Exploring the acceptability of option b plus among hiv-positive nigerian women engaged and not engaged in the prevention of mother-to-child transmission of hiv cascade: A qualitative study

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Study Justification:
– The acceptability of lifelong antiretroviral therapy (ART) among HIV-positive women in Nigeria is not well-known.
– This study aimed to explore the readiness of users and providers of prevention of mother-to-child transmission of HIV (PMTCT) services to accept lifelong ART before Option B plus was implemented in Nigeria.
– The findings of this study can inform policy and programmatic decisions regarding the scale-up of Option B plus in Nigeria.
Study Highlights:
– The study conducted 142 key informant interviews among 100 PMTCT users and 42 PMTCT providers in rural North-Central Nigeria.
– PMTCT users had mixed views about lifelong ART, influenced by motivation to prevent infant HIV and the presence or absence of maternal illness.
– Newly-diagnosed women were most enthusiastic about lifelong ART, while postpartum and lost-to-follow-up women expressed conditionalities for acceptance and adherence.
– Providers corroborated user findings, identifying the postpartum period as problematic for lifelong ART acceptability and adherence.
– Option B plus scale-up in Nigeria will require addressing user fears about ART side effects, continuous education on long-term maternal and infant benefits, and addressing structural barriers such as availability of trained providers, long clinic wait times, and patient access to ART.
Recommendations:
– Proactively address PMTCT user fears about ART side effects.
– Provide continuous education on the long-term maternal and infant benefits of lifelong ART.
– Address structural barriers such as the availability of trained providers, long clinic wait times, and patient access to ART.
Key Role Players:
– Healthcare workers stationed at study primary health centers (PHCs) who deliver clinical, counseling, and drug dispensing services to PMTCT clients.
– Doctors, pharmacists or pharmacy technicians, nurses, and community health workers providing direct clinical services to PMTCT clients.
Cost Items for Planning Recommendations:
– Training and capacity building for healthcare workers.
– Development and dissemination of educational materials.
– Improvement of clinic infrastructure and resources.
– Strengthening of supply chain management for ART drugs.
– Monitoring and evaluation of program implementation.
– Community engagement and awareness campaigns.

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is based on a cross-sectional qualitative study conducted in 2014. The study employed semi-structured key informant interviews among women living with HIV enrolled in PMTCT programs and PMTCT service delivery personnel. The study provides insights into the acceptability of lifelong antiretroviral therapy (ART) among HIV-positive women in Nigeria. The qualitative data were manually analyzed via Grounded Theory. The study identifies mixed views among PMTCT users about lifelong ART, influenced by motivation to prevent infant HIV and the presence or absence of maternal illness. Providers corroborated these findings and identified the postpartum period as problematic for lifelong ART acceptability and adherence. The study suggests that addressing user fears about ART side effects, providing continuous education on long-term maternal and infant benefits, and addressing structural barriers such as the availability of trained providers and patient access to ART are necessary for the successful scale-up of Option B plus in Nigeria. However, the evidence is limited to a specific population and time period, and the study design does not allow for causal conclusions. To improve the evidence, future research could include a larger sample size, a longitudinal design, and quantitative measures to complement the qualitative findings.

The acceptability of lifelong antiretroviral therapy (ART) among HIV-positive women in high-burden Nigeria, is not well-known. We explored readiness of users and providers of prevention of mother-to-child transmission of HIV (PMTCT) services to accept lifelong ART-before Option B plus was implemented in Nigeria. We conducted 142 key informant interviews among 100 PMTCT users (25 pregnant-newly-diagnosed, 26 pregnant-in-care, 28 lost-to-follow-up (LTFU) and 21 postpartum women living with HIV) and 42 PMTCT providers in rural North-Central Nigeria. Qualitative data were manually analyzed via Grounded Theory. PMTCT users had mixed views about lifelong ART, strongly influenced by motivation to prevent infant HIV and by presence or absence of maternal illness. Newly-diagnosed women were most enthusiastic about lifelong ART, however postpartum and LTFU women expressed conditionalities for acceptance and adherence, including minimal ART side effects and potentially serious maternal illness. Providers corroborated user findings, identifying the postpartum period as problematic for lifelong ART acceptability/adherence. Option B plus scale-up in Nigeria will require proactively addressing PMTCT user fears about ART side effects, and continuous education on long-term maternal and infant benefits. Structural barriers such as the availability of trained providers, long clinic wait times and patient access to ART should also be addressed.

This was a cross-sectional qualitative study conducted in 2014, employing semi-structured key informant interviews (KIIs) among women living with HIV enrolled in PMTCT programmes (‘Users’) and PMTCT service delivery personnel (‘Providers’). Providers were healthcare workers stationed at study PHCs who delivered clinical, counseling and drug dispensing services to Users. The study was conducted at PHCs located in semi-rural and rural communities in two high-burden states in North Central Nigeria. The Federal Capital Territory (FCT) and Nasarawa State had high antenatal HIV prevalence of 5.8% and 6.3%, respectively, ranking above the national average of 3.0% (Federal Ministry of Health Nigeria, 2010b). HIV services at the study PHCs are supported by the Institute of Human Virology-Nigeria (IHVN), a large public health non-governmental organisation that is an implementing partner of the United States government’s President’s Emergency Plan for AIDS Relief (PEPFAR). At the time of the study, IHVN was providing support to nearly 1,500 primary, secondary and tertiary health facilities in 10 states, including the FCT and Nasarawa state. In these locations, IHVN was the single largest PEPFAR implementing partner providing HIV services, including HIV testing, PMTCT, ART and TB/HIV services. All women enrolled in PMTCT programmes at the time of the study (2014) were prescribed Option B ART as recommended by the then-national guidelines, in line with WHO recommendations (Federal Ministry of Health Nigeria, 2014; World Health Organization, 2013). All Users to be interviewed were HIV-infected women ≥18 years old living in the PHC catchment area and accessing care from the study PHC. As we envisaged interviewing women at key points of the PMTCT cascade, we recruited Users based on the following criteria: Purposive sampling was employed in selecting these respondents because women in rural areas, especially HIV-positive women, have low rates of facility-based healthcare service utilisation (Federal Ministry of Health Nigeria, 2012; National Bureau of Statistics, 2015). Eligible women attending clinic were identified and briefed about the study by healthcare workers at the study sites. Interested clients were then individually approached by study staff for informed consent. LTFU women were also identified from medical registers and then were contacted by phone by healthcare workers; those interested were then invited to the PHC for the interview. Home interviews were also arranged for LTFU women who were interested in participating in the study but declined to interview at the facility. PMTCT providers at study sites were recruited to contribute their perspectives, based on their experiences, on Option B attitudes and practices, for their opinions on Option B+ acceptability among Users. Providers recruited included doctors, pharmacists or pharmacy technicians, nurses, and community health workers providing direct clinical services to PMTCT clients. During orientation to the study and consent process, researchers introduced themselves, stating where they worked (with an NGO/university and not the health facility or government), and the reason for conducting the study, namely, to improve the quality of health services for women living with HIV. Written informed consent was obtained and study interviews conducted only by trained research staff who had neither an affiliation with the healthcare facility nor an affiliation with IHVN’s PMTCT programme. Data was collected in private rooms of health care facilities during non-clinic hours. While we did not collect information on the reasons why, less than 10% of participants who were approached declined to participate. No one else was present during these interviews besides participants and researchers. Multi-theme, semi-structured questionnaires were developed and presented to physicians, nurses, public health specialists and social/behavioural researchers (Table 1). The questionnaire was modified to suit the clinical and cultural context. KII guides were developed by the authors, taking care to pose open-ended questions that were amenable to reframing by facilitators if participants did not understand them, regardless of language used. Questions on highly sensitive issues eg self-stigma, poor adherence and poor retention were posed as third person questions (ie ‘they’; not ‘you’) in order to allow participants to freely express their opinions without ‘implicating’ themselves. The guides were adjusted as interviews were conducted, per emerging data and recurring questions. Users and providers were interviewed only once for this study. The Users KII questionnaire contained open-ended questions organised under four specific themes (Table 1). During these interviews, PMTCT user perceptions on the acceptability and feasibility of changing practice from Option B to Option B+ were elucidated. For the Providers, we explored their perspectives regarding Option B+ acceptability and readiness among PMTCT clients. Each KII was facilitated by two trained research staff: one posed questions and the other took notes. All interviews were digitally recorded, and each recorded KII was transcribed verbatim. Each KII took an average of 45 minutes to one hour to complete. For participants who did not speak English, KIIs were conducted in the dominant local language Hausa by skilled bilingual study staff, who then transcribed and translated the local-language interviews into English. Data transcription, translation, review and preliminary analysis started in conjunction with data collection. All KIIs were transcribed by the same study staff who conducted the interviews. For the manual qualitative analysis, we adopted the constant comparative method in a grounded theory approach (Glaser & Strauss, 2009). In this approach, inductive methodology is used to systematically generate theory from the data collected. Analysts read transcripts multiple times to become familiar with the data, identify patterns and generate initial codes. Following this initial analysis, emerging content-driven themes and sub-themes were discussed, codes refined and categories developed independently by a panel of eight paired researchers. Finally, all researchers collaborated in triangulation as a means of verification of our findings as well as to eliminate any biases that may have occurred during individual analysis. Quantitative demographics data was analysed with Statistical Package for Social Sciences (SPSS V.16.0) for Windows. Ethical Considerations: This study was approved by the Nigerian National Health Research Ethics Committee and the Institutional Review Board of the University of Maryland Baltimore.

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Based on the provided description, here are some potential innovations that could improve access to maternal health:

1. Mobile health (mHealth) interventions: Develop mobile applications or text messaging services to provide information and reminders about antiretroviral therapy (ART) and maternal health to HIV-positive women. This can help improve adherence to treatment and provide support throughout the pregnancy and postpartum period.

2. Telemedicine: Implement telemedicine services to connect HIV-positive women in rural areas with healthcare providers who can provide guidance and support remotely. This can help overcome barriers such as long clinic wait times and limited access to trained providers.

3. Community health worker programs: Train and deploy community health workers to provide education, counseling, and support to HIV-positive women in their own communities. These workers can help address fears and misconceptions about ART and provide ongoing support throughout the PMTCT cascade.

4. Task-shifting: Expand the roles of healthcare workers, such as nurses and pharmacists, to provide ART and PMTCT services. This can help alleviate the burden on doctors and increase the availability of trained providers in rural areas.

5. Addressing structural barriers: Improve the availability and accessibility of ART by strengthening supply chains and ensuring consistent drug availability. Additionally, address transportation challenges by providing transportation vouchers or arranging transportation services for women who need to access healthcare facilities.

6. Health education and awareness campaigns: Conduct targeted campaigns to raise awareness about the benefits of lifelong ART and the importance of PMTCT services. These campaigns should address concerns about ART side effects and emphasize the long-term maternal and infant benefits.

It’s important to note that these recommendations are based on the information provided and may need to be adapted to the specific context and resources available in Nigeria.
AI Innovations Description
Based on the description provided, the following recommendation can be developed into an innovation to improve access to maternal health:

1. Addressing user concerns about antiretroviral therapy (ART) side effects: Develop educational programs and materials that provide accurate information about the potential side effects of lifelong ART. This can help alleviate fears and misconceptions among pregnant and postpartum women living with HIV, increasing their acceptance and adherence to ART.

2. Continuous education on long-term maternal and infant benefits: Implement regular educational sessions for pregnant and postpartum women living with HIV, highlighting the long-term benefits of lifelong ART for both maternal health and prevention of mother-to-child transmission of HIV. This can help improve their understanding and motivation to adhere to ART.

3. Proactive management of maternal illness: Develop strategies to identify and manage maternal illnesses that may affect the acceptability and adherence to lifelong ART. This can involve close monitoring of maternal health during the postpartum period and providing appropriate medical interventions to address any potential barriers to ART adherence.

4. Addressing structural barriers: Improve the availability of trained healthcare providers in rural areas to ensure access to ART for pregnant and postpartum women living with HIV. Additionally, reduce clinic wait times and improve patient access to ART by implementing streamlined processes and efficient service delivery models.

By implementing these recommendations, it is possible to improve access to maternal health for HIV-positive women in Nigeria and enhance the acceptability and adherence to lifelong ART, ultimately leading to better health outcomes for both mothers and infants.
AI Innovations Methodology
Based on the provided description, here are some potential recommendations to improve access to maternal health:

1. Strengthening education and awareness programs: Implement comprehensive education and awareness programs targeting pregnant women, their families, and healthcare providers. These programs should focus on the importance of maternal health, the benefits of lifelong antiretroviral therapy (ART), and address any misconceptions or fears related to ART side effects.

2. Improving healthcare infrastructure: Address structural barriers such as the availability of trained providers, long clinic wait times, and patient access to ART. This can be achieved by increasing the number of healthcare providers, improving healthcare facilities, and streamlining the process of accessing ART.

3. Enhancing postpartum support: Develop postpartum support programs that specifically address the challenges faced by women in adhering to lifelong ART during the postpartum period. This can include providing additional counseling, support groups, and resources to ensure continued adherence to ART.

4. Collaboration with community organizations: Partner with community organizations to reach out to pregnant women and provide them with information, support, and resources related to maternal health and lifelong ART. This can help increase awareness and acceptance of ART among pregnant women.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could be developed as follows:

1. Define the indicators: Identify key indicators that measure access to maternal health, such as the number of pregnant women receiving prenatal care, the number of women initiating lifelong ART, and the rate of adherence to ART during the postpartum period.

2. Collect baseline data: Gather data on the current status of these indicators before implementing the recommendations. This can be done through surveys, interviews, and data collection from healthcare facilities.

3. Implement the recommendations: Roll out the recommended interventions, such as education and awareness programs, improving healthcare infrastructure, enhancing postpartum support, and collaborating with community organizations.

4. Monitor and evaluate: Continuously monitor the implementation of the recommendations and collect data on the indicators identified in step 1. This can be done through regular data collection from healthcare facilities, surveys, and interviews with pregnant women and healthcare providers.

5. Analyze the data: Analyze the collected data to assess the impact of the recommendations on the identified indicators. Compare the baseline data with the data collected after the implementation of the recommendations to determine any improvements in access to maternal health.

6. Draw conclusions and make adjustments: Based on the analysis of the data, draw conclusions about the impact of the recommendations on improving access to maternal health. Identify any gaps or areas for improvement and make adjustments to the interventions as needed.

7. Repeat the process: Continuously repeat the monitoring and evaluation process to track progress and make further improvements to ensure sustained access to maternal health services.

By following this methodology, it will be possible to simulate the impact of the recommendations on improving access to maternal health and make evidence-based decisions for further interventions.

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