A cross-sectional study design was adopted using a mixed methods approach where qualitative and quantitative data was collected and analysed.

A study was conducted at Mama Lucy Kibaki Hospital (MLKH), a government hospital in the Eastland of Nairobi city.

The study population was all infants who were born to mothers living with HIV, currently enrolled at the Mama Lucy Kibaki Hospital EID register.

The Cochran formula was used for sample size calculation. A 95% confidence level with 5% as the tolerable error and the 68% proportion of HEIs who were timely enrolled in EID in Kenya, was substituted in the formula [14]-[16]. After the calculations, a systematic random sampling was used to select 153 HEIs. For the in-depth interviews, a healthcare provider; three nurses, two clinicians and two mother mentors who were running the EID clinic were all interviewed.

Pre-test semi-structured interviews were administered a questionnaire containing 4 parts was developed. An In-depth interview guide to understand how the health facility contributed to the late enrolment of HEIs was used.

The quantitative data entry, cleaning, coding, and analysis were done using STATA Version 14. Descriptive statistics (frequency, proportion and measures of central tendency) were used to summarize the data. Fisher’s exact test and regression were used to analyze the data at the bivariable and multivariable levels, respectively. All analyses were done at a 95% confidence level.

The study outcome was to determine the Maternal and Facility Level Factors Influencing Enrolment Time for Early Infant Diagnosis Services. This was done by categorising the infants enrolled at birth and before the age of 6 weeks as enrolled in time and the ones after 6 weeks of age as late enrolled.

Qualitative data were entered using the NVIVO software which was then presented thematically by describing emerging themes obtained from the healthcare workers working at the EID clinic.

Ethical approval was sought from Jomo Kenyatta University of Agriculture and Technology Institutional Research Ethical Committee (IREC) JKU/ISERC/02316/ 0824.

The research permit was sought from the National Commission for Science, Technology & Innovation, NACOSTI/P/23/24655.

The permission was also sought from the Nairobi County Ministry of Health through the Medical Superintendent and its research committee of Mama Lucy Kibaki Hospital. Risks, benefits, confidentiality and voluntary participation were clearly explained. Written and informed consent was obtained and duly signed by the study participants.

3.1.1. Sociodemographic Characteristics of Respondents

The majority fall between the age group of 25 - 34 with a median age of 29.5 years. Approximately 83.0% were married with only 8.5% single mothers. Most of the mothers (49.0%) formally employed. Most of the mothers had a guardian, out of the 153 mothers at least 84 (54%) had a husband as their guardian. Almost all mothers attended school with only 2 (1.3%) who did not attend and the majority of the mothers (60.1%) with secondary school level (15.7%) were women who went far up to primary level and 35 (22.9%) were women who went far up to tertiary level (see Table 1).

Table 1. Demographic data.

3.1.2. HIV Disclosure

Most of the mother (85%) disclosed their HIV status to their husband. Almost half of the mothers (56.2%) disclosed their HIV status to their relatives (see Figure 1).

3.1.3. Time of HIV Diagnosis

At least 55.6% of the mothers were diagnosed HIV positive before they got pregnant. 30.7% of the mothers were diagnosed HIV positive during the time of pregnancy. There were 3.3% of mothers who were diagnosed HIV positive during the time of delivery. At least 10.5% of the mothers were diagnosed as HIV-positive during the time of breastfeeding (see Figure 2).

3.1.4. Gestation Age at 1st PMTCT/ANC Visit

Most of the mothers (79.1%) attended the PMTCT/ANC visit during their first trimester of this baby (Figure 3). At least 3.3% of mothers attended the PMTCT/ANC visit in the second trimester. At least 3.9% of mothers attended the PMTCT/ANC visit in the third trimester. At least 13.7% of the mothers attended the PMTCT/ANC visit after giving birth (Table 2).

3.1.5. The Proportion of Infants Enrolled in Care

9.2% of infants were enrolled after 6 weeks, which was considered a delay in EID services (see Figure 4).

3.1.6. Factors Associated with Delayed Enrolment

1.Sociodemographic characteristics and other maternal characteristics inassociation with the enrolment in the EID program

The association of individual values between maternal sociodemographic characteristics and the enrolment time in the EID services was measured using chi-square and Fisher exact test as some cells had expected counts less than five. At 95% confidence level p-value of 0.05, the Fisher’s exact test values for several social demographic variables were significant including marital status, occupation and household income (0.016), (0.001) and (0.010) respectively (see Table 2).

On the maternal side, the age of gestation at the first PMTCT/ANC visit influenced the time of enrolment in the EID clinic (p = 0.000). The time of HIV diagnosis and the time of initiating the ART to the mother influenced the time of enrolment in the EID program (p = 0.000) and (p = 0.001) respectively. Mothers disclosing their HIV status to either their husbands or other relatives influenced infant enrolment in the EID program (p = 0.002) and (p = 0.045) respectively (see Table 2).

Table 2. The association of individual factors and the time of HEI enrollment for EID services.

2.Binary logistics regression on maternal factors associated with EID enrolment time

The regression model was run using STATA to find factors that are associated with the time of enrolment in the EID services among infants. There were four variables (marital status, number of PMTCT/ANC visits, time of HIV diagnosis, disclosure status and time of ART initiation) that were significant at a p-value of 0.05. The mothers who were married [OR = 0.468 (95% CI 0.006 - 0.324), p = 0.012] were less likely to be delayed in the enrolment than single mothers. The mothers who had who attended four, three and two PMTCT/ANC visits were less likely to delay in enrolment than those who attended one PMCTC/ANC visit with [OR = 0.800 (95% CI 0.001 - 0.188), p = 0.004], [OR = 0.347 (95% CI 0.003 - 0.395), p = 0.009] and [OR = 0.473 (95% CI 0.010 - 0.190), p = 0.011] respectively. Mothers who were diagnosed HIV positive during the time of childbirth and during breastfeeding were more likely to delay in enrolment than those who were diagnosed before becoming pregnant with [OR = 3.530 (95% CI 0.004 - 1.077), p = 0.044] and [OR = 2.089 (95% CI 0.001 - 0.979), p = 0.009] respectively. The mothers who disclosed their HIV status to their husbands [OR = 0.313 (95% CI 00.049 - 2.000), p = 0.019] were less likely to be delayed in the enrolment than the mothers who did not disclose their HIV status. The mothers who were initiated on ART before becoming pregnant [OR = 0.313 (95% CI 00.049 - 2.000), p = 0.019] were less likely to be delayed in the enrolment than mothers who were initiated on ART after giving birth (see Table 3).

Table 3. The Binary logistic regression on maternal factors associated with EID enrolment time.

3.2.1. Social Demographic Characteristics of Qualitative Study Participants

To understand the hospital-level factors influencing the delayed enrolment at MLKH, a qualitative research method was conducted. The healthcare providers at MLKH PMTC/EID clinic were interviewed using an in-depth interview guide and saturation was reached at 6 participants (see Table 4).

Table 4. Social Demographic characteristics of respondents.

3.2.2. Thematic Areas Assessed

The data was analysed using Nvivo and the following thematic areas were assessed:

Human resource factorsMedical supplies availabilityOrganization of services Referral mechanismAttitude toward clients

1. Themeone: Human resource factors

The healthcare providers working at the PMTCT/EID clinic were interviewed using an in-depth interview guide and some of the word were coated.

“Itisnotallthedepartmentsatthishospitalthatwearetrainedonthisservicedelivery. Youmightfindsomeofthedepartment’sonlyonepersonistrainedonPMTCT/EIDandsometimesnotatall.”

“WeusuallystruggletrackingtheHIVExposedInfantsoncetheHIVstatuswasunknownthetimeofdeliveryorifthemotherjustcomeatourfacilityfordeliveryandANCservicesweredoneinotherfacilities. Iwilltalkonmyside, asamothermentor, weareonlytwomothers’ mentorsandimagineasIamtalkingmycolleagueisonannualleave.” … a female mother mentor with 6 years’ experience participant.

2.Theme two: Medical supplies

It was another theme that was reported as one of the factors contributing to the delayed enrolment among infants in the EID services. The term “drug stockout” was reported many times by the healthcare worker. The issue of drug stockout though is not a common one but it was reported to be at the beginning of the year 2023.

“YouknowMamaLucyisareferralhospital, somostofthetimethemotherwhoattendedANCsomewhereelseapartfromheremightpresentwithoutnevirapineprophylaxis. Thismightbeduetostockoutofthenevirapinefromtheirfacility.” … a female mother mentor with 5 years’ experience participant.

“Usually, wedon’thavethosescenarios. TheonlytimeIrememberitwastheeraofcovid 19 whenwehadshortsupplybutnotreallyfornevirapine.” … … a female clinician with 8 years’ experience participant.

“Sometimesweexperiencethestockoutoftheprophylaxissothemothermightgohomewithoutthemedicationandcomeafterdelivery.” ... a female clinician with 9 years’ experience participant.

“Atthebeginningofthisyear, asacountry, wewerestruckbadlywithCOVID-19 soIcouldsuggestthatwastheproblemthatbroughtashortageofmedicalsuppliesincludingtheDBStestkit, ARTsyrupprophylaxisandadultART.” … a female mother mentor with 6 years’ experience participant.

“Thechallengeofdrugsupplywasthere, wecouldevenshareonebottlewithtwomotherssothattheycomeagainnexttimetorefilltheirARThopingthedrugswillbeavailablebythen.” … a female nurse with 7 years’ experience participant.

3.Theme three: Organization of services

The mother once known to be pregnant is supposed to receive the ART at the PMTCT/EID clinic till the baby is born then the baby is enrolled into care. The mother is given scheduled visits of one month up to six months depending on the bottle of ART supply.

“SometimesyoufindthatamotherhasmanipulatedthewrittenresultsofHIVtestintheirHealthpassportbooknottobeknownasHIVpositivepersonevenchangingthebookwillmakeahealthypersonmisstheclients. Sometimeswhenthemothershavedelivered, theydodgeHIVtestingandevenmissitthentheycometothehospitalafterseeingthebabyissickthenyoufindoutthatboththemotherandthebabyarepositiveoronlythemotherispositive. Afterprobingmore, themotherthenmightbeopenreviewingherselfbeingonARTfromacertainhospitalbutshestoppedbychoice. MotherssometimesaremissedatthePMTCTclinic, ithappensthatamotherispregnantfor 7 or 8 monthsandhassentaguardianfortheART. IteasyforthismothertomisscollectingARTforherbabywithinthe 6 weeksoflife.” … a male clinician with 13 years’ experience participant.

“Thesystemmightfailussometimes, talkingoftwomothermentorsmightsoundtobeenoughbutwhenitcomestohavingdefaultersthennowtracingcomesachallenge. Ourtracingsystemisnotgoodenough, resourceshortagebeingoneofthereasons.” … a female mother mentor with 6 years’ experience participant.

4.Theme four: Referral mechanism

The facility of MLKH is a referral hospital and received several clients from level 3 and 4 hospitals. Again within the facility, the clients are being referred to PMTCT/EID clinic. Much interest was referral within the facility as all intransit infants were excluded in this study.

“PMTCT/EIDareallofferedatoneplace, theonlychallengewehaveisawomanbeingreferredfromCCCtoPMTCT/EIDclinic, sometimeswefairtolinkthesewomenintime.” … a female mother mentor with 6 years’ experience participant.

“Wemissclientspregnantmothershere, awomanwillappearforthefirstPMTCT/EIDclinicwhileinthethirdtrimesteroraftergivingbirthbecauseourreferralsystemisnotsogood.” … a female clinician with 8 years’ experience participant.

“YouknowMamaLucyisareferralhospital, somostofthetimethemotherwhoattendedANCsomewhereelseapartfromheremightpresentwithoutnevirapineprophylaxis. Therefore, inthelabourward, thehealthcareproviderattendingtothispregnantmothermightoverlooktheissueofNevirapinesyrup.” … a female nurse with 9 years’ experience participant.

“Iwouldsuggestthatwomenaresupposedtobeescortedfromwheretheyarebeingreferred. Iamsayingthisfromexperience, awomancanbeseenattheOutpatientdepartmentandthenreferredforPMTCT/EIDservicesbutthesewomendonotshowup. Usually, theyaretiredoflongqueuesatOPDandtheyhavethesameimpressionthatisthesamethingthisside.” … a female nurse with 7 years’ experience participant.

5.Theme five: Attitude of healthcare providers toward clients

The word “attitude” was widely reported by a good number of healthcare providers. This attitude was reported as how some healthcare workers express towards HIV-positive mothers when they are receiving the services.

“Sometimestheattitudeofthehealthcareworkercontributealot. Forexample, apregnantmotheroraninfantmothercametotheclinicandthiswomanisnotonART. FortheHealthcareworkerregardingthattherearehighchancesforthebabytocontractHIV, He/Shemightoverreactfrustratingthemother. Themothermightbepsychologicallydisturbedandnotwillingtocomebackagain.” ... a female clinician with 8 years’ experience participant.

“IdounderstandthatsomehealthcareworkerhasbadattitudeandjudgmentaloncesomeoneisHIVPositiveandcanaffectthecarebecausemostofthetimetheseclients’ needsloveandcaring.” … a female mother mentor with 6 years’ experience participant.

“SometimestheattitudeofthehealthcareworkerscontributestolossofinterestfortheHIVservices.” … a female clinician with 8 years’ experience participant.