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Counseling facilitates women's utilization of CD4 count testing in Lilongwe, Malawi
K.P. Gilles1, E.A. Bobrow2, C. Zimba3, I. Mofolo3, G. Hamela3, A.P. Banda3, P. Khruza3, S. Maman1, F. Martinson3, I. Hoffman1, M. Hosseinipour1,3
1University of North Carolina at Chapel Hill, Chapel Hill, United States, 2Elizabeth Glaser Pediatric AIDS Foundation, Washington, United States, 3University of North Carolina Project - Lilongwe, Lilongwe, Malawi
Background: Initiating antiretroviral treatment (ART) at lower CD4 levels is associated with increased mortality, but individuals frequently wait to seek treatment until progression to an advanced disease stage. To increase early enrollment of HIV-positive women in ART programs, prevention of mother-to-child transmission (PMTCT) clinics are implementing regular CD4 count testing up to 18 months postpartum. Successful retention of women has proved challenging. This study examined factors influencing women's utilization of extended CD4 count testing offered through PMTCT clinics.
Methods: The study was conducted in 3 antenatal clinics in Lilongwe, Malawi. In-depth interviews were conducted with 19 HIV-positive pregnant women with CD4 counts < 250/mm3, 9 HIV-positive women who received a follow-up CD4 count test, 3 social support persons, 17 nurses and 5 government health officials. Two focus groups were conducted with community leaders.
Results: Accurate, comprehensive counseling and positive interaction with staff emerged as critical factors for service utilization. Women wanted to know their CD4 count and knew there was the possibility of starting ART if it was low, but did not understand the importance of early ART initiation. Disclosure to and support from husbands facilitated women's return to the clinic. Reminders were perceived as helpful but ineffectively employed. Transportation was identified as a possible barrier and proximity to services was valued. Staff identified challenges to tracking women and coordinating referrals from various sites.
Conclusions: Counseling should be taken as an opportunity to provide social support, with messages emphasizing the importance of starting ART soon after the CD4 count drops below 250. Clinics should focus on encouraging disclosure to husbands and expanding testing and counseling services to couples, recognizing the emotional and financial support husbands provide. Increased focus should be placed on case management, staff communication and support, and appointment reminders. Follow-up should be offered at multiple service points.
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