The impact of HIV infection on mothers and children: Maternal quality of life and childhood immunization coverage in Rakai District, Uganda

Background. The high prevalence of maternal human immunodeficiency virus (HIV) infection in sub-Saharan Africa has important implications for the ability of mothers to provide routine child health care. This study assessed the impact of maternal HIV-infection in Rakai District, Uganda by measuring childhood immunization rates. Methods. 1,055 HIV+ and HIV- mothers with children aged 6--36 months were sampled in a 1:2 ratio from a community cohort study into four strata based on HIV-serostatus and use of voluntary counseling and testing (VCT) services: HIV+/VCT+ (n = 181); HIV+/VCT- (n = 154); HIV-/VCT+ (n = 390); HIV-/VCT- (n = 330). Our survey measured three domains: (1) quality of life using the Medical Outcomes Study HIV health survey (MOS-HIV); (2) childhood immunization using immunization cards and maternal recall; and (3) knowledge, attitudes and practices regarding immunization. Focus group discussions (n = 3 HIV+; n = 3 HIV-) were conducted to complement overall findings. Results. We interviewed 835 respondents (238 HIV+ and 596 HIV-, response rate = 79%). As hypothesized, mean MOS-HIV scores indicated that HIV+ women reported significantly poorer functioning and well-being than HIV- women in almost all dimensions. Immunization coverage in the sample for all vaccines was 26.1%. Coverage for individual vaccines was BCG, 62.2%; 3 doses of DPT, 31.7%; 3 doses of polio, 35.6%; and measles, 40.7%. There was a statistically significant interaction between maternal HIV-infection and maternal knowledge of HIV-infection (p = 0.034): children whose mothers knew they were infected (HIV+/VCT+) had two-fold increased odds of underimmunization (OR = 2.21, 95% CI: 1.14, 4.29) compared to children of mothers who were HIV-/VCT-. Other factors associated with immunization included: increased antenatal visits, knowledge about the immunization schedule, child age, access to the immunization venue and utilization of government outreach clinics. Focus group discussions revealed substantial hardship among HIV-infected women with children. Discussion. Children of HIV-infected women who knew their HIV status had significantly elevated odds of incomplete immunization. Possible explanations for reduction in immunization emerged from the survey and focus groups discussions: Compared to HIV- women, HIV+ women scored significantly lower on many quality of life scales, had a higher proportion of ill husbands, and may have inadequate support for childcare.