Factors associated with HIV infection among infants born to mothers with HIV in Blantyre, Malawi: a mixed methods study.

backgroundHIV infection is a major cause of mortality and morbidity among infants in Malawi. Despite the scale-up of elimination of mother-to-child transmission (e-MTCT) services in Malawi, the mother-to-child transmission rate was 6.5% in 2021. Therefore, the study aimed to assess factors that are associated with HIV infection among infants born to mothers with HIV in Blantyre, Malawi.

methodsA cross-sectional study was conducted using a mixed-methods convergent (triangulation) approach. The study was conducted at Bangwe, Limbe, and Ndirande Health Centres which are primary care health facilities in Blantyre City. The study participants were mothers with HIV and their infants exposed to HIV, aged 0 to 24 months, receiving e-MTCT care and e-MTCT service providers at the health facilities. The study population were nine purposively-selected e-MTCT service providers for the qualitative component of the study and 271 mothers with HIV and their infants exposed to HIV for the quantitative component sampled using probability proportional to size across the three facilities and simple random sampling within each facility. In-depth qualitative interviews were conducted with the service providers and tape-recorded while quantitative data were retrospectively extracted from e-MTCT logbooks and hospital records for the mothers and infants receiving e-MTCT care from January 2020 to December 2021. Quantitative data was entered and analyzed in Stata Version 17. Descriptive statistics (frequency, mean and percentage) were used to summarise data for each variable. Binary logistic regression was employed to determine association variables of HIV in infants. A p-value of less than 0.05 was considered significant in deciding on the association of variables. Interviews were transcribed verbatim, and the cleaned data were imported into NVivo software for thematic coding and analysis.

resultsOf the 271 infants exposed to HIV reviewed, 12.2% (95% CI = 8.5% - 16.7%) were HIV-infected. Factors that were significantly associated with infant HIV infection included: mixed feeding before six months (aOR = 5.8, 95% CI = 1.38-24.29), high maternal viral load (aOR = 78.6, 95% CI = 22.74-271.7) and receiving ARV prophylaxis at birth (aOR 0.2, 95% CI = 0.05-0.56). A qualitative study found that maternal and service provider individual-level and general health system factors were associated with suboptimal uptake of e-MTCT intervention. These included negative attitudes among mothers, tardiness by healthcare workers and mothers, the provision of incorrect contact details, defaulting on treatment, frequent relocation, religious beliefs, poor adherence to treatment protocols and late initiation of antiretroviral therapy, multiple service delivery locations, lack of proper training or knowledge gaps, high workload and lack of resources.

conclusionHIV infection among infants exposed to HIV remains unacceptably high, mostly due to sub-optimal e-MTCT program implementation. This requires intensified monitoring and evaluation (M&E) of the e-MTCT programme implementation and use of M&E data for targeted quality improvement.