Final HIV status outcome for HIV-exposed infants at 18 months of age in nine states and the Federal Capital Territory, Nigeria

PLoS ONE, Volume 17, No. 2, Year 2022

Ukuhunyushwa

Introduction While antiretroviral therapy (ART) coverage for pregnant women has undergone steady scale-up, Nigeria’s final mother- to-child transmission of HIV (MTCT) rate remains unacceptably high at 10%. This study aimed to determine final outcomes (MTCT rates) and thei≥r correlates among HIV-exposed infants (HEI) in nine states and the Federal Capital Territory, Nigeria. Methods This retrospective, cross-sectional study was conducted at 96 primary, secondary and tertiary health facilities supported by the Institute of Human Virology Nigeria. Data was abstracted for a birth cohort of HEI born between October 30, 2014 and April 30, 2015 whose 18–24 month final outcome was assessed by October 30, 2016. Only infants with a six-week first DNA PCR result, and a rapid HIV antibody test result at age 18 to 24 months were included. Multivariate logistic regression (adjusted odds ratios [aORs]) evaluated for predictors of HIV positivity at ≥18 months. Results After testing at ≥18 months, 68 (2.8%) of the 2,405 exposed infants in the birth cohort were HIV-positive. After a minimum of 18 months of follow-up, 51 (75%) HIV-positive infants were alive on ART; 7 (10%) had died, 5 (7.3%) were lost to follow-up and 5 (7.3%) were transferred out. Rural maternal residence, lack of maternal ART/ARV prophylaxis, mixed infant feeding and infant birth weight less than 2.5 kg correlated with an HIV-positive status for infant final outcomes. Conclusion The final HIV positivity rate of 2.8% is encouraging, but is not population-based. Nevertheless, supported by our findings, we recommend continued programmatic focus on early access to quality prenatal care and maternal ART for pregnant women, especially for women living with HIV in rural areas. Furthermore, implementation of nationwide sensitization and education on six-months’ exclusive infant breastfeeding with concurrent maternal ART should be strengthened and sustained to reduce MTCT rates. This retrospective cross-sectional study focused on HEI seen at public and private healthcare facilities across nine states and the Federal Capital Territory in Nigeria, namely, Benue, Delta, Ekiti, Kano, Katsina, Nasarawa, Ogun, Ondo and Osun. HIV services at healthcare facilities in these states were supported by the Institute of Human Virology Nigeria (IHVN) with PEPFAR funding. IHVN is a large local non-governmental organization that provides public health services including for malaria, tuberculosis, and HIV, to healthcare facilities in Nigeria [16]. The primary, secondary and tertiary facilities supported by IHVN and included in the analysis were located across the spectrum of rural and urban settings, with primary facilities located largely in rural areas, secondary facilities in both rural and urban areas, and tertiary facilities concentrated in urban areas. Additionally, tertiary facilities also serve as referral centers at which patients from within and outside the state access higher-level care. We reviewed available records of infants born between October 30, 2014 and April 30, 2015 who had final outcome results available by October 30, 2016. This birth cohort attained 18 to 24 months of age by October 30, 2016. We prioritized data analysis for this birth cohort of HEI because 2014 was the first year of implementation for a newly-implemented longitudinal birth cohort register that linked the mother-infant pair in the PMTCT program. HIV positive final outcome refers to the status of HEIs identified as HIV-infected after testing positive for HIV antibodies at ≥18 months of age and/or 6 weeks after cessation of breastfeeding [17]. In 2014/2015, national guidelines recommended that all HEI were to be tested for HIV by DNA PCR using dried blood samples, for early infant diagnosis (EID) between 6 weeks and 2 months of age, and at 6 weeks after breastfeeding [17]. Infants older than 9 months could first be screened with rapid antibody testing, and if positive, undergo PCR testing for confirmation [17]. There was no birth testing nor mandatory repeat PCR testing recommendation after first DNA PCR for HEI in 2014/2015 [17]. HEI testing negative at first DNA PCR were tested for final outcome by rapid antibody testing between 18 and 24 months of age [17, 18]. The delay period of final outcome testing to up to 24 months is to reduce the possibility of false positives from maternal antibodies which may occur in younger children. Only HEI with an available DNA PCR result at ≤6 weeks of birth and an HIV rapid test result at ≥18 months of age were eligible for inclusion. All HEI who had a positive DNA PCR test collected between 6 weeks and less than 18 months of age were excluded from final outcome analysis. In addition to HEI HIV test data, socio-demographic and clinical parameters were collected on infants and their HIV-positive mothers. Site-level data clerks de-identified data from IHVN’s electronic HIV program database and from hard-copy program registers at supported facilities in the nine states and the Federal Capital Territory. State-level Monitoring and Evaluation program officers collated site data and submitted it to the Central Strategic Information Unit in secured, encrypted Excel files for analysis. After abstraction and cleaning, relevant data from mother-infant pairs meeting the eligibility criteria were migrated into Stata 14 (StataCorp. 2015. Stata Statistical Software: Release 14. College Station, TX: StataCorp LP). Descriptive analysis was performed, after which bi-variate analysis using Chi-square, Fisher’s exact and likelihood ratios were conducted to test for associations between HEI final outcomes and maternal-infant characteristics. Explanatory variables significant at p<0.05 from bi-variate analysis were inputted into a model for multivariate logistic regression to establish predictors of HIV infant positivity at 18–24 months of age. The binary dependent variable was HEI who were positive or negative after HIV rapid testing at ≥18 months. Independent variables were divided into two main domains: maternal data including age and marital, education and employment status at antenatal care clinic booking, facility type attended, place of delivery, and receipt of ART; and infant data including gender, birth weight, DNA PCR result, and infant feeding practice. The study was approved by the Nigerian National Health Research Ethics Committee (NHREC/01/01/2007-01/03/2021D) for secondary analysis of routine data collected by the Institute of Human Virology Nigeria’s HIV program. The data reviewed and presented in this study were collected as part of routine HIV program activities.

I-AI Digest

Study Justification:

– Nigeria has a high mother-to-child transmission of HIV (MTCT) rate of 10%.
– Despite the scale-up of antiretroviral therapy (ART) coverage for pregnant women, the MTCT rate remains unacceptably high.
– This study aimed to determine the final outcomes (MTCT rates) and their correlates among HIV-exposed infants (HEI) in nine states and the Federal Capital Territory, Nigeria.

Study Highlights:

– The study included a birth cohort of HEI born between October 30, 2014, and April 30, 2015.
– Data was collected from 96 primary, secondary, and tertiary health facilities supported by the Institute of Human Virology Nigeria.
– Only infants with a six-week first DNA PCR result and a rapid HIV antibody test result at 18 to 24 months were included.
– After testing at 18 months, 2.8% of the exposed infants were HIV-positive.
– Of the HIV-positive infants, 75% were alive on ART, 10% had died, 7.3% were lost to follow-up, and 7.3% were transferred out.
– Factors associated with HIV-positive status included rural maternal residence, lack of maternal ART/ARV prophylaxis, mixed infant feeding, and infant birth weight less than 2.5 kg.

Recommendations for Lay Reader and Policy Maker:

– Continued programmatic focus on early access to quality prenatal care and maternal ART for pregnant women, especially in rural areas.
– Strengthening and sustaining nationwide sensitization and education on six-months’ exclusive infant breastfeeding with concurrent maternal ART to reduce MTCT rates.

Key Role Players:

– Institute of Human Virology Nigeria (IHVN): Provides support and funding for HIV services at healthcare facilities in the nine states and the Federal Capital Territory.
– Primary, secondary, and tertiary health facilities: Provide healthcare services and support for HIV-exposed infants.

Cost Items for Planning Recommendations:

– Funding for prenatal care and maternal ART services.
– Resources for sensitization and education programs on exclusive infant breastfeeding and maternal ART.
– Support for healthcare facilities to provide HIV services for HEI, including testing and treatment.
Please note that the cost items mentioned are general categories and not actual cost estimates.

Amandla Obufakazi

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is moderately strong. The study design is retrospective and cross-sectional, which limits the ability to establish causality. However, the study includes a large sample size and uses multivariate logistic regression to identify predictors of HIV positivity. To improve the strength of the evidence, future studies could consider a prospective design and include a control group for comparison. Additionally, conducting follow-up assessments beyond 18-24 months could provide more comprehensive data on long-term outcomes.

Abstract

This retrospective cross-sectional study focused on HEI seen at public and private healthcare facilities across nine states and the Federal Capital Territory in Nigeria, namely, Benue, Delta, Ekiti, Kano, Katsina, Nasarawa, Ogun, Ondo and Osun. HIV services at healthcare facilities in these states were supported by the Institute of Human Virology Nigeria (IHVN) with PEPFAR funding. IHVN is a large local non-governmental organization that provides public health services including for malaria, tuberculosis, and HIV, to healthcare facilities in Nigeria [16]. The primary, secondary and tertiary facilities supported by IHVN and included in the analysis were located across the spectrum of rural and urban settings, with primary facilities located largely in rural areas, secondary facilities in both rural and urban areas, and tertiary facilities concentrated in urban areas. Additionally, tertiary facilities also serve as referral centers at which patients from within and outside the state access higher-level care. We reviewed available records of infants born between October 30, 2014 and April 30, 2015 who had final outcome results available by October 30, 2016. This birth cohort attained 18 to 24 months of age by October 30, 2016. We prioritized data analysis for this birth cohort of HEI because 2014 was the first year of implementation for a newly-implemented longitudinal birth cohort register that linked the mother-infant pair in the PMTCT program. HIV positive final outcome refers to the status of HEIs identified as HIV-infected after testing positive for HIV antibodies at ≥18 months of age and/or 6 weeks after cessation of breastfeeding [17]. In 2014/2015, national guidelines recommended that all HEI were to be tested for HIV by DNA PCR using dried blood samples, for early infant diagnosis (EID) between 6 weeks and 2 months of age, and at 6 weeks after breastfeeding [17]. Infants older than 9 months could first be screened with rapid antibody testing, and if positive, undergo PCR testing for confirmation [17]. There was no birth testing nor mandatory repeat PCR testing recommendation after first DNA PCR for HEI in 2014/2015 [17]. HEI testing negative at first DNA PCR were tested for final outcome by rapid antibody testing between 18 and 24 months of age [17, 18]. The delay period of final outcome testing to up to 24 months is to reduce the possibility of false positives from maternal antibodies which may occur in younger children. Only HEI with an available DNA PCR result at ≤6 weeks of birth and an HIV rapid test result at ≥18 months of age were eligible for inclusion. All HEI who had a positive DNA PCR test collected between 6 weeks and less than 18 months of age were excluded from final outcome analysis. In addition to HEI HIV test data, socio-demographic and clinical parameters were collected on infants and their HIV-positive mothers. Site-level data clerks de-identified data from IHVN’s electronic HIV program database and from hard-copy program registers at supported facilities in the nine states and the Federal Capital Territory. State-level Monitoring and Evaluation program officers collated site data and submitted it to the Central Strategic Information Unit in secured, encrypted Excel files for analysis. After abstraction and cleaning, relevant data from mother-infant pairs meeting the eligibility criteria were migrated into Stata 14 (StataCorp. 2015. Stata Statistical Software: Release 14. College Station, TX: StataCorp LP). Descriptive analysis was performed, after which bi-variate analysis using Chi-square, Fisher’s exact and likelihood ratios were conducted to test for associations between HEI final outcomes and maternal-infant characteristics. Explanatory variables significant at p<0.05 from bi-variate analysis were inputted into a model for multivariate logistic regression to establish predictors of HIV infant positivity at 18–24 months of age. The binary dependent variable was HEI who were positive or negative after HIV rapid testing at ≥18 months. Independent variables were divided into two main domains: maternal data including age and marital, education and employment status at antenatal care clinic booking, facility type attended, place of delivery, and receipt of ART; and infant data including gender, birth weight, DNA PCR result, and infant feeding practice. The study was approved by the Nigerian National Health Research Ethics Committee (NHREC/01/01/2007-01/03/2021D) for secondary analysis of routine data collected by the Institute of Human Virology Nigeria’s HIV program. The data reviewed and presented in this study were collected as part of routine HIV program activities.

Izinto zokwakha

N/A

Emisha

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

1. Mobile Health (mHealth) Solutions: Develop and implement mobile applications or text messaging services to provide pregnant women with information on prenatal care, HIV testing, and ART adherence. These tools can also be used to send reminders for appointments and medication schedules.

2. Telemedicine: Establish telemedicine platforms that allow pregnant women in rural areas to consult with healthcare providers remotely. This can help overcome geographical barriers and ensure access to quality prenatal care, including HIV testing and counseling.

3. Community Health Workers: Train and deploy community health workers to provide education, counseling, and support to pregnant women in underserved areas. These workers can conduct home visits, facilitate HIV testing, and promote adherence to ART.

4. Integration of Services: Integrate maternal health services with existing healthcare programs, such as family planning and immunization services. This can improve efficiency and ensure comprehensive care for pregnant women, including HIV prevention, testing, and treatment.

5. Task Shifting: Train and empower nurses, midwives, and other healthcare workers to provide comprehensive maternal health services, including HIV testing and counseling. This can help address the shortage of skilled healthcare providers in many areas.

6. Quality Improvement Initiatives: Implement quality improvement initiatives to enhance the delivery of maternal health services. This can involve regular monitoring and evaluation, feedback mechanisms, and continuous training for healthcare providers to ensure adherence to best practices.

7. Public-Private Partnerships: Foster collaborations between public and private healthcare sectors to expand access to maternal health services. This can involve leveraging the resources and expertise of private healthcare providers to reach underserved populations.

8. Health Information Systems: Strengthen health information systems to improve data collection, analysis, and reporting for maternal health. This can help identify gaps in service delivery, monitor progress, and inform evidence-based decision-making.

9. Community Engagement: Engage communities in the design and implementation of maternal health programs. This can involve community mobilization, awareness campaigns, and the establishment of support groups to promote positive health-seeking behaviors.

10. Policy and Advocacy: Advocate for policies and funding that prioritize maternal health, including HIV prevention and treatment. This can involve engaging policymakers, civil society organizations, and international partners to drive change and ensure sustained investment in maternal health services.

AI Innovations Description

Based on the description provided, the recommendation to improve access to maternal health and reduce mother-to-child transmission of HIV includes the following:

1. Focus on early access to quality prenatal care: It is recommended to prioritize and promote early access to quality prenatal care for pregnant women, especially those living with HIV. This includes ensuring that pregnant women receive comprehensive HIV testing, counseling, and appropriate antiretroviral therapy (ART) or antiretroviral prophylaxis to prevent mother-to-child transmission of HIV.

2. Strengthen and sustain nationwide sensitization and education: Implementation of nationwide sensitization and education programs should be strengthened and sustained. This includes raising awareness about the importance of exclusive infant breastfeeding for the first six months, along with concurrent maternal ART. These programs should target both healthcare providers and communities to ensure accurate information and support for HIV-positive mothers.

3. Improve access to maternal ART in rural areas: Efforts should be made to improve access to maternal ART in rural areas. This can be achieved by expanding the availability of healthcare facilities that provide comprehensive HIV services, including antenatal care and ART, in rural areas. Additionally, strategies such as mobile clinics or outreach programs can be implemented to reach pregnant women in remote areas.

4. Enhance monitoring and evaluation systems: It is important to establish robust monitoring and evaluation systems to track the progress and outcomes of maternal health interventions. This includes regular data collection, analysis, and reporting on key indicators related to maternal HIV testing, ART coverage, and mother-to-child transmission rates. These systems can help identify gaps and areas for improvement, leading to more effective interventions.

By implementing these recommendations, it is expected that access to maternal health services will be improved, leading to a reduction in mother-to-child transmission of HIV and improved health outcomes for both mothers and infants.

AI Innovations Methodology

Based on the provided information, here are some potential recommendations to improve access to maternal health:

1. Strengthen prenatal care: Focus on early access to quality prenatal care for pregnant women, especially those living in rural areas. This can include increasing the number of healthcare facilities in rural areas, improving transportation options, and providing education and awareness about the importance of prenatal care.

2. Enhance maternal ART coverage: Ensure that pregnant women living with HIV have access to antiretroviral therapy (ART) and ARV prophylaxis. This can involve expanding the availability of ART medications, training healthcare providers on the administration of ART, and implementing strategies to improve adherence to ART among pregnant women.

3. Promote exclusive breastfeeding with maternal ART: Implement nationwide sensitization and education campaigns to promote exclusive breastfeeding for the first six months of an infant’s life, along with concurrent maternal ART. This can include providing information and support to mothers, training healthcare providers on breastfeeding counseling, and addressing cultural and societal barriers to exclusive breastfeeding.

4. Improve healthcare infrastructure: Invest in the development and improvement of healthcare facilities, particularly in rural areas. This can include building new facilities, upgrading existing ones, and equipping them with necessary medical equipment and supplies.

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 reflect access to maternal health, such as the number of pregnant women receiving prenatal care, the percentage of pregnant women living with HIV on ART, the rate of exclusive breastfeeding, and the availability and quality of healthcare facilities.

2. Collect baseline data: Gather data on the current status of these indicators in the target areas. This can be done through surveys, interviews, and data collection from healthcare facilities and relevant organizations.

3. Develop a simulation model: Create a simulation model that incorporates the identified indicators and their interrelationships. This model should consider factors such as population demographics, healthcare infrastructure, availability of resources, and the impact of the recommended interventions.

4. Input intervention scenarios: Input different scenarios into the simulation model to represent the potential impact of the recommendations. For example, simulate the effect of increasing the number of healthcare facilities in rural areas, improving ART coverage, and promoting exclusive breastfeeding.

5. Analyze the results: Analyze the simulation results to assess the potential impact of the recommendations on improving access to maternal health. This can involve comparing the indicators between different scenarios and identifying the most effective interventions.

6. Refine and validate the model: Continuously refine and validate the simulation model based on new data and feedback from experts in the field. This will ensure that the model accurately reflects the real-world situation and provides reliable insights into the potential impact of the recommendations.

7. Communicate the findings: Present the findings of the simulation analysis to relevant stakeholders, such as policymakers, healthcare providers, and community organizations. This can help inform decision-making and prioritize interventions to improve access to maternal health.

It’s important to note that the methodology for simulating the impact of recommendations may vary depending on the specific context and available data. The above steps provide a general framework that can be adapted and customized as needed.

Umbhali

Dima Health

Statistics:

Citations: 1

Identifiers:

DOI: 10.1371/journal.pone.0263921

Research Areas:

Genetics and Genomics, Health System and Policy, Infectious Diseases, Maternal Access, Maternal and Child Health, Quality of Care, Social Determinants, Technology and Innovations

Study Countries:

Nigeria

Study Design:

Cohort Study, Cross Sectional Study

Study Approach:

Quantitative

Participants Gender:

Female

Yabelana ngalokhu: