Exploring the Influence of Patient-Provider Interactions on Prevention of Mother-To-Child Transmission of HIV Service Use in Rural Tanzania

Interactions between patients and service providers frequently influence uptake of prevention of mother-to-child transmission (PMTCT) HIV services in sub-Saharan Africa, but this process has not been examined in depth. This study explores how patient-provider relations influence PMTCT service use in four government facilities in Kisesa, Tanzania. Qualitative data were collected in 2012 through participatory group activities with community members (3 male, 3 female groups), in-depth interviews with 21 women who delivered recently (16 HIV-positive), 9 health providers, and observations in antenatal clinics. Data were transcribed, translated into English and analysed with NVIVO9 using an adapted theoretical model of patient-centred care. Three themes emerged: decision-making processes, trust, and features of care. There were few examples of shared decision-making, with a power imbalance in favour of providers, although they offered substantial psycho-social support. Unclear communication by providers, and patients not asking questions, resulted in missed services. Omission of pre-HIV test counselling was often noted, influencing women’s ability to opt-out of HIV testing. Trust in providers was limited by confidentiality concerns, and some HIV-positive women were anxious about referrals to other facilities after establishing trust in their original provider. Good care was recounted by some women, but many (HIV-positive and negative) described disrespectful staff including discrimination of HIV-positive patients and scolding, particularly during delivery; exacerbated by lack of materials (gloves, sheets) and associated costs, which frustrated staff. Experienced or anticipated negative staff behaviour influenced adherence to subsequent PMTCT components. Findings revealed a pivotal role for patient-provider relations in PMTCT service use. Disrespectful treatment and lack of informed consent for HIV testing require urgent attention by PMTCT programme managers. Strategies should address staff behaviour, emphasizing ethical standards and communication, and empower patients to seek information about available services. Optimising providerpatient relations can improve uptake of maternal health services more broadly, and ART adherence. Citation: Gourlay A, Wringe A, Birdthistle I, Mshana G, Michael D, et al. (2014) ‘‘It Is Like That, We Didn’t Understand Each Other’’: Exploring the Influence of Patient-Provider Interactions on Prevention of Mother-To-Child Transmission of HIV Service Use in Rural Tanzania. PLoS ONE 9(9): e106325. doi:10.1371/journal. pone.0106325 Editor: Nathan Maclyn Thielman, Duke University Medical Center, United States of America Received April 23, 2014; Accepted July 29, 2014; Published September 2, 2014 Copyright: 2014 Gourlay et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Data Availability: The authors confirm that, for approved reasons, some access restrictions apply to the data underlying the findings. Data are not publicly available due to ethical restrictions, but are available on request by contacting researchdatamanagement@lshtm.ac. uk. Funding: This study was funded through the East Africa IeDEA Consortium by the United States National Institutes of Health – the Eunice Kennedy Shriver National Institute Of Child Health & Human Development (NICHD) and the National Institute Of Allergy And Infectious Diseases (NIAID), grant award 3U01AI069911-06S2 (http://www.nih.gov/ http://www.iedea.org/) – and the Global Fund Round 9, grant number TNZ-911-G14-S (http://www.theglobalfund Competing Interests: The authors have declared that no competing interests exist. * Email: annabelle.gourlay@lshtm.ac. uk