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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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