Missed opportunities in the prevention of mother-to-child transmission of HIV infection: experience from a national programme in Nigeria

Background

With HIV prevalence among pregnant women at 3.0% according to the 2014 antenatal care (ANC) sentinel survey, Nigeria still has the highest number of vertically transmitted childhood HIV infections, accounting for 30% of the global burden of mother-to-child transmission (MTCT) of HIV. ¹ MTCT of HIV, though preventable, is currently responsible for the majority of all new infections among children. In Nigeria, all pregnant women who attend ANC for the first time are offered a HIV screening test and those identified as HIV-positive are further offered prevention of MTCT (PMTCT) services. For many years, uptake and coverage of PMTCT in Nigeria have been inadequate. In 2014, the elimination of MTCT (eMTCT) by 2020 was adopted as a national priority. ² To achieve the goal of eMTCT, at least 90% of all pregnant women should receive quality HIV testing and counselling (HTC) and receive their results, and HIV-infected women should have access to comprehensive PMTCT services. ³ We aimed to determine the progress made and identify the unaddressed needs regarding access to HTC, utilization of PMTCT services by pregnant women and opportunities for strengthening service delivery in order to achieve a HIV-free generation in Nigeria.

Methods

This is a secondary analysis of validated consolidated national HIV service data from 2008 to 2014, national Millennium Development Goals-reported data and Spectrum estimates. The service delivery data were derived from aggregated state-level data, which were collected prospectively for routine monitoring purposes. Quarterly meetings were conducted to merge and validate the data, attended by the stakeholders, including programme managers from the 36 states and Federal Capital Territory. To estimate the number of expected pregnancies, the crude birth rate from the 2013 National Demographic and Health Survey and 2006 National Census were used to make projections using the Spectrum software (version 5.06 Beta 2). Simple proportions and Chi square test for trend were conducted using SPSS version 20, with a p value of < 0.05 considered significant.

Results

The estimated total number of pregnancies per year is 6,551,637. Attendance at least one ANC visit increased from 3,368,491 (54.5%) in 2008 to 4,762,784 (68.9%) in 2014 (for HIV-positive or HIV-negative women); representing an average 2.4% increase annually (χ² test for trend = 273,613, p < 0.001) (Figure 1). OPEN IN VIEWER

Despite service scale-up, only 2,693,788 (39%) of the population of all the expected pregnant women in the country attended their first ANC at PMTCT sites in 2014. However, there has been a fivefold increment in the number of pregnant women accessing ANC services at these PMTCT sites between 2008 and 2014. This implies that in 2014, 2,068,996 (43%) of the ANC attendees booked at non-PMTCT sites (Figure 2). OPEN IN VIEWER

In the same year, 3,118,206 (45%) of the estimated number of pregnant women were tested for HIV during the pregnancy, labour or postpartum. This represents an improvement from 9.8% in 2008 to 24% in 2013 (χ² test for trend = 2,667,686, p < 0.001). The HIV programme prevalence rate declined from 6.6% (2008) to 3.2% (2014) (χ² test for trend = 29,317, p < 0.001).

The annual number of HIV-positive mothers identified at PMTCT sites have increased from 42,344 (21.3%) in 2008 to 107,957 (51%) in 2014. It was observed that at the PMTCT sites, 44,607 (41.9%) of the identified HIV-positive mothers did not receive antiretroviral (ARV) prophylaxis. However, based on the yearly estimates of HIV-positive pregnant women, the coverage of ARV prophylaxis ranged from 26,084 (13%) in 2008 to 63,350 (30%) in 2014 (χ² test for trend = 27,312, p < 0.001).

Discussion

HIV testing is the entry point for HIV prevention, treatment, care and support services. ³ It is essential that pregnant HIV-positive women who are unaware of their status in the community are identified and provided with PMTCT interventions. Nigeria continues to make steady progress towards achieving eMTCT; however, the national HIV data revealed low PMTCT coverage. A major impediment to the successful implementation of PMTCT in Nigeria is the inability to identify pregnant HIV-positive women for enrolment into the PMTCT programme. Our analysis has shown that the achievement of comprehensive PMTCT provision is hampered by low ANC attendance, hence making it difficult to reach all HIV-positive pregnant women in the community. ² The low levels of ANC visits at PMTCT sites are clear indications that promoting pull factors and eliminating barriers in order to increase ANC attendances is essential. These factors include issues affecting the national maternal, neonatal and child health (MNCH) programmes such as structural (long distance to PMTCT facilities, inadequate and uneven distribution of public and private service delivery points), socio-economic (lack of empowerment of women, inability to pay transport costs and cost of medical services) and operational (lack of consistent implementation of provider-initiated testing and counselling for pregnant women, weak integration of PMTCT with MNCH services).^2,4

Unfortunately, traditional birth attendants (TBAs), which are usually untrained, provide maternity services to a substantial number of pregnant women in Nigeria. ⁴ A recent survey revealed that in 2013, more than half (63%) of pregnant women delivered at home compared with 37% of deliveries conducted at health facilities. Of all deliveries, 38% were assisted by a skilled provider such as a doctor, nurse or midwife, 23% births were conducted by a relative, 22% were assisted during labour by TBAs and 13% were unassisted. ⁴ The specific reasons cited for not patronizing health facilities included but were not limited to long distance, transportation costs and expensive medical bills while others perceived it was not necessary to deliver at a health facility because of alternatives such as TBAs.

There has been less acceptance of the use of TBAs to provide PMTCT services due to their lack of formal training and provision of poor quality services. ² Conversely, programmatic experiences from Malawi and Cameroon have reported significant increases in the number of pregnant women who receive PMTCT services when TBAs are accepted and supported.^5,6

Our analysis also reveals the significant unmet need for ARV prophylaxis for the HIV-positive mothers identified at PMTCT sites. There is an unacceptably high number of HIV-positive pregnant women identified, who did not receive ARV prophylaxis. We speculate that the most important reasons include stigma and discrimination, poor partner notification, sub-optimal quality of post-test counselling and follow-up, poor referral linkages, inadequate number of trained health workers to provide services, staff attrition and stock-outs of consumables, particularly ARVs. Therefore, further qualitative studies are recommended to explore issues around traditional cultural practices that may prevent women from accessing PMTCT services when needed.

Conclusions

This study strongly suggests that initiatives such as scaling-up of ANC services, as well as making ANC services universally acceptable through increased demand creation and community partnership is necessary. Introduction of PMTCT services in every ANC clinic and innovative PMTCT service models at the primary health care level and in informal health systems targeting women who prefer to deliver at home; active testing of pregnant women at antenatal clinics by adequately engaging private health service providers at formal and informal settings are essential to ultimately achieve the eMTCT goal in Nigeria.