CRITICAL ANALYSIS OF PMTCT IN NIGERIA
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Mother-to-child transmission of HIV (MTCT) is the main route by which infants acquire HIV infection globally. In 2010, children living with HIV in Nigeria contributed 15.3% to the 370,000 infected children worldwide, thus, the region with the highest number of unprotected childhood infection. This accounts for about 90% of HIV infection in children below 15 years of age.Most children below 15 years living with HIV contract diseases through MTCT (FMoH, 2010) Overall incidence of MTCT without intervention is 20%-45% distributed over -Antenatal period -Labour & Delivery -Breastfeeding Without intervention, About 30% of infants of HIV infected mothers will be infected during pregnancy and delivery An additional 5-20% will also be infected through breastfeeding practices.
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CRITICAL ANALYSIS OF PMTCT IN NIGERIA
- 1. CRITICAL ANALYSIS OF PMTCT IN NIGERIA HIV
- 2. OVERVIEW Describe Mother to child transmission of HIV (MTCT) as a key public health issue Describe the Prevention of mother to child transmission of HIV ‘PMTCT’ intervention Demonstrate ability to integrate and interpret sources of evidence to provide rationale for PMTCT Examine potential barriers & drivers to successful implementation of PMTCT Examine the theoretical framework and communication channel. Examine the evaluation of the PMTCT programme
- 3. MOTHER TO CHILD TRANSMISSION OF HIV (MTCT) “Mother to child transmission of HIV (MTCT) or vertical transmission occur when HIV is transmitted from an HIV infected mother to child during pregnancy, labour and delivery or while breastfeeding” (WHO, 2014)
- 4. CONTINUED.... Most children below 15 years living with HIV contract diseases through MTCT (FMoH, 2010) Overall incidence of MTCT without intervention is 20%-45% distributed over -Antenatal period -Labour & Delivery -Breastfeeding Without intervention, o About 30% of infants of HIV infected mothers will be infected during pregnancy and delivery An additional 5-20% will also be infected through breastfeeding practices. (FMoH, 2009)
- 5. ESTIMATED MAGNITUDE OF MTCT IN NIGERIA (2009) Indicator Estimate National Median HIV prevalence (ANC) 4.6% Estimated Number of people living with HIV Total: 2.98 million Annual HIV positive births Total: 56,681 Annual AIDS deaths Total: 192,000 • Male 86,178 , Female 105,822 Number requiring anti-retroviral therapy Total 857.455 • Adult 754,375 ,Children 103,080 New HIV infection Total: 336,379 • Male 149,095 Female 187,284 Number of children orphaned by AIDS 2,175,760 Source: FMOH (2008) ANC 2008 Report HIV estimates and projection
- 6. RISK FACTORS FOR MTCT High maternal viral load Vaginal delivery Sexually Transmitted Infections Low literacy level Preterm delivery Prolonged labour Prolonged breastfeeding Cultural beliefs Premature rupture of membrane Low birth weight Non utilisation of modern health care for antenatal and delivery (Burr et al., 2007) (Siame, 2009)
- 7. IMPLICATIONS AIDS Anaemia (abnormality in red blood cells) Nausea and vomiting Diarrhoea Headaches Pain and nerve problems Rash Fatigue (Aids.gov, 2009) Anxiety Depression Death Suicide Homelessness Low self-esteem (Seameo, 2002).) Physiological Psychological
- 8. COST OF HIV Estimates specifies that the cost directly attributed to the prevention of MTCT would cost $22billion - $24billion annually in 2015 Socio-economic cost -Loss of productivity -Un employment -Poverty (UN, 2010)
- 9. THE INTERVENTION: PMTCT PROGRAMME Prevention of mother to child transmission of HIV Programme in Niger state Target group are women ,pregnant women and nursing mothers Managed by the Niger state ministry of health in collaboration with other stakeholders Counsel for HIV test Voluntary HIV test, explain result (optional) Perform CD4 test Dispense ARVs Safe obstetrics(Planned caesarean at 38 weeks of pregnancy Discuss infant feeding option Reinforce exclusive infant feeding Perform HIV test at 12 months Explain results.
- 10. AIMS OF PMTCT PROGRAMME Aim: • To reduce the risk of HIV infection for the infant during pregnancy, childbirth, and breastfeeding by 90% in 2015. • To increase antenatal clinic attendance • To ensure at least 90% of all HIV positive pregnant women and breastfeeding infant - mother pairs receive ARV prophylaxis by 2015 • To increase the number of pregnant women tested for HIV
- 11. THE RATIONALE FOR PMTCT SERVICES In Nigeria HIV accounts for 90% of children infection (NACA, 2010). MTCT is the main route of children’s HIV infection An estimate of 300,000 newborn contract HIV through breastfeeding (Msellati, 2009) Children constitute of 6% of PLHIV In Africa, over 1,000 newborns infected with HIV daily (Besser, 2010) 30–45% of MTCT are without intervention in Nigeria, (FMoH,2009)
- 12. POTENTIAL DRIVERS TO THE SUCCESSFUL IMPLEMENTATION OF THE INTERVENTION Male partner involvement Engagement of community/opinion leaders Involvement of key people (grandmothers and mother- in-laws) Involvement of gatekeepers Effective collaboration of stakeholders Trained health professionals Involvement of traditional birth attendants (TBAs) Community health workers
- 13. POTENTIAL BARRIERS TO THE SUCCESSFUL IMPLEMENTATION OF THE INTERVENTION Lack of male partner involvement Fear or Stigma and discrimination Lack of knowledge of importance of PMTCT Fear amongst Health workers Loss of follow up Negative attitude of health care providers Poor utilisation on health care services Strong culture of breastfeeding with very low rates of exclusive breast feeding before 6 months (Ugba, 2012; FMoH, 2010; Maman, Mbwambo, Hogan, Kilonzo & Sweat, 2001s)
- 14. THEORIES AND CHANGE MODELS Health belief models - Perceived benefit - Perceived barrier - Cues to actions (posters, billboards, death) (Becker, 1974) Implementation of PMTCT services was based on Diffusion theory of innovation which influences decision to adopt or reject an innovation people, as part of a social system, adopt or perceive a new idea (Rogers. 1995)
- 15. COMMUNICATION CHANNEL Mass media Information, education and communication materials (IEC) such as posters, billboard, prints, calendars One on one (FMoH, 2010)
- 16. EVALUATION To assess the quality of PMTCT implementation in the antenatal clinic. To measure the effectiveness of PMTCT Services and intervention outputs, outcomes and impact in ANC. Elements such as number of ANC participants, uptake of mothers‘ infant feeding choice, utilisation of ARVs and number of infections averted in infants are measured. Coverage and access analysis of PMTCT services Effectiveness of ARV medication for PMTCT Behaviour change impact of PMTCT program
- 17. CONCLUSION MTCT is a key public health issue in Nigeria Interventions : PMTCT Programme Rationale from epidemiological data There are Potential drivers to the success of PMTCT Programme There are potential barriers e.g. lack of family support Evaluation of the PMTCT services.
- 18. THANK YOU FOR LISTENING
- 19. REFERENCE LIST Aids.gov,. (2009). Side Effects. Retrieved 27 November 2014, from http://www.aids.gov/hiv-aids-basics/just-diagnosed-with-hiv- aids/treatment-options/side-effects/. Burr, C., Lampe, M., Corle, S., Margolin, F., Abresh, C., & Clark, J. (2007). An End to Perinatal HIV: Success in the US Requires Ongoing and Innovative Efforts that Should Expand Globally. J Public Health Pol, 28(2), 249-260. doi:10.1057/palgrave.jphp.3200126 Becker, M. (1974). The health belief model and personal health behavior (1st ed.). Thorofare, N.J.: C.B. Slack Federal Ministry of Health (2010). National HIV sero-prevalence sentinel survey among pregnant women attending antenatal clinics in Nigeria. Technical Report 2010. Abuja: FMOH Federal Ministry of Health (2009) – Nigeria. National PMTCT and HIV & infant feeding guidelines Nigeria.
- 20. Maman, S., Mbwambo, J., Hogan, N., Kilonzo, G., & Sweat, M. (2001). Women's barriers to HIV-1 testing and disclosure: Challenges for HIV-1 voluntary counselling and testing. AIDS Care, 13(5), 595-603. doi:10.1080/09540120120063223 Siame, G. (2009). 140 Risk factors associated with a high chance of mother to child transmission (MTCT) of HIV: a retrospective study of HIV-exposed infants/children in Kitwe, Zambia. JAIDS Journal Of Acquired Immune Deficiency Syndromes, 51, 1. doi:10.1097/01.qai.0000351097.32772.7d Seameo.org,. (2002). virtual library form. Retrieved 27 November 2014, from http://www.seameo.org/vl/hiv-aids/20h-re32.htm United Nation. (2010). UN News Service Section - UN study finds overall drop in funding for AIDS response in 2010. Retrieved 27 November 2014, from http://www.un.org/apps/news/story.asp?NewsID=39305#.VHbb8mcqf k8 Ugba, E.A.(2012) Increasing PMTCT uptake in a rural hospital using community-based volunteers and male involvement campaigns: experience from northern Nigeria. In: Nineteenth International AIDS Conference, Washington DC. 60-87. 2012.
- 21. WHO. (2014). WHO | Mother-to-child transmission of HIV. Retrieved 8 December 2014, from http://www.who.int/hiv/topics/mtct/en/
Editor's Notes
- This presentation will critically analyse the prevention of mother to child transmission of HIV programme in an antenatal clinic in kano state of Nigeria.
- This presentation will firstly describe MTCT as a public health issue. Following this the PMTCT programme will be described along with the rationale behind it. In addition the potential barriers and drivers to the successful implementation of PMTCT will be identified and the theoretical framework underpinning the programme. Finally the communication medium and evaluation will be explored.
- MTCT, also known as vertical transmission of HIV is the major route of child infection of HIV in Nigeria.
- Without effective intervention, the risk of MTCT ranges from 20% to 45%. However, effective intervention reduces the rate of MTCT to 2%. A study by Burr et al indicates that while MTCT has been virtually eliminated in most developed world, many developing countries like Nigeria still have a record of high rate of MTCT. The Nigerian federal ministry of health estimate that without intervention between 67,500 and 125,000 newborns will be affected (FMoH, 2010) In situations where a mother is not given ARVs while breast-feeding, the breast-fed child should receive ARV medications until one week after all breast-feeding is ceased. Where breastfeeding is not possible however, the use of infant formula is an alternative .
- Of course we must not forget the magnitude of MTCT. This next point shows data on the impact of MTCT in 2009
- The presence of various risk factor increases the risk of vertical HIV transmission from mother to child, which are listed above
- Being diagnosed with HIV infection could be highly distressing, and feelings depression and anxiety are common psychological effect Some negative health implications of HIV which can be physiological and psychological are higher level of HIV leading to AIDS (Acquired Immunodeficiency Virus) which weakens the immune system, the body’s natural defence against various infection which then leads to secondary infections (such as skin cancer, diarrhoea, pneumonia). Others are Fear of pain and dying (especially dying alone) Depression as a result of absence for HIV cure and feeling of helplessness Suicidal attempt as a way to reduce pain and to reduce grief and shame of family Self blame and anger for acquiring disease and towards other for their predicament Feelings of loss related to their ambitions, confidence Anxiety over risk of infection with other illness (Aids.gov, 2009; Seameo, 2002)
- Estimates from 2011 by the united nation indicates that the effective response of HIV based on the 2010 WHO treatment guidelines will cost $22billion to $24billion annually in 2015 (UN, 2010). PMTCT will realize substantial savings from reduced cost of health care and infants will likewise maintain good health (UN, 2010) The cost of inaction, delay and in decision in the acceleration of PMTCT programme is very high, as every child's HIV infection increases, social and economic cost to individual family, community and society will result to loss of productivity, unemployment, poverty and even death (UN, 2010).
- As the MTCT is such a major issue affecting the population PMTCT interventions was implemented to reduce the maternal and infant mortality and morbidity. ‘PMTCT ’ Prevention of mother to child transmission of HIV Programme for pregnant women and nursing mothers in antenatal settings is a highly effective intervention and it has huge potential to improve both maternal and child health. In march 2002, the Namibian Ministry of health piloted a PMTCT programme in 2 states hospital which yielded to 292 health centres providing PMTCT services. Aftewards,this led to achieving the United Nations General Assembly Special Session (UNGASS) goal of 80% coverage with PMTCT rolled out to over 85% of all health facilities in Namibia. The PMTCT programme involves identifying HIV positive women through Voluntary Counselling and Testing as the first step into the PMTCT programme. Though the PMTCT is managed by the kano state government, it involves the collaboration of other stakeholders in which members are: Community leaders (religious, traditional, heads of community networks Household heads Men and women of reproductive age PLHIV CBOs, NGOs, FBOs, Support Groups of PLHIV Health service providers (obstetricians, gynaecologist, nurses, midwives working in maternity units, paediatricians) The private sector, including pharmaceutical companies Mass media. (FMoH, 2010) When a mother goes to the clinic, Midwife Obstetric Unit or hospital for her first antenatal visit, she is offered routine HIV counselling and voluntary testing. The results are confidential, which means that only the counsellor and healthcare workers looking after the mother will discuss the results. Mothers will have the option to join the PMTCT programme free of charge. If the mother tests HIV positive, a CD4 count and staging will be done, so that she can be started on Antiretroviral Treatment (ARV). Other activities involves Community engagement Organising steering groups HIV testing Counselling Infant feeding Follow up activities
- The programme aims to reduce MTCT and also to save children from mortality and morbidity by reducing the impact of HIV epidemic on family and the society at large.
- It has been outlined that the rationale behind the PMCT programme is as a result of the burden of HIV on unborn children HIV infection, which accounts for 90% of children infection (NACA, 2010). In addition , an estimate of 300,000 newborn contract HIV through breastfeeding (Msellati, 2009). In 2011 the Nigerian government provided policy guidance to control HIV/AIDS in the country (FMoH, 2011). Outlined to meet the millennium development goal 4 and 5 (reducing child mortality and improving maternal health).
- The potential drivers to the successful execution of the PMTCT programme in Kano state includes the involvement of key people such as husband, grandmothers and mother-in-laws in the promotion of PMTCT has a positive impact on the uptake of the PMTCT services. Role of Community Gate keepers and Religious leaders • Support and encourage Community in awareness creation on PMTCT • Promoting f husbands involvement in ANC/MCH e.g. by active participation in town hall meetings for male focused groups and use of peer educators The role of the male partner: • provides finance and makes final decision on ANC utilization, delivery location and services and infant feeding practices • Acceptance and support to facilitate access to ANC and PMTCT services and support for infant feeding that promote HIV-free survival of infant and good health outcomes for mother . Male partners play an equally important role in the scale-up of PMTCT services. In Botswana and Zambia, where disclosure of HIV status among pregnant women is relatively high, families and male partners were involved in decisions around ART and infant feeding. Community involvement; health services should maintain dialogue with the community to keep members informed about the purpose and availability of programme services and to monitor acceptability and impact of the programme within the community Roles of TBAs • Providing counselling and information on PMTCT to pregnant women and their families • serves as referral for all pregnant women to PMTCT Sites • Assist health care providers in community mobilisation • Collaborate with health services in providing psychosocial support, treatment preparedness, and home visits to nursing mothers and pregnant women. Effective collaboration of stakeholders is also a key element to the success of the programme. This involves partnership between organisational bodies (WHO, PEPFAR, UNICEF), local health authorities, ministry of health and the state government. Each stakeholder has their responsibilities in the success of the programme such as monitoring of effectiveness and evaluation, funding for project, implementing national guidelines and policies, the supply of effective services. Reduces stigma by engaging opinion leaders at the community level, normalize HIV and facilitate access to services for all women living with HIV (including sex workers and drug users). Programmes must also strengthen the relationship between the formal health system and community organizations to expand HIV prevention services and treatment literacy and preparedness. National programmes should ensure that antenatal care, labour and delivery, and postpartum services provide a user-friendly environment for women living with HIV. Community health workers play an important role in increasing the uptake of PMTCT services by providing information on access to services, expanding treatment literacy related to the use of ARTs, supporting treatment preparedness and adherence, and encouraging positive prevention and disclosure of HIV status.
- There are also potential barriers to the successful implementation of the programme. In 2008/9, 58% of pregnant HIV infected women received ART prophylaxis for the prevention of MTCT. At that time transmission risk was reported to be at 12.7%. Medicines for PMTCT are available and financially supported, although there is an overall shortage of health workers trained in the latest PMTCT guidelines In an evaluation of the PMTCT programme , there was a high rate of loss of follow up as women feared stigmatisation due to HIV infection. Health worker are usually given in correct home address as mothers do not want their community to be aware of health status. A second potential barrier to the successful implementation of the intervention is the fear of abandonment, separation and divorce from husband. Male partner also see the programme as women’s responsibility. As it is obligatory for women to obtain permission from their husbands before making decision and attempt to seek healthcare services, women tends to fail to participate in the PMTCT services (Ugba, 2012). Studies, reports the fear of discovery of the test results and fear of spouse’s negative reaction towards the women’s test for HIV have been found to be barriers to HIV testing for pregnant women in the PMTCT programme (Maman, Mbwambo, Hogan, Kilonzo & Sweat, 2001). Contrary to the anticipated fear, many men have been found to be quite supportive of their partners participating in the PMTCT programme.
- The Health Belief Model (HBM) is used as conceptual framework to inform interventions and women’s health-seeking behaviour. HBM focuses on the perceived susceptibility (threats) that describes mothers’ acceptance to test for HIV, receiving the result, and accepting the fact that her child is susceptible to the vertical transmission of HIV disease. -Perceived benefits are related to mothers’ knowledge and belief that PMTCT interventions are beneficial and effective in preventing mother-to-child transmission . -Perceived barriers are defined as es the mother believe that the benefit of adhering to PMTCT outweighs the costs/barriers. Perceived self-efficacy indicates the woman’s level of confidence that she is able to complete the steps necessary for PMTCT adherence . A study in soth africa reported thatHIV-positive pregnant women who participated in the Mothers2Mothers intervention were “significantly more likely to feel that they could do things to help themselves” and to “feel less overwhelmed by problems”(Besser, 2010). HBM attempt to increase knowledge through counselling and education as the “cue to action” for mothers. cues to action may increase HIV testing during antenatal care (ANC), which is the first step of PMTCT. Diffusion theory of innovation is a process that descries how potential adopters of innovation influence change (Rogers. 1995)
- Face to face communication holds the key to stimulating demand for PMTCT services as well as strengthening positive behaviours toward PLHIV
- For the assessment on this PMTCT programme impact in preventing new infant infection and HIV free infant survival, the progress on the impact of PMTCT programme was measured based on the number of HIV tested mothers and pregnant women and the receipt or ARVs by these women. Data gathered indicated the progress of the programme to reduce the risk of MTCT and by effective coverage, that is the number of target group that accessed and correctly utilised the services, although translating this data into impact was limited.
- To conclude, MTCT of HIV is an increasing burden within developing countries specifically in Nigeria This has lead to the implementation of PMTCT programme in kano state of Nigeria The rationale behind the PMTCT intervention has been described above There are various potential drivers to the success of the Implementation of the PMTCT Programme such as the involvement of traditional birth attendants (TBAs). In contrast, there are many potential barriers to the success of the PMTCT programme such as lack of involvement of partners. The intervention also focused on the utilisation of community health workers to scale up women participation in the PMTCT services. however ,there was loss of follow up in the PMTCT services due to fear of stigmatisation and discrimination for mothers. Actions needs to be taken to promote follow up services. Follow up is a major challenge faced by women in the PMTCT programme. Most women in this community tend to avoid home visit which then leads to loss of follow up, as it is seen as a license to stigmatisation once health visitors visit their household, as this may create awareness to neighbours of mother’s health status. one way of resolving this challenge to the participation of PMTCT services to reduce loss of follow up in the programme is the introduction of a mentor mothers group. They serve as teachers, resource persons and community guides to provide required support, home base care, voluntary counselling and testing and providing basic HIV information in the ANCs. Their involvement will reduce the burden of stigmatisation and fear among women with HIV and they also have influence over couple’s decisions on their pregnancy