The effect of Covid-19 and its mitigation measures on access to PMTCT services in north central region Uganda: a mixed methods study

Abstract

Background: The Corona virus disease pandemic (COVID-19) and its mitigation measures presented a unique experience for the health system and HIV care programs in Uganda. Nationwide control measures implemented from April to June 2020 included total country lockdown, public transport ban and pre-requisites for travel permits for pregnant women to access health facilities. Mothers and HIV-exposed infants (HEI)on the Prevention of mother to child transmission of HIV (PMTCT) program, faced disruption in access to these services. This thesis examines the effect of COVID-19 and the first country lockdown on access to PMTCT services in North Central region, Uganda. Methods: A retrospective observational study employing both quantitative and qualitative techniques was conducted. Eligible patients were mothers and infants attending 96 public health facilities. Qualitative interviewees (DHO’s, midwives and PMTCT mothers) were selected by purposive sampling. Data were extracted from clinical registers on monthly anti-retroviral therapy (ART) refill attendances, health facility deliveries, and timely testing of HEIs for HIV (within two months of birth). Data were analysed using STATA version 14.0 by segmented regression of interrupted time series with Newey-West standard errors to accommodate for serial autocorrelation. Level and slope changes for each indicator were analysed across periods, pre-lockdown (October 2019, to March 2020), lockdown (April 2020, to June 2020) and post-lockdown (July 2020, to December 2020). Statistical significance of differences was considered at p< 0.05. Qualitative interviews were conducted by interview guides and data analysed by manual thematic content analysis method. Results: At the start of pre-lockdown period, October 2019, there were 448 health facility deliveries,2676 ART refills and 556 timely HIV tests for HEI at a proportional attendance of 80%. During lockdown, there was level reduction in proportions accessing ART, 13.7% (95% CI 11.2 to 16.2; p<0.0001), delivering at facilities 9.8% (95% CI 3.7 to 15.8; p=0.002) and timely DNA_PCR testing 6.3% (95% CI 0.9 to 11.7; p=0.022). There was an increasing pre-lockdown trend for ART refills while a declining trend for deliveries and HEI tests. At the start of lockdown (April 2020), there was a level decline for all indicators although only significant for deliveries, -60(95% CI -102 to -18; p=0.01). Lockdown trends were positive with 68 more HEI tested (95% CI 42 to 93, p<0.0001) and 51 more deliveries (95%CI 9 to 94; p=0.023). ART refill averages were not different across months. Overall, health facility deliveries increased by 45 per month (95% CI 6 to 83; p=0.027) and timely PCR tests increased by 57 per month (95% CI 53 to 60, p<0.0001). At the start of post-lockdown (July 2020), there was level decline for HEI tests -28 (95%CI -48 to -8; p=0.011) and non-significant level changes for deliveries and ART refills. Post-lockdown monthly trend was negative for HEI testing with 70 fewer HEI tested (95%CI -79 to -62; p<0.0001. Monthly averages were not different across months for deliveries and ART refills. Overall, timely HEI tests decreased by 14 per month (95% CI -21 to -6; p=0.002). Barriers to access of care were lack of transport, fear of COVID-19 infection, concerns for personal safety due to ruthless security personnel and disclosure of HIV status as a pre-requisite to obtain travel permits. Coping measures by the health system were home services delivery, multi-month ART dispensing, provision of PPE and community sensitisation. Conclusion: COVID-19 and its mitigation measures affected access to PMTCT services differently. Significant level decline was observed for only health facility deliveries. However, all service rates rapidly recovered after the initial drop with positive trends for deliveries and timely HEI HIV tests compared to the pre-lockdown period. Overall, coping mechanisms of the health system helped to restore service utilization. Further investigations are needed to explain the ongoing decline in timely DNA-PCR tests post-lockdown.