Uptake of ART is influenced by distance to the health facility in rural Zambia

A Zambian study at 8th INTEREST showed that the distance between a woman’s home and clinic affects the uptake of ART during pregnancy and breastfeeding.

This finding was from a pilot project to offer Option B in four rural clinics in the Kafue District. The programme included household surveys to evaluate the effect on infant HIV-free survival at a population level.

The investigators collected medical data from all women who had delivered a child within the past two years. The women were also tested for HIV.

In the second part of the survey, which provided data for this analysis, geographic coordinates of households were also collected. The analysis included: antenatal care <4 months gestation, uptake of any PMTCT regimen, and use of ART. The investigators measured the distance between households and clinics (in a straight line not taking into account topographical features) using ArcGIS 10.0 – a computer programme for mapping and spatial analysis.

They used multivariable regression models to measure the association between clinic distance and the outcomes of interest and to explore the relationship between clinic distance and Option B uptake.

They reported that between March and December 2011, 2,448 mother-infant pairs were enrolled, of which 1,708 (70%) had evaluable data. A total of 771(45%) mothers reported having an antenatal visit before four months gestation, but this had no association with distance from the clinic, p=0.30.

When the analysis was limited to 256 HIV positive women, 168 (66%) of these reported using any antiretroviral drugs during pregnancy and 102 (40%) started ART for PMTCT.

The investigators found that uptake of any PMTCT regimen and ART for PMTCT decreased as the per-km distance to the clinic increased, AOR respectively: 0.89 (95%CI 0.82 to 0.96) and 0.88 (95%CI 0.80 to 0.96). The probability of starting Option B was highest within 3 km of the clinic, after which the investigators reported a gradual decline.

“Programme models that further decentralise care into the community are urgently needed” they wrote.

Comment

That every kilometre travelled means loss to follow up might be stating the obvious. Seeing data on decline in uptake associated with distance from the clinic properly evaluated gives weight to the importance of further steps towards decentralised care and treatment.

Escamilla V et al. Distance to clinic and uptake of “Option B” PMTCT services in rural Zambia. 8th International Workshop on HIV Treatment, Pathogenesis and Prevention Research in Resource-Poor Settings (INTEREST). 5-6 May 2014. Lusaka, Zambia. Poster abstract P_28.