4.1. Discussion
According to Fonsah etal. (2017), non-adherence was defined as missing an ART refill for more than 48 hours, a threshold previously associated with suboptimal viral suppression in sub-Saharan Africa [23]. Our study revealed a notably high ART uptake completion rate of 96.5% (223 out of 231) among HIV-positive mothers at Mbale Regional Referral Hospital, indicating that nearly 97 out of every 100 mothers successfully initiated ART before childbirth. This demonstrates a commendable level of engagement with ART services within this population. However, even with this encouraging result, efforts should be directed towards reaching a 100% utilisation rate to prevent mother-to-child transmission. Our finding contrasts with a systematic review [24] which highlighted significant challenges in linking women who test HIV-positive during pregnancy to ongoing HIV care. Further, research in Mwanza, Tanzania [25] found that a substantial proportion of women identified as HIV-positive during pregnancy were not assessed for Highly Active Antiretroviral Therapy (HAART) eligibility during pregnancy or in the early postpartum period. These discrepancies highlight the importance of continued efforts to improve linkage to care, assessment for treatment eligibility, and prevention of loss to follow-up from the point of HIV diagnosis onwards. Watson-Jones et al. (2012) specifically suggest initiating HAART at the antenatal clinic, improving counselling and linkages between PMTCT and adult HIV treatment services, and reducing stigma surrounding disclosure of HIV results as beneficial strategies for enhancing the ongoing care of HIV-positive pregnant women [25].
HIV-related stigma impedes intervention efforts, causing delayed testing, reduced care engagement, and poorer treatment adherence. This stigma manifests visibly as enacted discrimination but also subtly through personal beliefs. Internalised stigma reflects self-stigmatisation through acceptance of negative beliefs, while anticipated stigma involves expecting prejudiced attitudes from others [26]. For instance, women with lower income levels or those in stigmatised occupations may often face compounded stigma that limits their ability to access healthcare services without fear of judgement or discrimination.
Age emerged as an important factor influencing ART adherence, with our study revealing that older women between the ages of 26 and 49 were more adherent compared to their younger counterparts. However, the impact of age is nuanced. For example, research in Malawi revealed that younger patients and single women were more likely to be non-adherent or drop out by day 360. While there were no significant differences in occupation, education level, or marital status among pregnant women who were adherent versus those who were not, being separated was associated with a decreased likelihood of adherence to Option B+ compared to married women [27]. Another study in Cameroon found better treatment adherence among older participants (over 40), who experienced fewer days of non-adherence compared to younger ones. Furthermore, the length of non-adherence following an ART regimen change predicted future adherence: shorter initial periods of non-adherence correlated with better long-term adherence, while longer periods predicted poorer adherence. However, this study noted that neither age nor education independently influenced overall ART adherence [23].
In our study, while bivariate analyses revealed significant associations between individual-level factors (age, occupation, marital status, and income) and ART completion, subsequent multivariate regression analysis demonstrated that these associations were not statistically significant after controlling for potential confounders. This highlights the importance of considering the complex interplay of factors influencing ART uptake. For instance, the apparent association between age and ART completion may be mediated by socioeconomic factors, such as access to resources [28] and social support networks. This is consistent with findings that gender power relations, including unequal access to resources and decision-making authority, significantly impact health outcomes for women in Uganda [29].
Similarly, the influence of occupation and marital status may be intertwined with cultural norms and gender dynamics within the Ugandan context, as societal expectations around women’s roles often limit their autonomy and decision-making power regarding health care. For example, women involved in sex work in Kampala, Uganda, face heightened gender inequities that exacerbate their vulnerability to poor health outcomes due to stigma, economic dependence, and limited access to supportive networks [30].
In many sub-Saharan African communities, men often hold influential roles as decision-makers within their families and societies. Consequently, their choices significantly impact the health and well-being of their family members, for better or worse [31]. The involvement of male partners in the healthcare of HIV-positive mothers significantly influences adherence to antiretroviral therapy (ART) and overall health outcomes. A community-based study across 26 communities in Cameroon, Côte d’Ivoire, South Africa, and Zambia revealed that only 36.4% of 976 HIV-infected women completed the PMTCT cascade, which includes antenatal care visits, HIV testing, receiving results, and initiating maternal and infant prophylaxis. The study emphasises the significance of early HIV diagnosis, revealing that women diagnosed before pregnancy are more likely to complete the PMTCT cascade, which includes starting and maintaining ART. Additionally, awareness of a partner’s HIV status is crucial; women who know their partner’s status tend to engage more in PMTCT services and adhere to ART. To help improve outcomes, the authors advocated for integrated, patient-centred interventions that enhance access to care and address barriers throughout the PMTCT process [32]. Male partner involvement not only enhances the uptake of PMTCT services but also fosters a supportive environment that improves adherence to treatment regimens.
A level-one study investigating social and structural determinants of household support for ART adherence in low- and middle-income countries acknowledged the critical role of social context in shaping health-related behaviours and influencing the success of interventions, drawing on socio-ecological theory. The study noted the importance of household dynamics as a micro-environment within socio-ecological models, pointing out that households can provide various forms of support to PLWH, such as practical assistance, emotional encouragement, and the sharing of information. It further highlighted that households fostering open communication, supporting disclosure, and engaging in prevention efforts can be described as “HIV competent”, thereby creating a health-enabling environment that facilitates ART adherence and promotes preventive behaviours [33].
Income levels also play a critical role in ART adherence [19]. Economic constraints can limit access to healthcare services and transportation, directly affecting consistent engagement with ART programmes. Financial insecurity often exacerbates the challenges faced by HIV-positive mothers, making it difficult for them to attend regular appointments or afford associated costs.
Additionally, health facilities situated at considerable distances from patients’ homes, the accessibility of health centres, and the perceived side effects of antiretroviral medications were identified as significant institutional factors affecting ART uptake among HIV-positive mothers at Mbale Regional Referral Hospital. Situated in Mbale District in eastern Uganda, this hospital serves a wide population from neighbouring districts such as Dusia, Budaaka, Bukwo, Butaleja, and Manafwa. The limited number of vehicles operating at irregular times means that if a mother misses her transport option, she may have to wait until the next day or hour for another means of transportation to get to MRRH. These findings point to the critical role that institutional factors play in shaping patient experiences and outcomes within ART programmes. Furthermore, such barriers reflect the complex relationship between healthcare accessibility and ART adherence, highlighting broader structural challenges that can undermine efforts to ensure consistent treatment for HIV-positive mothers. However, contrasting evidence from other studies conducted in Uganda suggests that distance may not always act as a barrier to accessing HIV care. For instance, researchers found that among patients LTFU, those living farther from clinics were more likely to re-establish care at alternative sites. This trend was attributed to the decentralisation of ART services in Uganda, which saw a significant increase in rural treatment sites, from a single ART provider in southwest Uganda in 2000 to over 60 sites by 2009. This decentralisation likely reduced geographic barriers by bringing services closer to patients [34].
A study highlighted that ART is associated with various side effects, ranging from mild issues like fatigue and gastrointestinal discomfort to more severe complications such as lactic acidosis and metabolic disorders. These adverse effects can significantly impact a patient’s adherence to treatment, often leading to discontinuation or non-compliance. Although newer ART regimens have reduced the incidence of severe side effects, managing both short- and long-term toxicities remains essential for maintaining adherence and achieving effective viral suppression [35]. Likewise, our study demonstrates that side effects are a significant factor influencing ART adherence. The findings reveal that the burden of side effects negatively impacts ARV uptake among HIV-positive mothers in Mbale, highlighting the importance of addressing these challenges within ART programmes to improve adherence and health outcomes.
Access to ART has significantly improved across sub-Saharan Africa in recent years, with millions of people now receiving treatment. An earlier study by Kipp et al. (2012) highlighted that while ART has become increasingly available in sub-Saharan Africa, significant disparities persist in rural areas, where much of the population resides. In Uganda, despite improvements in ART provision, major gaps remain due to a shortage of trained healthcare professionals. This limits the consistent availability and accessibility of ART services in these areas. Involving community members in delivering high-quality ART care could address these challenges by ensuring routine follow-ups and improving the distribution of medications, thereby alleviating the burden on clinical staff [15]. Strengthening community-based approaches is crucial to ensuring the consistent availability of ART drugs and improving treatment access for underserved rural populations.
Waiting time significantly affects the uptake and adherence to ART among pregnant women in Uganda. Long waiting periods at healthcare facilities can discourage patients from seeking timely care or lead them to miss appointments altogether. In the context of our study, where a percentage of respondents reported consistently waiting for service delivery, with some waiting over 30 minutes, these delays can contribute to frustration and decreased motivation to adhere to treatment regimens. For example, a scoping review by Nwagbara et al. (2024) found that overcrowding, staff shortages, and inefficient administrative systems contribute significantly to extended waiting times in primary healthcare facilities in South Africa. These delays often result from high patient volumes, inadequate infrastructure, and poor time management among staff, which collectively create bottlenecks in service delivery [15]. Another study emphasised that long waiting times can lead to patient dissatisfaction and reduced adherence to treatment, as overcrowding and resource constraints hinder timely access to care [36]. To address waiting times in rural Uganda, feasible strategies include implementing basic appointment scheduling systems to manage patient flow and reduce overcrowding, as well as introducing simple triage protocols [37][38] to prioritise patients based on urgency. Engaging community health workers to assist with routine follow-ups and patient education can alleviate the burden on healthcare providers while improving service delivery. Additionally, decentralising ART services through community-based drug distribution points or outreach programmes can bring services closer to patients, reducing congestion at health facilities. Finally, modest investments in staffing, such as training and deploying more nurses or clinical officers, can enhance efficiency and ensure timely service delivery.
These intersecting factors highlight the need for integrated approaches that address both structural and cultural barriers to improve health outcomes for women. Therefore, ensuring every HIV-positive mother successfully navigates the pathway from diagnosis to sustained ART adherence requires integrated patient-centred interventions that prioritise accessible care, minimise loss to follow-up, and address individual challenges throughout the pregnancy and postpartum period.
Although our study demonstrates a high initial ART uptake, this does not guarantee sustained adherence over time. The challenges associated with distance, economic constraints, and side effects, as revealed in our findings (Table 1,Table 4,Table 6), are likely to compound in the postpartum period, potentially leading to decreased adherence and increased risk of vertical transmission. Sustaining adherence requires a multifaceted approach that addresses these persistent barriers and empowers women to remain engaged with ART services throughout their lives.
The complex interplay of individual, social, and institutional factors identified in our study underscores the need for a holistic, integrated approach to PMTCT programmes. Focusing solely on ART initiation without addressing the broader determinants of adherence is unlikely to yield sustainable results. For example, addressing stigma and promoting male involvement (as highlighted by [26][31][32]) can create a more supportive environment for women to adhere to ART, while decentralising ART services as suggested by [34] and improving transportation options can reduce geographical barriers. Ultimately, a comprehensive strategy is needed that empowers women to overcome the various challenges they face in accessing and adhering to ART.
Our findings suggest that while Uganda’s Option B+ programme has been successful in achieving high ART uptake rates, sustained efforts are needed to ensure long-term adherence and retention in care. This requires a shift from a primarily clinic-based approach to a more community-centred model that leverages the resources and expertise of local communities. Community health workers can play a vital role in providing ongoing support and monitoring, identifying and addressing barriers to adherence, and linking women to necessary resources. By empowering communities to take ownership of the PMTCT programme, we can create a more sustainable and equitable system of care.