Implementing prevention of mother-to-child transmission of HIV in Dar es Salaam, Tanzania : human resources, client and provider satisfaction and cost-effectiveness

Abstract: Despite advancement in global efforts to prevent mother-to-child transmission of HIV (PMTCT), more work needs to be done to protect children from HIV transmission particularly in eastern and southern Africa. The integration of PMTCT into routine antenatal care (ANC) services is one costeffective intervention for averting mother-to-child transmission (MTCT) of HIV. However, adherence to PMTCT services in ANC and throughout the breastfeeding period, when the infant is at risk of MTCT, is limited due to stigma, lack of knowledge and weak health systems in countries like Tanzania. The main aim of the thesis was to assess patient and provider satisfaction in PMTCT clinics, the potential for task-shifting and cost-effectiveness aspects of uptake of and adherence to the PMTCT programme in Dar es Salaam, Tanzania. Four studies were conducted based on data collected in Dar es Salaam in 2014 and 2016. In Paper I, we conducted a cross-sectional survey using Likert scale questions administered face-to-face to 595 pregnant women living with HIV and attending ANC services. In Paper II, we used a selfadministered survey to 213 PMTCT providers. In Paper III, we used direct-time motion observations to assess time spent on each PMTCT task, and in Paper IV, we conducted a cost-effectiveness analysis from a providers perspective using health outcomes which were based on a secondary data analysis of de-identified health system data including a cohort of 2309 women newly diagnosed with HIV who delivered a baby between August 2014 and May 2016 in Dar Es Salaam. Descriptive statistics were used to summarize data in all four papers and logistic regression models were used to identify predictors of satisfaction/dissatisfaction (Papers I and II). Only 8% of patients were dissatisfied with PMTCT services, in particular with poor provider communication skills (OR 4.9, 95% CI 1.8 ± 1 3.4), low capacity to understand client concerns (OR 5.7, 95% CI 2.3 ± 14.0) or if the hospital visits took over 2 hours (OR 2.3, 95% CI 1.1 ± 4.7) (Paper I). More than half of health care providers were dissatisfied with their current job and one third had turnover intentions. Dissatisfaction with the job was influenced by: low salaries (OR 5.6, 95%CI 1.2-26.8), unreasonably long working hours (OR 3.2, 95% CI 1.3-7.6), unclear job descriptions (OR 4.3, 95% CI 1.2-14.7) and poor safety measures (OR 4.0, 95% CI 1.5-10.6). Turnover intention was influenced by: poor job stability (OR 3.7, 95% CI 1.3-10.5), lack of recognition from one’s superior (OR 3.6, 95% CI 1.7-7.6) and inadequate feedback (OR 2.7, 95% CI 1.3-5.8) (Paper II). Nurses spent more time on the first antenatal and postnatal clinic visit (54 minutes, 95% CI 42–65 and 29 minutes, 95% CI 26-32) than follow-up visits (15 minutes 95% CI 14-17) and 13 minutes, 95% CI 11-16). A large proportion of this time (84%-100%) could be task-shifted to community health care workers. If these tasks were shifted to lower cadres, the average cost-saving per patient visit ranges from US$ 0.4 to 1.3 (Paper III). Most (91.3%) pregnant women living with HIV do not attend ANC in the first trimester, and more than half make fewer than 4 visits during the entire pregnancy. The overall MTCT rate was 2.8% (95% CI 2.2%-3.6%) at 12 weeks of life. More visits protected against HIV transmission: The MTCT rate was 4.8% (95% CI 3.6%-6.4%) for women with fewer than 4 visits and only 1% (95% CI 0.5%- 1.7%) for women who made at least 4 visits. The incremental cost-effectiveness ratio was US$ 336.37 per MTCT averted when at least 4 visits were made, which is less than one year’s cost of HIV treatment for an HIV-positive infant initiating ART (Paper IV). In conclusion, patient satisfaction was influenced by good patient-provider interaction but providers themselves were not satisfied with their job for various reasons including high workload. Thus, interventions such as task-shifting can potentially improve job satisfaction, quality of care and retention in care and contribute to the elimination of MTCT in Tanzania and other resource limited countries. Furthermore, early uptake of and retention in ANC/PMTCT care can protect children from being born with HIV and also reduce future treatment costs for Tanzania.