Abstract：
BACKGROUND: Many women in sub-Saharan Africa initiate antenatal care (ANC) late in pregnancy, undermining optimal prevention of mother-to-child-transmission (PMTCT) of HIV. Questions remain about whether and how late initiation of ANC in pregnancy is related to adherence to antiretroviral therapy (ART) in the era of national dolutegravir roll-out.
METHODS: This study employed a qualitative design involving individual interviews and focus group discussions conducted between August 2018 and March 2019. We interviewed 37 pregnant and lactating women living with HIV selected purposively for early or late presentation to ANC from poor urban communities in South Africa and Uganda. Additionally, we carried out seven focused group discussions involving 67 participants in both countries. Data were analysed thematically in NVivo12.
RESULTS: Women described common underlying factors influencing both late ANC initiation and poor ART adherence in South Africa and Uganda. These included poverty and time constraints; inadequate health knowledge; perceived low health risk; stigma of HIV in pregnancy; lack of disclosure; and negative provider attitudes. Most late ANC presenters reported relationship problems, lack of autonomy and the limited ability to dialogue with their partners to influence household decisions on health and resource allocation. Perception of poor privacy and confidentiality in maternity clinics was rife among women in both study settings and compounded risks associated with early disclosure of pregnancy and HIV. Women who initiated ANC late and were then diagnosed with HIV appeared to be more susceptible to poor ART adherence. They were often reprimanded by health workers for presenting late which hampered their participation in treatment counselling and festered provider mistrust and subsequent disengagement in care. Positive HIV diagnosis in late pregnancy complicated women\'s ability to disclose their status to significant others which deprived them of essential social support for treatment adherence. Further, it appeared to adversely affect women\'s mental health and treatment knowledge and self-efficacy.
CONCLUSIONS: We found clear links between late initiation of ANC and the potential for poor adherence to ART based on common structural barriers shaping both health seeking behaviours, and the adverse impact of late HIV diagnosis on women\'s mental health and treatment knowledge and efficacy. Women who present late are a potential target group for better access to antiretrovirals that are easy to take and decrease viral load rapidly, and counselling support with adherence and partner disclosure. A combination of strengthened health literacy, economic empowerment, improved privacy and patient-provider relationships as well as community interventions that tackle inimical cultural practices on pregnancy and unfair gender norms may be required.
METHODS: This study employed a qualitative design involving individual interviews and focus group discussions conducted between August 2018 and March 2019. We interviewed 37 pregnant and lactating women living with HIV selected purposively for early or late presentation to ANC from poor urban communities in South Africa and Uganda. Additionally, we carried out seven focused group discussions involving 67 participants in both countries. Data were analysed thematically in NVivo12.
RESULTS: Women described common underlying factors influencing both late ANC initiation and poor ART adherence in South Africa and Uganda. These included poverty and time constraints; inadequate health knowledge; perceived low health risk; stigma of HIV in pregnancy; lack of disclosure; and negative provider attitudes. Most late ANC presenters reported relationship problems, lack of autonomy and the limited ability to dialogue with their partners to influence household decisions on health and resource allocation. Perception of poor privacy and confidentiality in maternity clinics was rife among women in both study settings and compounded risks associated with early disclosure of pregnancy and HIV. Women who initiated ANC late and were then diagnosed with HIV appeared to be more susceptible to poor ART adherence. They were often reprimanded by health workers for presenting late which hampered their participation in treatment counselling and festered provider mistrust and subsequent disengagement in care. Positive HIV diagnosis in late pregnancy complicated women\'s ability to disclose their status to significant others which deprived them of essential social support for treatment adherence. Further, it appeared to adversely affect women\'s mental health and treatment knowledge and self-efficacy.
CONCLUSIONS: We found clear links between late initiation of ANC and the potential for poor adherence to ART based on common structural barriers shaping both health seeking behaviours, and the adverse impact of late HIV diagnosis on women\'s mental health and treatment knowledge and efficacy. Women who present late are a potential target group for better access to antiretrovirals that are easy to take and decrease viral load rapidly, and counselling support with adherence and partner disclosure. A combination of strengthened health literacy, economic empowerment, improved privacy and patient-provider relationships as well as community interventions that tackle inimical cultural practices on pregnancy and unfair gender norms may be required.
摘要：
背景：撒哈拉以南非洲的许多妇女在怀孕后期开始产前护理（ANC），破坏对艾滋病毒母婴传播（PMTCT）的最佳预防。在国家dolutegravir推出的时代，关于是否以及如何在怀孕期间启动ANC与坚持抗逆转录病毒治疗（ART）有关的问题仍然存在。
方法：本研究采用了定性设计，涉及2018年8月至2019年3月进行的个人访谈和焦点小组讨论。我们采访了37名感染艾滋病毒的孕妇和哺乳期妇女，这些妇女有目的地从南非和乌干达的贫困城市社区向ANC早期或晚期介绍。此外,我们进行了七次有重点的小组讨论，涉及两国的67名参与者。数据在NVivo12中进行了主题分析。
结果：在南非和乌干达，妇女描述了影响ANC启动晚和ART依从性差的共同潜在因素。其中包括贫穷和时间限制；健康知识不足；认为健康风险低；怀孕期间艾滋病毒的污名化；缺乏披露；和提供者的负面态度。大多数已故的ANC主持人都报告了关系问题，缺乏自主性和与合作伙伴进行对话以影响家庭在健康和资源分配方面的决策的能力有限。在这两种研究环境中，妇女对妇产科诊所的隐私和机密性不佳的认识很普遍，并且与怀孕和艾滋病毒的早期披露相关的风险也很复杂。启动ANC较晚，然后被诊断为HIV的女性似乎更容易受到ART依从性差的影响。他们经常因迟到而受到卫生工作者的谴责，这阻碍了他们参与治疗咨询，加剧了提供者的不信任，并随后脱离了护理。妊娠晚期HIV阳性诊断使妇女向重要的其他人披露自己的状况的能力变得复杂，这剥夺了她们对治疗依从性的基本社会支持。Further,它似乎对女性的心理健康、治疗知识和自我效能产生不利影响。
结论：我们发现，基于共同的结构性障碍形成两种寻求健康的行为，ANC的晚期启动与ART依从性差的可能性之间存在明显的联系。以及晚期HIV诊断对女性心理健康和治疗知识及疗效的不利影响。迟到的女性是一个潜在的目标群体，可以更好地获得易于服用并迅速降低病毒载量的抗逆转录病毒药物。以及通过遵守和合作伙伴披露提供咨询支持。结合加强健康素养，经济赋权，可能需要改善隐私和患者与提供者的关系，以及社区干预措施，以解决有关怀孕的有害文化习俗和不公平的性别规范。
方法：本研究采用了定性设计，涉及2018年8月至2019年3月进行的个人访谈和焦点小组讨论。我们采访了37名感染艾滋病毒的孕妇和哺乳期妇女，这些妇女有目的地从南非和乌干达的贫困城市社区向ANC早期或晚期介绍。此外,我们进行了七次有重点的小组讨论，涉及两国的67名参与者。数据在NVivo12中进行了主题分析。
结果：在南非和乌干达，妇女描述了影响ANC启动晚和ART依从性差的共同潜在因素。其中包括贫穷和时间限制；健康知识不足；认为健康风险低；怀孕期间艾滋病毒的污名化；缺乏披露；和提供者的负面态度。大多数已故的ANC主持人都报告了关系问题，缺乏自主性和与合作伙伴进行对话以影响家庭在健康和资源分配方面的决策的能力有限。在这两种研究环境中，妇女对妇产科诊所的隐私和机密性不佳的认识很普遍，并且与怀孕和艾滋病毒的早期披露相关的风险也很复杂。启动ANC较晚，然后被诊断为HIV的女性似乎更容易受到ART依从性差的影响。他们经常因迟到而受到卫生工作者的谴责，这阻碍了他们参与治疗咨询，加剧了提供者的不信任，并随后脱离了护理。妊娠晚期HIV阳性诊断使妇女向重要的其他人披露自己的状况的能力变得复杂，这剥夺了她们对治疗依从性的基本社会支持。Further,它似乎对女性的心理健康、治疗知识和自我效能产生不利影响。
结论：我们发现，基于共同的结构性障碍形成两种寻求健康的行为，ANC的晚期启动与ART依从性差的可能性之间存在明显的联系。以及晚期HIV诊断对女性心理健康和治疗知识及疗效的不利影响。迟到的女性是一个潜在的目标群体，可以更好地获得易于服用并迅速降低病毒载量的抗逆转录病毒药物。以及通过遵守和合作伙伴披露提供咨询支持。结合加强健康素养，经济赋权，可能需要改善隐私和患者与提供者的关系，以及社区干预措施，以解决有关怀孕的有害文化习俗和不公平的性别规范。
