.2 Active knowledge of health workers about HIV transmission 15 4.22.3 Passive knowledge of health workers about HIV transmission 15 4.2.3 Health workers knowledge about PMTCT measures 16 4.2.3.1 Active knowledge of health workers about PMTCT 16 4.2.3.2 Passive knowledge of health workers about PMTCT 17 4.2.3.3 Health worker's recommendations on infant feeding in HIV positive women 17 4.3 Interviews with Traditional Birth Attendants (TBAs) 17 4.3.1 Description of surveyed birth attendant population 18 4.3.2 TBAs knowledge about HIV transmission 19 4.3.2.1 Passive knowledge of TBAs about HIV transmission 19 4.3.2.2 Active knowledge of TBAs about HIV mother-to-child transmission 19 4.3.2.3 Passive knowledge of TBAs about HIV mother-to-child transmission 19 4.3.3 TBAs knowledge about PMTCT measures 20 4.3.3.1 Active knowledge of TBAs about PMTCT 20 4.3.3.2 Passive knowledge of TBAs about PMTCT 20 5. CONCLUSIONS 22 2

LIST OF ABBREVIATION MTCT PMTCT TBA Mother to Child Transmission of HIV Prevention of Mother to Child Transmission of HIV Traditional Birth Attendant 3

1. SUMMARY Commissioned by the German government, GTZ supports an intervention on the prevention of HIV transmission from mother-to-child (PMTCT) using the drug nevirapine in western Uganda. Intervention sites are Fort Portal/Buhinga Hospital and Virika Mission Hospital in Fort Portal, Kabarole District, Rukunyu Health Centre in Kamwenge District and Kyenjojo Health Centre in Kyenjojo District. Since an efficient implementation of a PMTCT-programme requires awareness and acceptance by the target group, by the health personnel and by the community this survey was carried out before the implementation of the programme in order to assess the current status of awareness and knowledge about HIV-transmission from the mother to the child, about preventive measure, attitude towards HIV testing and, to assess basic concepts of feeding patterns of the newborns in the area. A total of 751 interviews were held with 440 clients (400 females, 40 male) and 43 health workers at the four future PMTCT intervention sites as well as with 239 villagers (159 female, 80 male) and 29 traditional birth attendants in four randomly chosen rural villages. The table summarises active and passive knowledge about HIV transmission and preventive measures. Questions Active knowledge: HIV transmitted through? Sex Blood MTCT Pregnancy Delivery Breastfeeding Passive knowledge: Is HIV transmitted through? Sex Blood MTCT Pregnancy Delivery Breastfeeding Active knowledge: MTCT preventive measures? Safe delivery procedures Drugs Cesarean section Replacement feeding Passive knowledge:is MTCT prevented by? Drugs Cesarean section Replacement feeding Clients of urban health units Female Male % 98 100 19 47 1 0 98 100 80 90 62 55 53 80 Clients of rural health units Female Male % 100 100 6 17 1 6 96 90 72 85 65 50 62 50 Villagers Health workers TBAs Female Male % 100 100 15 34 3 18 99 100 85 83 77 91 65 22 % % 37 91 40 100 67 100 84 65 16 2 26 72 44 81 35 57 26 100 86 66 48 59 31 24 0 7 3 24 24 17 While active knowledge about mother-to-child transmission of HIV and preventive measures in the general population, of health workers and TBAs was poor, passive knowledge was existing in the two first groups but still poor in the TBAs. Extensive sensitisation measures in terms of talks, meetings, brochures and leaflets, radio spots, video shows, drama and theatre performances should be designed in order to raise knowledge and awareness in the general population with special emphasis on males. Training of health personnel including TBAs on all aspects of mother-to-child transmission including feeding recommendations is indispensable. Availability of HIV testing was known to 89%; acceptance of HIV testing was stated to be 92% but only 10% of the interviewees had been tested so far. In males, acceptance of a drug during pregnancy was 94%, acceptance of replacement feeding 68%. On average women breastfeed for 19 months and solids are added at months 6, liquids at month 5. The type of food and liquids introduced varies according to the educational level, residence and occupation. 4

2. BACKGROUND In Africa, mother-to-child transmission is the overwhelming mode of HIV infection in children under the age of 15 years. In some parts of southern Africa about 30% of the pregnant women are HIV infected and of the estimated 40 million adults living with HIV worldwide half are women of childbearing age. Due to the high prevalence of HIV in pregnant women and high fertility rates, about 90% of the estimated 600 000 children infected with HIV annually live in sub-saharan Africa. Since the beginning of the pandemic, more than five million children worldwide have been infected with HIV, most of them during pregnancy, delivery or during breastfeeding from the HIV-infected mother. Because of the growing importance of AIDS as one of the main reasons for falling child survival rates in many areas of the African continent, the reduction of mother-to-child transmission of HIV is at present one of the biggest challenges in the public health sector. Commissioned by the German Government, the Deutsche Gesellschaft für Technische Zusammenarbeit (GTZ) supports a programme targeted at the reduction of HIV transmission from the mother to the child (PMTCT Prevention of Mother-to-Child Transmission of HIV) in three Districts in western Uganda. The programme is integrated into existing services at Buhinga and Virika Hospitals in Fort Portal, the capital of Kabarole District, and in Rukunyu and Kyenjojo Health Centres which are both situated in a more rural surrounding in Kamwenge and Kyenjojo District, respectively. The success of such a programme will strongly depend on the compliance of the pregnant women, acceptance and support by the health personnel and, very important, support by the communities. Sensitisation of the health personnel and of the communities and a consequently good knowledge about the scope and benefits of the intervention are crucial for a successful implementation of a PMTCT-programme. This survey was therefore carried out before the implementation of the PMTCT-programme in order to assess awareness and knowledge about HIV-transmission from the mother to the child and preventive measures, to assess the attitude towards HIV testing and towards antiretroviral treatment in pregnancy and, to assess basic concepts of feeding patterns of the newborns in the area. The latter aspect was included before the background that feeding options need to be considered in order to prevent transmission of HIV by breastfeeding. 5

3. METHODS The assessment had the following objectives: To assess knowledge and awareness about mother-to-child transmission of HIV and of preventive measures in pregnant women, in men and in health workers To assess knowledge, attitude and practice towards HIV testing To assess the attitude towards antiretroviral treatment of the mother during delivery and treatment of the newborn To collect basic information on feeding patterns of newborns To this end, interviews were conducted between November 2001 and February 2002 at the four PMTCT intervention sites Buhinga Hospital and Virika Mission Hospital in Fort Portal, Kabarole District, Rukunyu Health Centre in Kamwenge District and Kyenjojo Health Centre in Kyenjojo District. At each future PMTCT intervention site interviews were conducted with 100 women either ANC clients or in-patients of the maternity wards, ten male clients randomly chosen at the outpatient-departments and ten health workers, preferably midwives and nurses of ANC and MCH clinics. For each of the three interviewed groups, a standardised questionnaire with closed and open ended questions was used. To avoid that only clients attending health institutions and personnel of health institutions were interviewed and thus results were biased, additionally one village of each health Sub-District of the three future intervention Districts Kabarole, Kyenjojo and Kamwenge was randomly chosen. In each of these villages, at least 20 women and 10 men including the local chairmen were interviewed. Starting at the centre of the village a direction was chosen with the help of a bottle turned on the ground. Consecutive houses were visited in the direction of the bottle opening until a minimum of 20 women and 10 men were found and interviewed in 30 separate households. Additionally, 29 traditional birth attendants were interviewed in the randomly chosen rural villages. The interviews were held with the help of local interviewers and in the local language Rutooro. Data were analysed using the EPI-Info and SPSS programmes. The chi-square test was used for comparison of groups. For the analysis of differences and correlation in the different groups, linear regression was applied including age, residence, occupation and level of education in the model of analysis. 6

4. RESULTS 4.1 Interviews with female and male clients of health units and villagers 4.1.1 Description of the surveyed population A total of 679 persons, 559 females and 120 males were interviewed. Of these, 400 were women and 40 were men attending the 4 health institutions. 159 women and 80 men were interviewed in 4 randomly chosen rural villages of the 3 districts. The median age of women was 24 years and varied between 14 and 50 years, the median age of men was 30 years varying between 20 and 67 years. The majority of female interviewees (57.6%) were between 14 and 25 years old and 98.5% of the primigravidae belonged to this age group. Most male participants (51.7%) were between 26 and 35 years old. At the time of the interview 72.8% (407/559) of the women were pregnant, 24% (135) for the first time. Women interviewed in the villages were significantly older than those interviewed in the urban and rural health facilities (Table 1). Table 1: Age distribution of female interviewees according to their residence Residence Age group 14-25 years 26-35 years 36-45 years > 45 years n % n % n % n % Urban/Hospital (n=200) 145 72.5 44 22.0 11 5.5 - Rural/Health centre (n=200) 132 6.0 57 28.5 11 5.5 - Rural/Village (n=159) 45 28.3 75 47.2 32 20.1 7 4.4 4.1.1.1 Educational level 80.1% (544/679) of the interviewees had undergone at least one year of primary education. 19.9% (135/679) had never attended an educational institution. 22.9% of the 559 women had no education, 64.2% had 1-7 years and 12.9% had had more than 7 years of institutional education. Of the 120 interviewed men, 5.8% had no education, 58.3% had 1-7 years and 35.8% had undergone more than 7 years of education. Interviewed men had a higher level of education than women. 4.1.1.2 Occupation Most of the interviewees, 80% (446/559) of the women and 63% (76/120) of the men were farmers. In rural areas, 91% (326/359) of the women and 69% of the men were farmers. Most of the other interviewees worked as merchants and employees. 7

4.1.2 Knowledge about HIV transmission of health unit clients and villagers 4.1.2.1 Active knowledge about HIV transmission of health unit clients and villagers When asked to name ways of transmission of HIV, a total of 1003 answers were given by the 679 interviewees (Table 2). 33% of the females and 24% of the males could name one way of transmission, 32% of the females and 48% of the males named 2 ways, 7% of the females and 22% of the males named 3 ways and 5% of the males but no females could name more than 3 routes of HIV transmission. 56 persons, 7 male and 49 females said, that they would not know how HIV is transmitted. Table 2: Active knowledge about routes of HIV transmission of health unit clients and villagers Route of Clients urban health centre Clients rural health centre Villagers transmission Female Male Female Male Female Male n % n % n % n % n % n % Sex 174 97.8 20 100 177 100 20 100 155 100 119 100 Blood 33 18.5 9 47.4 10 5.6 3 16.7 23 14.8 26 34.3 Sharp instruments 58 32.6 7 36.8 57 32.2 7 38.9 67 43.2 55 72.4 MTCT 1 0.6 0 0 1 0.6 1 5.6 4 2.6 14 18.4 While sex was mentioned by 99.4% (99.2% of the females, 100% of the males) as a way of HIV transmission, MTCT was spontaneously mentioned by only 3.4% (1.2% of the females, 13.3% of the males). Rural female clients of health units mentioned blood contact as a route of HIV transmission significantly less often than female clients of urban health units and villagers (p 0.05). Women of older age were significantly more knowledgeable about HIV transmission through blood contact and through cutting or injuring with sharp instruments than women of the age group 15-25 years (p 0.05). Male villagers were significantly more aware of possible HIV transmission through use of sharp instruments than rural of urban health unit clients (p 0.001). Both, men and women with any schooling mentioned HIV transmission through blood (p 0.001) and through sharp instruments (p 0.1 women; p 0.001 men) significantly more often than those without school education. Surprisingly, male villagers were those who mentioned HIV transmission during pregnancy and delivery most often (18.4%) and significantly more often than any other group (p 0.001). 8

4.1.2.2 Passive knowledge about HIV transmission of health unit clients and villagers When given a choice of answers, 69.1% of the interviewees (67.1% of the females, 78.3% of the males) approved of MTCT (pregnancy and delivery) as a route of transmission of HIV, while 9% (8.9% of the females, 9.2% of the males) said that this way of transmission was not possible and 21.9% (24% of the females, 12.5% of the males) did not know whether HIV is transmitted during pregnancy and delivery (Table 3). HIV transmission through breastfeeding was affirmed by 59.4% of the females and 40.8% of the males while 16.5% of the females and 35.8% of the males did not think that breastfeeding was a possible route of HIV transmission and 24.4% of the females and 23.3% of the males did not know whether HIV is transmitted during breastfeeding (Table 3). Table 3: Passive knowledge about routes of HIV transmission of health unit clients and villagers Route of Clients urban health centre Clients rural health centre Villagers transmission Female Male Female Male Female Male n % n % n % n % n % n % Sex 188 94 20 100 192 96 18 90 157 99 80 100 Blood 159 79.5 18 90 143 71.5 17 85 135 84.9 66 82.5 Pregnancy/ Delivery 123 61.5 11 55 129 64.5 10 50 123 77.4 73 91.3 Breastfeeding 106 53 16 80 123 61.5 10 50 103 64.8 23 21.8 In women, knowledge about transmission during pregnancy and delivery was significantly higher in village women than in women interviewed at urban and rural health units (p 0.01). In males, passive knowledge about transmission during pregnancy and delivery (78.3%) was higher than in females (67%) and was highest in the group of male villagers (91.3%; p 0.001 as opposed to male health unit clients). Passive knowledge about HIV transmission through breastfeeding was very poor in male villagers (21.8%; p 0.001 as opposed to male health unit clients). Surprisingly, the more educated men were, the less was their knowledge about breastfeeding as a route of HIV transmission (p 0.05). In conclusion, almost all interviewees were aware that HIV is transmitted by sex and blood contact while on average 69% knew that HIV is transmitted during pregnancy and delivery. Knowledge about HIV transmission through breastfeeding was rather poor in females (60%), low in males (41%) but alarmingly poor in male villagers (22%). Awareness and knowledge on HIV mother-child-transmission need to be increased significantly and specific emphasis needs to be directed towards the participation and involvement of the male population. 9

4.1.3 Knowledge about HIV preventive measures of female health unit clients and villagers Female interviewees were asked whether protection from HIV infection is possible. 79.1% (442/559) affirmed this assumption, 5.9% denied and 15% (84/559) did not know. When asked about ways of protection, a total of 641 answers were given by those 442 women affirming that protection from HIV infection was possible. Table 4 shows frequencies of answers such as faithfulness of/towards the partner, condom use, abstinence from sex, avoiding cuts with sharp instruments and avoiding contact with blood. Table 4: Active knowledge about preventive measures of female health unit clients and villagers Measure of prevention Number of answers (641) Percentage of women knowing that protection is possible (442) and naming the preventive measure Percentage of all women naming the preventive measure Condoms 242 54.8 43.3 Abstinence 166 37.6 29.7 Faithfulness 152 34.4 27.2 Avoiding sharp 12.0 62 14.0 instruments Avoiding blood contact 15 3.4 2.7 Other 4 0.9 0.7 As shown in figure 1, knowledge about possible protection from HIV infection was significantly associated with the level of education. Figure 1: Knowledge about protection from HIV according to level of education 100 80 60 % 40 No education 1-7 years of school > 7 years of school 20 0 Yes No Do not know In conclusion, 79% of the women thought that protection form HIV is possible, naming condoms as a measure most frequently (43.3%), followed by abstinence (29.7%) and faithfulness (27.2%). 10

4.1.4 Availability and acceptance of HIV-testing in health unit clients and villagers 4.1.4.1 Knowledge about HIV-testing and testing facilities 89.3% (499 of 559) of the women and all men were aware about the possibility of testing for HIV-infection. No differences were found between rural and urban dwellers. 60.1% (300) of the 499 women who were aware of the possibility of testing for HIV-infection, 83.1% of those urban health unit clients, 42.8% of the rural health centre clients and 52.2% of the female villagers were able to name an institution where HIV-tests are performed. 4.1.4.2 Acceptance of HIV-testing 92.1% (515/559) of the females and 92.5% (111/120) of the males stated that they would accept to be tested for HIV-infection if a test was offered to them (Table 5). The major reason for not agreeing to being tested was fear of the test result. Almost all men (97.5%) said that they would agree if their partner wanted to have a HIV-test performed. While there was no difference for men, female urban health unit clients and female villagers stated significantly more often that they would agree to be tested for HIV (p 0.01). Table 5: Stated acceptance of HIV-testing of health unit clients and villagers Acceptance of HIV-test Female Male if offered n % n % Urban 189 94.5 19 95.0 Rural 174 87.0 18 90.0 Village 152 95.6 74 92.5 Total 515 92.1 111 92.5 Only 10% each of the women (58) and men (12) had undergone HIV-testing so far. Having been tested for HIV was significantly associated with the level of education (figure 2) and, in females, with urban residence (19.8%; p 0.001 as opposed to female rural health clients and villagers). Figure 2: Acceptance of HIV-testing according to level of education 100 80 % 60 40 20 0 Yes No No education 1-7 years of schooling > 7 years of schooling In conclusion, overall knowledge about availability of HIV-testing was high (89%) but differed significantly between female urban (60%) and female rural (52% and 43%) dwellers. Although acceptance of HIV-testing was stated to be above 92% only 10% of all interviewees but 20% of urban females had undergone a HIV-test. 11

4.1.5 Attitude of male health unit clients and villagers towards PMTCT measures 4.1.5.1 Attitude of male health unit clients and villagers towards antiretroviral drug treatment during pregnancy The vast majority of males (94.2%) said that they would allow their HIV-positive partner to take a drug during pregnancy in order to protect the child from transmission of HIV (Figure 3). 3 men each were afraid that taking drugs would do harm to the women or to the child. Figure 3: Acceptance by males of a HIV-protective drug during pregnancy 100 94,2 80 % 60 40 20 0 Yes 2,5 2,5 0,8 No, the woman would get infertile No, would do harm to woman or child No, other reason 4.1.5.2 Attitude of male health unit clients and villagers towards replacement feeding 67.5% of the male interviewees would accept replacement feeding instead of breastfeeding by the HIV-positive wife/partner in order to protect the child from transmission of HIV. 18.3% stated that replacement feeding would be too expensive, 8.3% thought that the child could not thrive without breast milk and 5.6% denied replacement feeding due to other reasons (Figure 4). Figure 4: Acceptance of replacement feeding by males if protecting from HIV transmission 80 67,5 60 % 40 20 18,3 8,3 5,9 0 Yes No, it would be too expensive No, the child would not thrive without breastmilk No, other reason In conclusion, the acceptance of a drug during pregnancy was high (94.2% ) while replacement feeding was thought to be beneficial in HIV infection by only 67.5% of the men. 12

4.1.6 Infant feeding practices of female clients of health units The duration of breast feeding was assessed in all 1610 children of the 424 primi- and multipara. The average duration of breastfeeding in urban and rural dwellers was 19.0 months (range 6 to 36 months). All children had been breastfed for some time. The duration of breastfeeding was independent of the occupation and residence of the women, but women with no schooling and lower educational level breastfed significantly longer than women with a secondary school level (22 months, 19 months and 17 months, respectively). 40 of the 1610 children had died after weaning. When asked about their feeding habits of their infants, the interviewed women stated to introduce solid food on average at month 6 (range month 2 to 30), 32 % started to introduce solids before month 6. Additional liquids are given on average at month 5 (range month 0 to 30) and 63% start to introduce additional liquids before month 6. This practice was independent of the educational level, occupation and residence of the women, with the exception that urban women add solid food significantly earlier than rural women. Table 6 shows the type of food and liquids introduced in urban and rural areas. Table 6: Type of food and liquids introduced to infants by urban and rural women Type of food Urban (n=98) Rural (n= 114) Total (n=212) n % n % n % Bananas 56 57.1 88 77.2 144 67.9 Potatoes 67 68.4 66 57.9 133 62.7 Millet porridge 23 23.5 59 51.8 82 38.7 Beans 24 29.5 74 64.9 64 30.3 Vegetables 11 11.2 11 9.6 22 10.4 Maize porridge 0 19 16.7 19 9.0 Rice 9 9.2 7 6.1 16 7.8 Milk 85 86.7 73 64.0 158 74.5 Water 0 2 1.8 2 0.9 Tea 2 2.0 4 3.5 6 2.8 Juice 3 3.1 2 1.8 5 2.4 Bananas, millet porridge, beans and milk were the most used additional food and liquids. Water, tea and juice did not play any significant role as additional liquids. Women with a higher educational level and women working as employees used potatoes significantly more often as additional food, while millet porridge was used significantly more often as additional food by women with no schooling and by female farmers. Milk was used more often by women with a higher educational level. Bananas, millet porridge, beans and maize porridge were used significantly more often in rural than in urban areas. Milk was used significantly more often in urban areas. 13

4.1.6.1 Water supply Before the background of possible necessity of replacement feeding for HIV positive women, the women were asked about their current sources of water. 48% collected their water from rivers or ponds, 52% had access to water from taps, pumps or wells (Figure 5) Figure 5: Water source used by female interviewees 50 40 30 % 20 10 0 River Protected well Tap Pump Pond Sources of water differed significantly between urban and rural dwellers. While 57% of the interviewees in the rural areas collected water from rivers or ponds, in urban areas 70% of the interviewees had access to tap water, water from pumps or protected wells (Figure 6). Figure 6: Water sources used in urban and rural area 50 40 % 30 20 urban rural 10 0 Tap Pump Protected well River Pond In conclusion, on average women breastfeed for 19 months and solids and liquids are added at month 6 and 5, respectively. The type of food and liquids introduced varies according to the educational level, residence and occupation. While 57% of the interviewees in the rural areas collected water from rivers or ponds, in urban areas 70% had access to tap water, water from pumps or protected wells. 14

4.2 Interviews with health workers 4.2.1 Description of surveyed health worker population A total of 43 health workers of Virika Hospital (13), Buhinga Hospital (10), Kyenjojo Health Centre (10) and Rukunyu Health Centre (9) were interviewed. In the hospitals, preferentially staff of ANC and MCH clinics and of maternities were interviewed, while in the health centres any health worker was chosen (Table 7). Table 7: Qualification of interviewed health staff (n= 43) Health Medical Clinical Nursing HIV Nurse Midwife Institution Officer Officer Assistant counsellor Other Buhinga - - 6-3 - 2 Virika - - 2 1 9 1 - Rukunyu - 3 1 2 2-1 Kyenjojo 1 2 1 4 2 - - Total 1 5 10 7 16 1 3 4.2.2 Health workers knowledge about mother to child transmission of HIV 4.2.2.1 Active knowledge of health workers about HIV transmission When asked by which routes HIV can be transmitted from the infected mother to the child 41/43 health workers could name 1 to 3 possible ways of transmission. 41.5% named one way, 41.5% named two ways and 17% named 3 ways of transmission. A total of 72 answers was given referring to transmission during pregnancy, during delivery and through breastfeeding (Table 8). Table 8: Active knowledge of health workers about routes of mother-to-child HIV transmission Route of transmission No. of answers by health workers (43) n % Pregnancy 16 37.2 Delivery 39 90.7 Breastfeeding 17 39.5 4.2.2.2 Estimated rates of HIV transmission When asked to estimate the rate of HIV infection from the mother to the child, estimates of health workers varied between 2% and 100%, the most frequent estimate was 50% (Figure 7). 15

Figure 7: Estimated rate of HIV transmission from mother-to-child by health staff (n= 40) 12 10 Number 8 6 4 2 0 2 10 15 20 25 30 50 60 70 80 90 100 Estimated rate of HIV transmission in percent 4.2.2.3 Passive knowledge of health workers about HIV transmission When asked whether HIV is transmitted from the mother to the child during delivery, all interviewed health staff agreed. 67.4% believed that HIV is transmitted to the child during pregnancy. 16.3 % each thought that this route of HIV transmission is not possible or did not know. 83.7% (36/43) affirmed that HIV is transmitted through breastfeeding, 7% denied this route and 9.3% did not know (Table 9). Table 9: Passive knowledge of health workers about routes of mother-to-child HIV transmission Route of transmission Yes No Do not know n % n % n % Pregnancy 29 67.4 7 16.3 7 16.3 Delivery 43 100 0 0 Breastfeeding 36 83.7 3 7 4 9.3 4.2.3 Health workers knowledge about PMTCT measures 4.2.3.1 Active knowledge of health workers about PMTCT All 43 health staff were asked whether they were aware of measures to reduce mother-to-child transmission of HIV. 79.1% (34/43) gave an affirmative answer and named different ways of prevention which were categorised as: drugs, early weaning and replacement feeding, safe delivery, cesarean section. Table 10 shows the frequencies of preventive measures of HIV transmission as mentioned by health staff. Table 10: Active knowledge of health workers about PMTCT Measures to prevent Answers by health staff mother-to-child transmission n % Safe delivery procedures 28 65.1 Drugs 7 16.3 Cesarean section 1 2.3 Replacement feeding 11 25.6 16

4.2.3.2 Passive knowledge of health workers about PMTCT Table 11 shows the percentage of the health staff who believed that the specific measure protects from HIV infection, when given these choices of answers. Table 11: Passive knowledge of health workers about preventive measures of mother- to-child transmission of HIV Measures to prevent Yes No Do not know mother-to-child transmission n % n % n % Drugs 31 72.1 5 11.6 7 16.3 Cesarean section 19 44.2 11 25.6 13 30.2 Replacement feeding 35 81.4 4 9.3 4 9.3 Of the 31 health workers who thought that drugs have a protective effect, 3 could name AZT and 2 named nevirapine as a suitable drug. The others could not name a drug. 4.2.3.3 Health workers recommendations on infant feeding in HIV positive women All health staff were interviewed (open question) on their recommendation on breastfeeding for HIV positive women. 22/43 recommended replacement feeding, 5 breastfeeding for 6 months, 3 breastfeeding for 3 months, 8 breastfeeding as long as suitable and 5 did not know what to recommend (Figure 8). Figure 8: Feeding recommendations to HIV-infected mothers by health staff 100 80 60 % 40 51,2 20 7 11,6 18,6 11,6 0 Breastfeeding for 3 months Breastfeeding for 6 months Breastfeeding as long as possible Do not know No breastfeeding Although 81.4% (35/43) knew that avoiding breastfeeding would reduce mother to child transmission of HIV only 51.2% would actually recommend replacement feeding. In conclusion, while all health workers knew that HIV transmission is possible during delivery, only 67% and 84%, respectively attributed transmission to pregnancy and breastfeeding. As preventive measures, safe delivery procedures were actively mentioned most often (65%) while replacement feeding was only mentioned by 25.6%. 17

4.3 Interviews with Traditional Birth Attendants (TBAs) 4.3.1 Description of surveyed traditional birth attendant population In rural areas with poorly equipped and staffed health facilities and shortage of transport and communication traditional birth attendants are a main pillar of care during pregnancy and delivery and, also of postnatal care. A total of 29 traditional birth attendants, 28 females and 1 male, were interviewed in the 4 randomly chosen rural villages. In the majority of the interviewed TBAs knowledge about antenatal and delivery care had been received and passed over from the mother or grandmother (Figure 9). 44.8% (13/29) of the interviewees had participated in an additional training, which had been organised by GTZ/Fort Portal during the years 1991 to 1998. Figure 9: Person / institution by whom the TBAs were trained 100 80 % 60 40 20 0 Mother/ Grandmother Government Another TBA No training 86.2% (25/29) of the interviewed TBAs reported to assist in 5 or less deliveries per month, the remaining 13.8% (4/29) attend 5 to 10 deliveries per month. 82.8% (24/29) of the TBAs also carry out antenatal care. 65.5% (19/29) of the TBAs reported to have the first contact with the women they will assist during delivery already during their pregnancy, 34.5% (10/29) of the interviewees stated to attend their client only for delivery. 58.6 % (17/29) of the TBAs reported to regularly use gloves in order to protect themselves. Only one TBA reported about the regular usage of cord clamps. Although only 20.7 % (6/29) of the interviewees have regular contact to a health unit or a hospital and report about the deliveries they are assisting, 82.8% (24/29) usually refer pregnant women to the next health unit or hospital when expecting a complicated pregnancy or delivery. 18

4.3.2 TBAs knowledge about HIV transmission 4.3.2.1 Passive knowledge of TBAs about HIV transmission When given a choice of answers all interviewees mentioned sexual intercourse as a possible route of HIV transmission. 86.2% were aware about the possibility of HIV transmission via blood transfusion or blood contact. However, only 65.5% affirmed that HIV can be transmitted from an HIV infected mother to her child (Table 12). Table 12: Passive knowledge of TBAs (29) about routes of HIV transmission Route of HIV transmission Yes No Do not know n % n % n % Sexual intercourse 29 100.0 0 0 Blood contact 25 86.2 2 6.9 2 6.9 Mother to child 19 65.5 7 24.1 3 10.3 4.3.2.2 Active knowledge of TBAs about HIV mother-to- child transmission When asked to name different ways of transmission the 19 TBAs affirming that HIV may be transmitted from the mother to the child gave a total of 27 answers. The percentage of all TBAs able to name a route of transmission from the mother to the child is given in table 13. Table 13: Active knowledge of TBAs about routes of HIV mother-to-child transmission of HIV Route of HIV mother-to-child transmission Number of answers Percent TBAs aware of MTCT (19) naming the route of transmission Percentage of all TBAs naming route of transmission Pregnancy 8 42.1 27.6 Delivery 13 68.4 44.8 Breastfeeding 6 31.6 20.7 4.3.2.3 Passive knowledge of TBAs about HIV mother-to-child transmission When those 19 TBAs who affirmed that mother to child transmission of HIV is possible were asked whether HIV is transmitted during pregnancy, 73.7% affirmed, 10.5% denied this route and 15.8% did not know. 89.5% (17/19) of the those TBAs aware of mother-to-child transmission confirmed that HIV transmission is possible during delivery. 5.3% each thought that this route of HIV transmission is not possible or did not know. Only 47.4% (9/19) believed that HIV is transmitted from mother to child through breastfeeding, 26.3% (5/19) each thought that this is not possible or did not know (Table 14). 19

Table 14: Passive knowledge of 19 TBAs about routes of mother to child transmission of HIV Route of HIV motherto-child transmission Yes n % No n % Do not know n % Percentage of all TBAs naming route of transmission Pregnancy 14 73.7 2/19 10.5 3/19 15.8 48.3 Delivery 17 89.5 1/19 5.3 1719 5.3 56.6 Breastfeeding 9 47.4 5/19 26.3 5/10 26.3 31 4.3.3 TBAs knowledge about PMTCT measures 4.3.3.1 Active knowledge of TBAs about PMTCT All TBAs who approved of mother-to-child transmission (19/29) were asked about possible measures to prevent HIV transmission from the mother to the child. 57.9% (11/19) could name at least one way to prevent MTCT, 42.1% (8/19) did not know about preventive measures. Table 15 shows the mentioned preventive measures. Table 15: Active knowledge of TBAs about preventive measures of mother-to-child transmission of HIV Measures to prevent mother to child transmission Number of answers Percentage of TBAs knowing that prevention is possible (11) naming the preventive measure Percentage of all TBAs naming the preventive measure Immediate cutting of the 24 7 63.6 umbilical cord Avoid blood contact between 6.9 2 18.2 mother and child during delivery Drugs administered to the mother 2 18.2 6.9 No breastfeeding 1 9.1 3.4 4.3.3.2 Passive knowledge of TBAs about PMTCT Table 16 shows the answers given when choices for PMTCT measures such as replacement feeding, drug interventions and cesarean section were offered to those TBAs who affirmed that it was possible to reduce the risk of mother-to-child-transmission of HIV (11). 20

When asked whether avoiding breastfeeding could reduce the risk of mother-to-child transmission of HIV, 45.5% of those interviewees aware of preventive measures (11) agreed, while 27.3% (3/11) each said that this would not have any benefit or did not know. Table 16: Passive knowledge of TBAs about preventive measures of mother- to-child transmission of HIV Measure to prevent mother-to-child transmission Yes n % No n % Do not know n % Percentage of all TBAs naming preventive measure Drugs 7 63.6 1 9.1 3 27.3 24 Cesarean section 7 63.6 1 9.1 3 27.3 24 Replacement feeding 5 45.5 3 27.3 3 27.3 17 In conclusion, 48%, 59% and 31% of the TBAs, respectively, knew that HIV may be transmitted during pregnancy, delivery and breastfeeding. Only 38% of all TBAs could name any way of prevention of HIV mother-to-child transmission. 21

5. CONCLUSIONS This assessment was done to get information about the status of awareness and knowledge on HIV transmission and preventive measures with particular regard to HIV mother- to-child transmission. 21% of the female clients and villagers did not think that protection form HIV is possible. As protective measures condoms were mentioned most frequently but still by only 43% followed by abstinence (30%) and faithfulness (27%). When given a choice of answers, almost all female and male clients and villagers were aware that HIV is transmitted by sexual and through blood contact. However, while on average 69% knew that HIV may be transmitted during pregnancy and delivery, even passive knowledge about HIV transmission through breastfeeding was rather low in women (60%) and very low in males (40%). Passive knowledge about HIV mother-to-child transmission in the general population was existing but inadequate. Extensive IEC measures in terms of talks, meetings, brochures and leaflet, radio spots, video shows, drama and theatre performances should be designed in order to sensitise and raise knowledge and awareness in the general population. Special efforts must be undertaken to increase awareness, knowledge and to involve males. Knowledge about availability of HIV-testing (89%) was adequate but, in females, differed significantly between urban and rural dwellers. Acceptance of being tested for HIV (92%) was high, but significantly lower in female rural health centre clients. Also, only 10% each of the interviewed women and men had been HIVtested so far. Since knowing the HIV status is a prerequisite for participation in a PMTC-programme and for a responsible bahaviour, efforts are to be undertaken to raise the willingness to be tested for HIV-infection in the target group and in the general population. In the survey area, women breastfeed on average for 19 months and solids and liquids are added at month 6 and 5, respectively. While in urban areas, 70% had access to tap water, water from pumps or protected wells, 57% of the interviewees in the rural areas collected water from rivers or ponds. Lack of access to clean water must therefore be taken into serious consideration before the background that women would have to prepare breastmilk replacements. All health workers knew that HIV transmission is possible during delivery, but only 67% and 84%, respectively thought that transmission is possible during pregnancy and breastfeeding. As preventive measures, safe delivery procedures were actively mentioned most often (65%) while replacement feeding was only mentioned by 25.6%. Furthermore, although 84% knew that HIV may be transmitted by breastfeeding, only 51% would recommend replacement feeding. 22

Passive knowledge of health personnel regarding mother to child transmission was existing but inadequate in several aspects. Therefore, thorough training of health personnel on all aspects of mother to child transmission, feeding recommendations and options and further preventive measures is indispensable. Only 48%, 59% and 31% of the TBAs, respectively, knew that HIV may be transmitted during pregnancy, delivery and breastfeeding. Only 38% of all TBAs could name any way of prevention of HIV mother to child transmission. Gloves for their own protection were used by only 59%. TBAs knowledge on mother to child transmission and preventive measures was overall poor. They should therefore receive training in all aspects including feeding options, postnatal care and regarding their own protection from infection. 83% of the TBAs reported to be involved during the antenatal phase. They could thus play an essential role as sources of information for the pregnant women and their families as well as in referring women to the health units which offer PMTCT programmes. 23

CONTACT ADDRESSES FOR ENQUIRIES Uganda: Dr. Fred Kagwire, PMTCT Co-ordinator Mrs. Rose Kabasinguzi, PMTCT Assistant Co-ordinator Basic Health Services P.O. Box 27 Fort Portal Western Uganda Tel: +256 483 22575 Fax +256 483 22743 Email bhsuga@imul.com Germany: International Co-ordination Office GTZ PMTCT-Projects: Dr. Gundel Harms, International Coordinator, GTZ PMTCT-Projects Dr. Gabriele Poggensee, Researcher, GTZ PMTCT-Projects Angelika Mayer, Programme Assistant GTZ PMTCT Office Berlin Institut für Tropenmedizin/Medical Faculty Charité, Humboldt Universität Berlin Spandauer Damm 130, 14050 Berlin Tel: +49-30-30102741 Fax +49 30-30102743 Email pmtct.gtz@t-online.de Text, design and photograph: G. Harms, A. Mayer 24