Prevention and care of paediatric HIV infection in Ouagadougou, Burkina Faso: knowledge, attitudes and practices of the caregivers

An estimated 3.3 million of children under 15 years of age are currently living with Human Immunodeficiency Virus (HIV) worldwide, with the majority in sub-Saharan Africa [1]. The infant mortality among perinatally HIV-infected children is high and can reach 52 % at 2 years of age in the absence of antiretroviral treatment [2, 3]. In 2008, the World Health Organization (WHO) recommended the universal early antiretroviral treatment (ART) for all HIV-infected children less than 12 months of age, irrespective of clinical status or symptomatology, because early infant antiretroviral treatment has proved to be efficient in improving their survival [4]. This recommendation was extended to all children less than 24 months of age in 2010 [5]. However, only 34 % of eligible children for treatment were actually on ART at the end of 2012, compared with a 63 % adult coverage, and only 35 % of infants born to HIV-positive mothers had an early infant HIV diagnosis (EID) in their first 2 months of life [1]. This inequity in access to EID and ART in children is worst in West Africa, compared to East and Southern Africa [6].

To improve early access to paediatric antiretroviral therapy in resource-limited settings, it is crucial to implement public health strategies to promote the acceptability of HIV EID at the community level, targeting both health care professionals and children’s caregivers [7]. This is even truer in West Africa [8, 9].

Thus, it is crucial to understand caregivers’ knowledge and perception in order to understand the barriers to paediatric HIV prevention and treatment strategies. Caregivers’ knowledge regarding paediatric HIV care is important for children’s antiretroviral treatment adherence as reported elsewhere [10–14].

Burkina Faso is a West African developing country with a gross national income per capita of $1,500 in 2013 [15]. The overall schooling rate at primary school in 2009/2010 was estimated at 74.8 % [16]. The public health system was divided into three levels: the health districts, the regional hospitals, and the university hospitals. In addition, there were 398 private health care facilities operating in the country in 2012 [17]. The 2010 health and demographic survey reported a national HIV prevalence of 1.0 %, reaching 2.1 % (sample size 2018) in Ouagadougou [18].

The 2010 health demographic survey also revealed that 98.3 % of women (sample size 17, 087) and 98.1 % of men, aged from 15 to 49 years (sample size 6,500) were aware of Acquired Immunodeficiency Syndrome (AIDS) in the whole country. In Ouagadougou, the capital of the country, 99.4 % (sample size 2,240) of women and 99.8 % (sample size 977) men were aware of AIDS. The use of condom as a mean of HIV prevention was known in 78.0 % (sample size 17,087) of women and 90.1 % (sample size 6,500) of men, aged from 15 to 49 years in the country. Knowledge related to the limited sexual intercourses to a single HIV-uninfected partner as a mean of prevention of sexual transmission, was mentioned by 86.1 % of women and 91.6 % of men aged from 15 to 49 years [18]. According to a study conducted in 2009 in Bobo Dioulasso, only 27.3 % (82/300) of women were aware of HIV MTCT through breastfeeding [19].

In Ouagadougou, Burkina Faso, it has been reported that 71 % of HIV exposed children did not have access to EID in 2011 [20]. Several factors are associated with this big gap: poor health facilities, health workers’ and caregivers’ low level of knowledge, negative attitudes and bad practices. In 2014, few data were available on caregivers’ knowledge about EID and paediatric HIV care in Burkina Faso’s field conditions. Thus, the objective of our study was to assess the knowledge, attitudes, and practices of the parents/caregivers regarding mother-to-child-transmission (MTCT) of HIV infection, EID, paediatric HIV infection, and antiretroviral treatment for HIV-infected children in Ouagadougou in 2011.

This survey gave an insight of caregivers’ knowledge and attitude about PMTCT, paediatric HIV infection diagnostic, existing prevention and HIV treatment strategies for children in Ouagadougou in 2011. Firstly, this study showed that despite an overall knowledge of MTCT modes, a few misconceptions still existed. Secondly, we highlighted the low level of knowledge among caregivers about the importance of performing EID even in asymptomatic HIV-exposed children allowing an earlier access to ART. Our results are useful to understand the barriers of EID uptake and paediatric HIV care in West-African children.

A total of 21 % of caregivers refused to participate in this survey, highlighting the possible lack of confidentiality and fear of stigma already mentioned in a similar context [21]. This lack of confidentiality may have also influenced the information collected among the responders, mainly in minimizing their difficulties facing the health care system or the health care workers.

Nevertheless, we were able to understand to some extent, caregivers’ knowledge, attitudes and practices at the different stages of paediatric HIV care cascade.

Our results showed that caregivers were globally aware of the HIV infection disease. We assume that this is the result of HIV prevention campaigns at community level in Burkina Faso since the early years when first cases of HIV infection were reported [22, 23].

Similarly, knowledge about PMTCT and EID using blood samples method was appreciable among caregivers, and there was no statistically significant difference between the groups when it comes to the method used to test their children. This result could be related either to a lack of statistical power, or to an absence of difference in terms of knowledge attitude and practices. However, as we expected a difference in knowledge about PMTCT and EID method in favour of those who were already in contact with HIV health care providers (groups 1 + 2 + 3), because of their frequent interactions with health staff, we could raise the hypothesis that health visits were not efficiently utilized to raise their awareness. So, health care providers should take advantage of the medical visits to cope with these issues.

But, the lack of difference in terms of knowledge of the group 4 versus the groups 1 + 2 + 3 can also be related to the level of education: the level of education amongst group 4 is greatly elevated and could account for any of the differences seen between the two groups.

In addition, caregivers misunderstanding and low level of knowledge about EID in asymptomatic children still remained. This could impede the routine EID coverage, and ultimately delay the ART treatment. This could partially explain the EID bottleneck in the 2011 cascade of care in Ouagadougou, with only 29 % of HIV-exposed children testing within their fist year of life [21]. Improving the coverage of the paediatric HIV care cascade at each stage requires addressing these misunderstandings through awareness campaigns. For instance in South Africa, a study showed that EID rate can be improved by using some strategies including awareness campaigns [24].

Some caregivers were reluctant to the practice of an EID without their consent, highlighting the fear of a possible stigmatization or mistrust of health workers’ practices. Conversely, they did not perceive the importance of consent prior to the infant antiretroviral treatment, whereas this formal consent would increase caregivers’ adherence to their infant ARV treatment [11, 14].

It is interesting to notice that all of the caregivers thought that early antiretroviral treatment was necessary for all HIV-infected infants, and this would decrease the mortality and morbidity rate if the service was accessible to the population. This could explain why we recorded a small proportion of refusal among caregivers referred for their infant HIV treatment initiation in the recruitment phase of the MONOD trial, implemented in Ouagadougou. The results of this trial will be presented elsewhere.

Some issues related to staff practices, such as carrying out the HIV test without caregivers’ prior consent, may be addressed by improving training in paediatric wards, as it has already been reported in Côte d’Ivoire [9] and South Africa [25]. However, changing caregivers’ attitudes may require interventions to raise their awareness at both individual and community level.

As for healthcare providers, they should actively promote HIV testing and care-seeking for children, by seizing all opportunities with caregivers.

Before concluding, we could discuss a few study limits. Although, our sample size was limited, the sampling method was adapted to qualitatively understand some perceptions, at the different steps of the cascade of paediatric HIV care from access to PMTCT services, EID services, and child care in Ouagadougou.

In addition, considering a group of “caregivers of HIV exposed but confirmed uninfected children” could have enriched the understanding of KAP in Ouagadougou, but it was not feasible in the cross-sectional design at the time of attendance in paediatric care.

In conclusion, although awareness of paediatric HIV infection among caregivers is significant in Ouagadougou, some misconceptions related to the moment of transmission and the importance of performing routine EID in all HIV-exposed children, still persist. These issues must be addressed by strengthening awareness campaigns and promoting best practices among medical staff. Therefore, changing caregivers’ attitudes may require interventions at both individual and community level. Healthcare providers should actively promote HIV testing and care-seeking for children in order to improve the uptake of EID among HIV-exposed children in Burkina Faso.