title: Sex inequality, high transport costs, and exposed clinic location: reasons for loss to follow-up of clients under prevention of mother-to-child HIV transmission in eastern Uganda - a qualitative study.
abstract: BACKGROUND
  In Iganga, Uganda, 45% of women who tested HIV-positive during antenatal care between 2007 and 2010 were lost to follow-up (LTFU). We explored reasons for LTFU during prevention of mother-to-child transmission (PMTCT) from a client perspective in eastern Uganda, where antiretroviral therapy (ART) awareness is presumably high.
  
  
  METHODS
  Seven key informant interviews and 20 in-depth interviews, including both clients who had been retained under PMTCT care and those LTFU during PMTCT were held. Ten focus-group discussions involving a total of 112 participants were also conducted with caretakers/ relatives of the PMTCT clients. Content analysis was performed to identify recurrent themes.
  
  
  RESULTS
  Our findings indicate that LTFU during PMTCT in eastern Uganda was due to sex inequality, high transport costs to access the services, inadequate posttest counseling, lack of HIV status disclosure, and the isolated/exposed location of the ART clinic, which robs the clients of their privacy.
  
  
  CONCLUSIONS
  There is a need for approaches that empower women with social capital, knowledge, and skills to influence health-seeking practices. There is also a need to train low-ranking staff and take PMTCT services closer to the clients at the lower-level units to make them affordable and accessible to rural clients. Posttest counseling should be improved to enable PMTCT clients to appreciate the importance of PMTCT services through increasing the number of staff in antenatal care to match the client numbers for improved quality. The counseling should emphasize HIV status disclosure to partners and encourage partner escort for antenatal care visits for further counseling. The exposed and isolated ART clinic should be integrated with the other regular outpatient services to reduce the labeling stigma.
authors.affiliation: District Health Office, Iganga District Administration, Iganga, Uganda ; Research Institute, Busoga University, Iganga, Uganda ; School of Graduate Studies and Research, Busoga University, Iganga, Uganda ; National Institutes of Health/NIAID-ICER American Embassy, Kampala, Uganda.
authors.forename: Muhamadi
authors.initials: M
authors.lastname: Lubega
authors.forename: Ibrahim A
authors.initials: IA
authors.lastname: Musenze
authors.forename: Gukiina
authors.initials: G
authors.lastname: Joshua
authors.forename: George
authors.initials: G
authors.lastname: Dhafa
authors.forename: Rose
authors.initials: R
authors.lastname: Badaza
authors.forename: Christopher J
authors.initials: CJ
authors.lastname: Bakwesegha
authors.forename: Steven J
authors.initials: SJ
authors.lastname: Reynolds
keywords: HIV; Uganda; mother-to-child transmission; sex inequality