In-depth: ART on the frontline

UGANDA: Providing PMTCT services in the unstable north

Photo: Keishamaza Rukikaire/IRIN
Insecurity has made provision of PMTCT services difficult in the north
KITGUM, 19 October 2006 (IRIN) - KITGUM - in northern Uganda's Kitgum district, where insecurity and a virtually non-existent road network means getting to hospital may take days, health workers battle to ensure that HIV-positive pregnant women access services to prevent mother-to-child transmission of the virus.

"We encourage pregnant women who have tested positive for HIV to admit themselves to our hospital two weeks before they are due to deliver, so they can receive their dose of nevirapine in good time," said Beatrice Opira, a counsellor at Kitgum's St Joseph's Hospital.

A single dose of nevirapine is given to the mother at the onset of labour and to her baby after birth to prevent the child from contracting HIV.

The United States Agency for International Development and the Italian NGO, Associazione Volontari per il Servizio Internazionale (AVSI) began the first prevention of mother-to-child transmission (PMTCT) services in Kitgum in 2002 at the government hospital and St Joseph's, which is run by a Roman Catholic mission.

So far, the results have been good. "About 75 percent of women in Kitgum town come to the hospital for ANC [antenatal care] and when they test positive, most come in to deliver and take their drugs," said Robert Ochola, coordinator of HIV/AIDS activities at St Joseph's.

According to AVSI, 97 percent of women receiving ANC in the northern districts of Kitgum and Pader accepted HIV tests by May 2005, and 88 percent of those enrolled in PMTCT programmes delivered in hospital, but only 53 percent of pregnant HIV-positive women enrolled in PMTCT programmes.

Opira said about eight percent of women who attended St Joseph's antenatal clinic tested positive for HIV, and less than one percent of babies born to HIV-positive mothers were found to be HIV-positive at the age of 18 months.

Despite the positive response to the service, prohibitive transport costs and medical fees prevent many women from coming to the hospital.

Most of St Joseph's PMTCT clients come from Kitgum town, but access to the treatment is much more difficult for the thousands of women in camps for the internally displaced, and when they do have it, staff shortages and poor training mean it may not be administered correctly.

At Akwang camp in Kitgum, home to 16,000 displaced people, attendance at the ANC clinic is high and women are willing to be tested for HIV, but the clinic is extremely short-staffed, with no doctor and just one midwife to help women give birth. Most women are assisted by traditional birth attendants (TBAs), who receive some training in handling HIV-positive pregnant women, but their activities are limited to counselling.

"We are not authorised to provide the medication to women who have HIV - only the midwife can do that," said Jenny Atoo, a TBA at Akwang's ANC clinic. "During the day we deliver the babies at the clinic and at night the women call us to their homes."

Caroline Adong, 22, (not her real name), who discovered her HIV status when she and her husband visited the voluntary counselling and testing centre at St Joseph's a year ago, received PMTCT services at the Akwang clinic. "I was coming for regular check-ups and when I went into labour I was given the medicine [nevirapine]; my son was also given the medicine when he was born," she said.

Ongoing hostilities in the region between government troops and the rebels of the Lord's Resistance Army have also hindered PMTCT service provision.

"Insecurity affected the supply and demand for PMTCT services. Procurement and transport of test kits, drugs and sundries grew more difficult and demanded a reliance on air transport," AVSI reported at the 15th International AIDS Conference in Thailand in 2004. "Accessing PMTCT sites became dangerous, which reduced access to antenatal clinics and interfered with deliveries."

After recent research showing HIV-positive mothers who had breast fed their babies for three months or more did not have a greater risk of HIV infection than those who had never been breast fed, health workers in low-income areas have been encouraging women to feed their babies on nothing but breast milk for the first six months, because poverty makes it very difficult to find replacement food.

The government, humanitarian agencies and hospitals in the region have been providing business skills training to women to enable them to make enough money to buy food for their babies. "We have a starter fund for income-generating activities for HIV-positive women," St Joseph's Ochola said. "We provide them with about 200,000 shillings [about US$109] which can start, say, a retail business."

He said the region's PMTCT services would benefit from more health workers being hired to monitor HIV-positive women during and after pregnancy, and encouraging them to give birth in health centres rather than at home.
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