Manuscript title: Facilitators and barriers to cotrimoxazole prophylaxis among HIV exposed babies: a qualitative study from Harare, Zimbabwe.
BACKGROUND
Implementation of cotrimoxazole prophylaxis (CTX-p) among HIV-exposed infants (HEI) is poor in southern Africa. We conducted a study to investigate barriers to delivery of CTX-p to HEI in Zimbabwe at each step of the care cascade. Here we report findings of the qualitative component designed to investigate issues related to adherence conducted among women identified as HIV positive whose babies were started on CTX-p postnatally. Of note, Zimbabwe also provided nevirapine prophylaxis for HIV exposed babies, so the majority were giving nevirapine and CTX-p to their babies.


METHODS
Between Feb-Dec 2011, the first 20 HIV infected mothers identified were invited for in-depth interview 4-5months postnatally. Interviews were recorded, transcribed, translated and analysed thematically.


RESULTS
All women desired their baby's health above all else, and were determined to do all they could to ensure their wellbeing. They did not report problems remembering to give drugs. The baby's apparent good health was a huge motivator for continued adherence. However, most women reported that their husbands were less engaged in HIV care, refusing to be HIV tested and in some cases stealing drugs prescribed for their wives for themselves. In two instances the man stopped the woman from giving CTX-p to the baby either because of fear of side effects or not appreciating its importance. Stigma continues to be an important issue. Mothers reported being reluctant to disclose their HIV status to other people so found it difficult to collect prescription refills from the HIV clinic for fear of being seen by friends/relatives. Some women reported that it was hard to administer the drugs if there were people around at home. Other challenges faced were stock-outs of CTX-p at the clinic, which occurred three times in 2011. The baby would then go without CTX-p if the woman could not afford buying at a private pharmacy.


CONCLUSIONS
The study highlights that adherence knowledge and desire alone is insufficient to overcome the familial and structural barriers to maintaining CTX-p. Improving adherence to CTX-p among HEI will require interventions to improve male involvement, reduce HIV stigma in communities and ensure adequate supply of drugs.
Centre for Sexual Health and HIV/AIDS Research, (CeSHHAR) Zimbabwe, 9 Monmouth Rd, Avondale West, Harare, Zimbabwe. euphemia@ceshhar.co.zw.
Euphemia L
EL
Sibanda
Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK. sarah.bernays@lshtm.ac.uk.
Sarah
S
Bernays
Department of Infection and Population Health, University College London Medical School, London, UK. i.weller@ucl.ac.uk.
Ian V D
IV
Weller
Department of Medicine, University of Zimbabwe College of Health Sciences, Harare, Zimbabwe. jhakim@mweb.co.zw.
James G
JG
Hakim
Centre for Sexual Health and HIV/AIDS Research, (CeSHHAR) Zimbabwe, 9 Monmouth Rd, Avondale West, Harare, Zimbabwe. f.cowan@ucl.ac.uk.|Department of Infection and Population Health, University College London Medical School, London, UK. f.cowan@ucl.ac.uk.
Frances M
FM
Cowan
D000328:Adult; D003430:Cross-Sectional Studies; D004338:Drug Combinations; D005260:Female; D015658:HIV Infections / Q000517:prevention & control* / Q000523:psychology*; D006801:Humans; D007223:Infant; D019829:Nevirapine / Q000627:therapeutic use; D056990:Post-Exposure Prophylaxis / Q000379:methods*; D036301:Qualitative Research; D057545:Social Stigma; D015662:Trimethoprim, Sulfamethoxazole Drug Combination / Q000008:administration & dosage*; D015030:Zimbabwe
D004338:Drug Combinations; D015662:Trimethoprim, Sulfamethoxazole Drug Combination; D019829:Nevirapine