PMTCT Implementation and Early Infant Diagnosis of HIV Infection in Lagos, Nigeria: The Mix, Missed and the Muffed

Abstract

Background: Nigeria has a large population of people living with HIV infection, with Lagos state as one of the six priority states for national HIV prevention interventions because of its high HIV prevalence. In Lagos state, the primary health care system is the most proximal to the populace, including pregnant women infected with HIV. National and state efforts to prevent new pediatric HIV infection using prevention of mother-to-child transmission (PMTCT) strategies, including early infant diagnosis (EID) of HIV infection have evolved and has been scaled since 2002 when PMTCT interventions commenced in Nigeria. With suboptimal uptake of PMTCT strategies and EID of HIV in Lagos, the dissertation research assessed the contemporary evidence on interventions to increase EID uptake and health systems barriers to a seamless implementation of PMTCT intervention at the primary health care level of Lagos state, Nigeria. Objectives: This dissertation comprises four studies. A systematic review and meta-analysis, a quantitative survey of service providers’ knowledge of the Nigerian PMTCT guidelines recommendations, mixed-method research, and a qualitative study. The studies’ aims were to achieve the following 1). Synthesize and provide the evidence quality of interventions to increase uptake of early infant diagnosis of HIV at 4-8 weeks of life for an HIV-exposed infant. 2). Assess the knowledge of PMTCT service providers of the Nigerian PMTCT treatment guidelines. 3). Assess the uptake and challenges of early infant diagnosis of HIV at the primary health level in Lagos state. 4). Assess the barriers encountered by service providers in the routine provision of PMTCT services at the primary health care level in Lagos state, Nigeria. Methods: A systematic review and meta-analysis were conducted between May and December 2020 to identify and critically appraise the evidence quality of interventions to increase uptake of early infant diagnosis of HIV infection at 4-8 weeks of life. Five databases (PUBMED, CINAHL, EMBASE, PsycINFO and Web of Science) were searched for eligible studies. Search output and data extraction were performed using Covidence® by two researchers independently. GRADE (Grading of recommendations, assessment, development, and evaluations) was used to present the quality of evidence of interventions. Data collection for the dissertation research involved quantitative and qualitative data collection. The quantitative data collection was both primary survey of health workers knowledge of the Nigerian PMTCT guidelines and secondary data collection using PMTCT program registers of the facilities. The qualitative research was in-depth interviews of service providers. The dissertation research was conducted in 23 primary health centers across all five administrative districts of Lagos state from July to September 2021. For the quantitative survey to assess knowledge of service providers and secondary data collection, REDCap® was used for data collection and statistical analysis was conducted with R. Responses of in-depth interviews were recorded on electronic voice recorders and transcription done verbatim before analysis with MAXQDA®. Inductive and deductive themes were created from the transcripts. The dissertation research was approved by the Human Research Ethics Committee of Lagos University Teaching Hospital, Lagos, Nigeria and given an Ethical deferral by the University of Arizona Institutional Review Board. Results: The systematic review and meta-analysis included 16 eligible studies involving 13,956 HIV-exposed infants. Included studies were published between 2014 and 2019 from sub-Saharan Africa and India. Nine experimental and seven observational studies included had low to moderate risk of bias and evaluated eHealth services, service improvement projects, service integration programs, behavioral interventions, and male partner involvement, compared to usual care.There was no evidence that eHealth, health systems improvements, integration of EID, conditional cash transfer, mother-to-mother support, or partner (male) involvement interventions increased uptake of EID at 4-8 weeks of age. There was also no evidence that any intervention was effective in increasing HIV-infected infants’ identification at 4–8 weeks of age.

Aim 2: One hundred and thirteen (113) respondents participated in the survey. Most respondents knew that HIV screening at the first prenatal clinic was an entry point to PMTCT services (97%) and that posttest counseling of HIV-negative women was necessary (82%). Similarly, most respondents (89%) knew that early infant diagnosis (EID) of HIV should occur at 6-8 weeks of life (89%). However, only four (3.5%) respondents knew the group counseling and opt-out screening recommendation of the guidelines; 63% did not know that hematocrit check should be at every antenatal clinic visit. Forty-eight (42.5%) service providers had good knowledge scores. Knowledge score was not influenced by health worker cadre (p=0.436), training(P=0.537) and professional qualification of  5years (P=0.43) Aim 3: Twenty-two Lagos state primary health centres participated in the research. Fifteen (68.2%) PHCs had both PMTCT HIV counseling and Infant follow-up registers. The documentation of DBS sample collection was observed in 12 (54.6%) PHCs, while both DBS sample collection and EID results documentation was observed in only 9 (40.9%) PHCs. There were both maternal and health systems’ challenges to early infant diagnosis of HIV infection. The denial of HIV status was the only maternal factor reported to militate against the utilization of EID services. Health systems challenges include unavailability of IED services, uncertainty of service providers about the provision of EID services in the facility in which they work, referral to secondary health facilities (with potential to loss to follow-up) for EID services and delayed availability of EID results in the facility. For aim 4: Twenty-two service providers participated in the in-depth interviews, comprising 18 nurses/midwives and four physicians. Patient-level barriers to PMTCT services encountered by service providers included non-disclosure of HIV status to husband, denial of HIV infection, non-compliance with combined antiretroviral therapy (cART), non-compliance with referral, sense of guilt and shame, loss to follow-up, difficulty in identifying HIV-infected women when they come in labour, mixed infant feeding and formular feeding challenges, non-compliance with infant prophylaxis with nevirapine and financial constraints. Health systems related barriers are unavailability of PMTCT services (PMTCT deserts), challenges with HIV counseling and testing, including inadequate test kits, challenges with repeat prenatal HIV screening for women with previous HIV-negative results, stigma and discrimination, lack of treatment guidelines, and manpower shortage. Conclusion: There was no evidence that common interventions increased uptake of EID at 4-8 weeks of age. Hence, further research is required to identify interventions that increase early infant diagnosis of HIV at 4-8 weeks of age.Service providers’ knowledge of PMTCT guidelines recommendations varied, with poor knowledge of group counseling and opt out screening recommendation. Also, the low uptake and constraints of EID uptake as well as the patient-level and health systems barriers to optimal PMTCT service provision require re-training of service providers on timing and documentation of EID and proper counseling of newly diagnosed HIV-infected pregnant women to ameliorate both individual and health systems barriers to a reducing new pediatric HIV infection in Lagos, Nigeria.