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      Playing the Catch-Up Game: Accelerating the Scale-Up of Prevention of Mother-To-Child Transmission of HIV (PMTCT) Services to Eliminate New Pediatric HIV Infection in Nigeria

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          Abstract

          Introduction

          As the world is making progress towards elimination of mother-to-child transmission of HIV, poor coverage of PMTCT services in Nigeria remains a major challenge. In order to address this, scale-up was planned with activities organized into 3 phases. This paper describes the process undertaken in eight high burden Nigerian states to rapidly close PMTCT coverage gaps at facility and population levels between February 2013 and March 2014.

          Methods

          Activities were grouped into three phases–pre-assessment phase (engagement of a wide range of stakeholders), assessment (rapid health facility assessment, a cross sectional survey using mixed methods conducted in the various states between Feb and May 2013 and impact modelling), and post-assessment (drawing up costed state operational plans to achieve eMTCT by 2015, data-driven smart scale-up).

          Results

          Over a period of 10 months starting June 2013, 2044 facilities were supported to begin provision of PMTCT services. This increased facility coverage from 8% to 50%. A 246% increase was also recorded in the number of pregnant women and their families who have access to HIV testing and counselling in the context of PMTCT. Similarly, access to antiretrovirals for PMTCT has witnessed a 152% increase in these eight states between October 2013 and October 2014.

          Conclusion

          A data-driven and participatory approach can be used to rapidly scale-up PMTCT services at community and facility levels in this region. These results present us with hope for real progress in Nigeria. We are confident that the efforts described here will contribute significantly to eliminating new pediatric HIV infection in Nigeria.

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          Barriers and facilitating factors to the uptake of antiretroviral drugs for prevention of mother-to-child transmission of HIV in sub-Saharan Africa: a systematic review

          Annabelle Gourlay, Isolde Birdthistle, Gitau Mburu … (2013)
          Objectives To investigate and synthesize reasons for low access, initiation and adherence to antiretroviral drugs by mothers and exposed babies for prevention of mother-to-child transmission (PMTCT) of HIV in sub-Saharan Africa. Methods A systematic literature review was conducted. Four databases were searched (Medline, Embase, Global Health and Web of Science) for studies conducted in sub-Saharan Africa from January 2000 to September 2012. Quantitative and qualitative studies were included that met pre-defined criteria. Antiretroviral (ARV) prophylaxis (maternal/infant) and combination antiretroviral therapy (ART) usage/registration at HIV care and treatment during pregnancy were included as outcomes. Results Of 574 references identified, 40 met the inclusion criteria. Four references were added after searching reference lists of included articles. Twenty studies were quantitative, 16 were qualitative and eight were mixed methods. Forty-one studies were conducted in Southern and East Africa, two in West Africa, none in Central Africa and one was multi-regional. The majority (n=25) were conducted before combination ART for PMTCT was emphasized in 2006. At the individual-level, poor knowledge of HIV/ART/vertical transmission, lower maternal educational level and psychological issues following HIV diagnosis were the key barriers identified. Stigma and fear of status disclosure to partners, family or community members (community-level factors) were the most frequently cited barriers overall and across time. The extent of partner/community support was another major factor impeding or facilitating the uptake of PMTCT ARVs, while cultural traditions including preferences for traditional healers and birth attendants were also common. Key health-systems issues included poor staff-client interactions, staff shortages, service accessibility and non-facility deliveries. Conclusions Long-standing health-systems issues (such as staffing and service accessibility) and community-level factors (particularly stigma, fear of disclosure and lack of partner support) have not changed over time and continue to plague PMTCT programmes more than 10 years after their introduction. The potential of PMTCT programmes to virtually eliminate vertical transmission of HIV will remain elusive unless these barriers are tackled. The prominence of community-level factors in this review points to the importance of community-driven approaches to improve uptake of PMTCT interventions, although packages of solutions addressing barriers at different levels will be important.
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            Increasing the uptake of prevention of mother-to-child transmission of HIV services in a resource-limited setting

            Kwasi Torpey, Mushota Kabaso, Prisca Kasonde … (2010)
            Background As in other resource limited settings, the Ministry of Health in Zambia is challenged to make affordable and acceptable PMTCT interventions accessible and available. With a 14.3% HIV prevalence, the MOH estimates over one million people are HIV positive in Zambia. Approximately 500,000 children are born annually in Zambia and 40,000 acquire the infection vertically each year if no intervention is offered. This study sought to review uptake of prevention of mother-to-child (PMTCT) services in a resource-limited setting following the introduction of context-specific interventions. Methods Interventions to improve PMTCT uptake were introduced into 38 sites providing PMTCT services in Zambia in July 2005. Baseline and follow up service data were collected on a monthly basis through September 2008. Data was checked for internal and external consistency using logic built into databases used for data management. Data audits were conducted to determine accuracy and reliability. Trends were analyzed pre- and post- intervention. Results Uptake among pregnant women increased across the 13 quarters (39 months) of observation, particularly in the case of acceptance of counseling and HIV testing from 45% to 90% (p value = 0.00) in the first year and 99% by year 3 (p value = 0.00). Receipt of complete course of antiretroviral (ARV) prophylaxis increased from 29% to 66% (p = 0.00) in the first year and 97% by year 3 (p value = 0.00). There was also significant improvement in the percentage of HIV positive pregnant women referred for clinical care. Conclusions Uptake of PMTCT services in resource-limited settings can be improved by utilizing innovative alternatives to mitigate the effects of human resource shortage such as by providing technical assistance and mentorship beyond regular training courses, integrating PMTCT services into existing maternal and child health structures, addressing information gaps, mobilizing traditional and opinion leaders and building strong relationships with the government. These health system based approaches provide a sustainable improvement in the capacity and uptake of services.
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              Health system constraints to optimal coverage of the prevention of mother-to-child HIV transmission programme in South Africa: lessons from the implementation of the national pilot programme.

              S Donohue, David McCoy, T. Doherty (2005)
              It is three years since the government of South Africa began implementing a PMTCT programme. Over this period of time attempts have been made to scale up this programme across all provinces under routine health service conditions. To report on the uptake and performance of South Africa's national pilot programme for preventing mother to child HIV transmission (PMTCT) and to identify health system constraints to optimal coverage. Routine programme data were collected from antenatal records and delivery registers at the pilot sites and interviews were conducted with health workers on site and with provincial programme managers. Routine PMTCT programme data were collected from all 18 pilot sites for the period January to December 2002. During this period, of 84406 women attending the sites for first antenatal visits, 47267 (56%) agreed to an HIV test. 14340 (30%) of the women tested were HIV positive and of these 7853 (55%) were dispensed nevirapine. 7950 (99%) of infants born to women identified as being HIV positive received nevirapine syrup. 58% (4196/7237) of HIV positive women expressed an intention to exclusively formula feed, and 42% (3041/7237) intended to exclusively breastfeed. 1907 infants were due for 12 month HIV testing between January and December 2002, of these 949 (50%) infants were tested. Programme effectiveness was limited by the low rate of HIV test acceptance, poor delivery of nevirapine to mothers and inability to track mother-infant pairs postnatally for 12-month HIV testing of infants. Infant feeding intentions of mothers suggest inadequate counselling and possible negative effects of the provision of free formula milk. The poor performance of the main components of this programme will seriously reduce its operational effectiveness. There is a need for greater integration of VCT within antenatal care, a review of the current policy of providing free formula milk and an alternative model for mother-infant follow up.
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                Author and article information

                Contributors
                Ravi Jhaveri: Role: Editor
                Journal
                Journal ID (nlm-ta): PLoS One
                Journal ID (iso-abbrev): PLoS ONE
                Journal ID (publisher-id): plos
                Journal ID (pmc): plosone
                Title: PLoS ONE
                Publisher: Public Library of Science (San Francisco, CA USA )
                ISSN (Electronic): 1932-6203
                Publication date (Electronic): 3 January 2017
                Publication date Collection: 2017
                Volume: 12
                Issue: 1
                Electronic Location Identifier: e0169342
                Affiliations
                [1 ]FHI360, Abuja, Nigeria
                [2 ]National AIDS and STI Control Programme, Federal Ministry of Health, Abuja, Nigeria
                [3 ]FHI 360, Washington DC, United States of America
                [4 ]UNAIDS Country Office, Abuja, Nigeria
                [5 ]College of Health Sciences, University of Ghana, Accra, Ghana
                University of North Carolina at Chapel Hill School of Dentistry, UNITED STATES
                Author notes

                Competing Interests: The authors have declared that no competing interests exist.

                • Conceptualization: EAO HK SA KT.

                • Data curation: JM MS KT CA.

                • Formal analysis: EAO URO O. Adedokun O. Adebayo.

                • Investigation: EAO HK SA MS URO CN CA CG MO O. Adedokun O. Adebayo.

                • Methodology: EAO HK SA KT.

                • Project administration: EAO.

                • Resources: EAO HK SA MS URO CN CA CG MO O. Adedokun O. Adebayo.

                • Supervision: HK KT.

                • Validation: EAO HK SA MS URO CN CA CG MO O. Adedokun O. Adebayo.

                • Visualization: EAO RD JM KT.

                • Writing – original draft: EAO CN RD JM KT.

                • Writing – review & editing: EAO HK SA MS URO CN CA CG MO O. Adedokun O. Adebayo RD JM KT.

                Article
                Publisher ID: PONE-D-16-13495
                DOI: 10.1371/journal.pone.0169342
                PMC ID: 5207649
                PubMed ID: 28046045
                SO-VID: b967dcdb-6c42-4979-8cf3-e04de31f9a73
                Copyright © © 2017 Oladele et al
                License:

                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.

                History
                Date received : 28 April 2016
                Date accepted : 15 December 2016
                Page count
                Figures: 5, Tables: 4, Pages: 18
                Funding
                This paper is based on work supported by the President’s Emergency Plan for AIDS Relief (PEPFAR) through United States Agency for International Development (USAID) under the terms of cooperative agreement AID-620-A-00002 of the Strengthening Integrated Delivery of HIV/AIDS Services (SIDHAS) project managed by FHI 360 and other partners. All the authors except CA and MO work with FHI 360.
                Categories
                Subject: Research Article
                Subject: Biology and Life Sciences
                Subject: Microbiology
                Subject: Medical Microbiology
                Subject: Microbial Pathogens
                Subject: Viral Pathogens
                Subject: Immunodeficiency Viruses
                Subject: HIV
                Subject: Medicine and Health Sciences
                Subject: Pathology and Laboratory Medicine
                Subject: Pathogens
                Subject: Microbial Pathogens
                Subject: Viral Pathogens
                Subject: Immunodeficiency Viruses
                Subject: HIV
                Subject: Biology and Life Sciences
                Subject: Organisms
                Subject: Viruses
                Subject: Viral Pathogens
                Subject: Immunodeficiency Viruses
                Subject: HIV
                Subject: Biology and Life Sciences
                Subject: Organisms
                Subject: Viruses
                Subject: Immunodeficiency Viruses
                Subject: HIV
                Subject: Biology and life sciences
                Subject: Organisms
                Subject: Viruses
                Subject: RNA viruses
                Subject: Retroviruses
                Subject: Lentivirus
                Subject: HIV
                Subject: Biology and Life Sciences
                Subject: Microbiology
                Subject: Medical Microbiology
                Subject: Microbial Pathogens
                Subject: Viral Pathogens
                Subject: Retroviruses
                Subject: Lentivirus
                Subject: HIV
                Subject: Medicine and Health Sciences
                Subject: Pathology and Laboratory Medicine
                Subject: Pathogens
                Subject: Microbial Pathogens
                Subject: Viral Pathogens
                Subject: Retroviruses
                Subject: Lentivirus
                Subject: HIV
                Subject: Biology and Life Sciences
                Subject: Organisms
                Subject: Viruses
                Subject: Viral Pathogens
                Subject: Retroviruses
                Subject: Lentivirus
                Subject: HIV
                Subject: Medicine and Health Sciences
                Subject: Women's Health
                Subject: Maternal Health
                Subject: Pregnancy
                Subject: Medicine and Health Sciences
                Subject: Women's Health
                Subject: Obstetrics and Gynecology
                Subject: Pregnancy
                Subject: Medicine and Health Sciences
                Subject: Pediatrics
                Subject: Pediatric Infections
                Subject: People and Places
                Subject: Geographical Locations
                Subject: Africa
                Subject: Nigeria
                Subject: Medicine and Health Sciences
                Subject: Health Care
                Subject: Health Care Policy
                Subject: Health Systems Strengthening
                Subject: Medicine and Health Sciences
                Subject: Women's Health
                Subject: Maternal Health
                Subject: Antenatal Care
                Subject: Medicine and health sciences
                Subject: Infectious diseases
                Subject: Viral diseases
                Subject: HIV infections
                Subject: Medicine and Health Sciences
                Subject: Health Care
                Subject: Health Services Research
                Custom metadata
                Data Availability All relevant data are within the paper and its Supporting Information files. Other data are available from referenced sources within the paper e.g. https://www.fhi360.org/resource/state-level-operational-plans-elimination-mother-child-transmission-hiv-nigeria-2013%E2%80%932015, and https://www.fhi360.org/resource/rapid-health-facility-assessments-eight-nigerian-states.

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