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Evaluation of PMTCT Programme Implementation in General Hospital, Iquita Oron, Akwa Ibom State, Nigeria

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Markson J. A[1]., Umoh A. V[2]

[1]Ministry of Health, Idongesit Nkanga Secretariat, Uyo, Akwa Ibom state, Nigeria
[2]Dept of Obstetrics and Gynaecology,University of Uyo Teaching Hospital, Uyo, Nigeria

ABSTRACT
Context: Although mother to child transmission is said to be responsible for over 90% of HIV infections in children, available evidence indicates that it is possible to reduce or stop such new infections with appropriate interventions.
Objective: To evaluate the PMTCT programme implemented in General Hospital, Iquita Oron, Akwa, Ibom state, Nigeria.
Method: Cross sectional, descriptive rapid evaluation of PMTCT programme undertaken in General Hospital, Iquita Oron. Data were collected through review of ante natal, labour and infants HIV early diagnosis records  from January to December, 2010 in addition to use of questionnaires.
Main outcome measure: Effectiveness of PMTCT programme, uptake of delivery services, quality of ANC and delivery services.
Results: Analysis revealed that 15.13% of ANC attendees were positive for HIV while only 4% of the exposed infants were infected with HIV at the age of 18 months. The mean gestational age at first booking was 24weeks; 99.2% of ANC attendees accepted HIV test and 82.1% were charged for services.
Conclusion: Early ANC booking and administration of anti retroviral drugs can result in significant reduction of mother to child transmission of HIV. The replication of the ‘Oron experience’ at other health facilities in the state and the scale up of PMTCT services to several more health facilities is recommended.

Key words: Human immunodeficiency virus (HIV), Mother to child transmission (MTCT) of HIV, Exposed infants, early infant diagnosis, Prevention of Mother to child transmission (PMTCT) of HIV.

INTRODUCTION
Women and children constitute about half of the global population of people living with HIV[1]. At the end of 2010, estimates had it that about 34 million people were living with HIV while over 90 percent of the 370,000 children infected with HIV were through mother-to-child transmission (MTCT)[2]. It is said that without interventions, about half of these children will die before the age of two years[1]. However, UNAIDS maintains that it is possible to stop new HIV infection in children and keep their mothers alive if pregnant women living with HIV and their children have timely access to quality life saving anti-retroviral drugs for their own health, or as prophylaxis to stop HIV transmission during pregnancy, delivery and breast feeding[2].
The Nigerian Federal Ministry of health estimates that 15-45 percent of infants born to HIV infected mothers could get the infection at any of these stages (pregnancy, delivery and breast feeding) if there are no interventions[3]. Mother to child transmission of HIV therefore becomes a major public health problem considering the estimated 210,000 pregnant women, living with HIV4 and about 56,681 annual HIV positive births at the end of 2009 in Nigeria[5].
Nigeria, through the Federal Ministry of Health, commenced Prevention of Mother to child Prevention (PMTCT) of HIV programme in 2002 in six tertiary health institutions spread across the six geo-political zones of the country with the support of UNICEF and other development and implementing partners.  The National guidelines for prevention of mother-to-child transmission of HIV[6] gave the overall goal of the Nigeria’s PMTCT programme as “to reduce the transmission of the HIV through MTCT by 50% by the year 2010 and to increase access to quality HIV counseling and testing services by 50% by the same year”[6]. Accordingly, the country adopted the United Nations’ four-prong strategic approach towards achieving this goal, thus; Primary prevention of HIV infection in women of child bearing age group and their partners; Prevention of unintended pregnancies among HIV infected women; Prevention of HIV transmission from HIV infected mothers to their infants and Care and support for HIV infected mothers, their infants and family members.
The initial target date of 2010 was reviewed with a new dateline and targets set. These were, to provide access to at least 90% of all pregnant women to quality HIV counseling and testing by 2015, to provide access to at least 90% of all HIV positive pregnant women to more efficacious prophylaxis by 2015 and to provide access to at least 90% of HIV exposed infants to more efficacious ARV prophylaxis by 2015. Other goals were to provide access to at least 90% of HIV positive pregnant women to quality infant feeding counseling by 2015 and to provide access to at least 90% of all HIV exposed infants to early infant diagnosis services by 2015.
Akwa Ibom state PMTCT programme In 1989, Akwa Ibom state reported her first case of HIV infection in a commercial blood donor in one of the general hospitals in the state[7]. Between then and 2010, the state HIV prevalence rates, using ante natal sentinel surveys as proxy for the general population had been between 12.7% in 1999 declining to 7.2% in 2003 only to remain on the increase from then to 10.9% in 2010. These surveys indicated significant differences in prevalence rates between urban and rural areas of the state with 14% in rural and 12% in the urban areas compared to state average of 10.9%. The prevalence rates of HIV have been consistently high in Oron from 14.7% in 2005, to 14.0% in 2008 and 15.9% in 2010[5]. Indeed, Oron had the highest point prevalence in the 2008 survey.  There are 15 health facilities in the LGA; a secondary facility, seven primary health care centres and seven private/mission clinics. The General hospital, Oron is the only secondary health facility in the LGA. The general hospital and three primary health centres offer PMTCT services in the LGA.
The general hospital, Iquita Oron is one of the rural sites for the sentinel surveys. In 2010, it had a prevalence rate of 15.9%[5].

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Interventions began in General Hospital, Iquita Oron in 2007, among other six facilities as an emergency response to the pandemic. The initial approach included training of health workers and later introduction of anti-retroviral drugs in 2009 as prophylaxis against mother to child transmission of HIV. The programme is being supported by the state and federal governments in addition to national and international development and implementing partners. PMTCT programme together with other HIV and AIDS programmes are coordinated by the state ministry of health through the state HIV/AIDS and sexually transmitted infections control programme (SASCP). This is supported by a PMTCT technical working group made up of development and implementing partners, relevant policy makers, PMTCT sites coordinators, the media and representatives of people living with HIV.
PMTCT programme is implemented in the facility based on the national guideline with a robust management information system in place. With the support of UNICEF and other partners, staff at this facility have been trained on monitoring and evaluation and the records unit equipped with information and technology equipment for data collection and entry. However, there was no baseline information available by 2009 prior to PMTCT programme implementation in the General Hospital just like in other health facilities in the state. Evaluating the programme at this point will therefore not only provide ‘baseline’ information, but will in addition, supply programme managers and implementers with evidence and information on programme effectiveness and lessons for modifications or replication at other health facilities.

MATERIALS AND METHODS
Study Setting
Akwa Ibom State is located in the south-south geopolitical region of Nigeria. The state shares boundaries with Rivers State on the west, Cross River on the east, to the north by Abia and Imo states and south by the Atlantic Ocean. The 8,412 square kilometre state has a projected population of 3.9 million[8] people spread across 31 LGAs.
Eighty-five percent of the population of the state lives in the rural areas with fishing, farming and petty trading as their major occupations. About 50% of the local government areas have riverine communities and many hard to reach areas are embedded within these communities.
Oron is one of the rural communities located in the riverine area of Akwa Ibom state with a projected population of 181,221. It is the headquarters of Oron local government area. Their main occupation is fishing with a few engaged in trading and fewer still in farming. Socio-economic issues such as poverty, early sexual debut and unemployment are contextual factors which might aid the spread of HIV. Social networking such as wake keep during burial ceremonies provides avenue for risky behaviours. Other prevailing socioeconomic issues include lack of women empowerment to negotiate sexual matters, polygamy, pervading poor access of women to sustainable income generating activities, and widow inheritance practice. Majority of the male out of school youths take to commercial motor-cycling business, an avenue for generation of easy disposable income and females are exposed to exploitation for transactional sex. Some of these females operate hairdressing saloons, restaurants and other sundry businesses as covers[9] and as contact/pick up points.

Methods
This evaluation was limited to the third prong (Prevention of HIV transmission from HIV infected mothers to their infants) of the strategic PMTCT programme approach. The evaluation thus concerned itself with the effectiveness of the intervention in this area. To achieve this, two questions adopted from Family Health international[9] were asked;
1. How much HIV transmission is prevented in exposed infants 18 months of age by use of anti retroviral (ARV) drugs in mothers?
2. What effect did the infant feeding method have on  HIV transmission  to  infants’ aged 18 months who were given ARV prophylaxis?
This was a quantitative, cross sectional descriptive  evaluation undertaken between the third and fourth weeks of September 2012. Approval was sought from the Hon. Commissioner, State Ministry of Health. Data collection methods included review of clients (women and infants) hospital records at ANC, labour ward, post natal and immunization clinics. Some authors[11] accept this facility evaluation method as it has a clear advantage of convenience and simplicity in addition to the fact that since PMTCT services are mainly situated in facilities, it provides the best opportunity to access clients for evaluation with the best chance of linking mother-child pair to their hospital records. In addition to desk review, questionnaires were developed, field tested, interviewers trained on their use and administered on women attending immunization and post natal clinics.
Maternal ANC records from January to December 2010 were reviewed to ascertain pregnancy age at first registration at ANC, PMTCT services received, especially HIV testing and counseling, ARV prophylaxis and infant feeding counseling. Using the maternal ANC hospital registration numbers, ARV drugs issued to HIV infected pregnant women were cross-checked and confirmed from the pharmacy records. The records of the infants born to HIV infected mothers were traced and linked with the mothers using the ANC numbers. Through this method it was possible to get the HIV status of the exposed infants at 18 months of age based on result obtained using dried blood spots (DBS) analysis with polymerase chain reaction (PCR) at the University of Uyo Teaching Hospital. These information on  the breast feeding practices of mothers from birth and up to 18 months of age. Early infant diagnosis (EID) records also contained information on  the breast feeding practices of mothers from birth and up to 18 months of age.
The questionnaires were used to obtain data on services received at clinic, cost of services, religious denominational affiliation and ways of improving services at facility. Data was collected, entered and analyzed using Microsoft Office Excel, 2007 and Epi Info version seven. Altogether, 2,630 ANC and 398 exposed infant records were reviewed while 54 out of 56 women responded to the questionnaires.

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RESULTS
Profile of respondents
Forty-eight of 54 (88.9%) of the pregnant women interviewed were married, almost half (46.4%) of them had attained secondary level education while 17.9% were educated up to the tertiary level. Only one respondent had no formal education. They were all Christians with 16.4% being primigravidae. Among the interviewed were 14 (25.9%) who had had four previous pregnancies while two had had nine  before.

PMTCT services provision
Results indicated that between January and December 2010, 2,632 were registered as first time ANC attendees at the General Hospital, Oron (table 1). This number ranged from 58 in December to 290 in January and September. The gestational ages at first registration at the ante natal clinic ranged from 12 to 40 weeks with a mean age of 24 weeks. Most (68%) of the respondents had made four or more visits to the ANC before delivery.
All the pregnant women except two (0.08%), accepted HIV counseling and testing with 15.1% being HIV infected. The HIV tests were performed using the rapid test kits (Determine, Stat Pak and Double check gold) based on the nationally approved serial algorithm. The study also found that all the pregnant women, including those infected with HIV, were engaged in mixed feeding of their infants in the first six months of birth, in spite of having received infant feeding counseling during the ante natal  period. All the HIV infected women and the exposed infants received ARVs as prophylaxis or treatment throughout the period of pregnancy and breast feeding. Sixteen of the 398 (4.0%) exposed infants were found to be infected with HIV when tested using the PCR method (table 2).

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Figure 4: Levels of clients’ satisfaction with service
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PMTCT programme outcome
Data review from the facility records indicated that 398 (15.13%) out of 2,630 women tested were found to be HIV infected. The infants of these 398 women were therefore exposed to the HIV. At the age of 18 months, 16 (4.0%) of these infants were found to be HIV infected compared to expected 15%-45% (60 -180 infants) in the absence of PMTCT interventions3.

Cost of services
The evaluation also looked at the cost of accessing ANC services at the hospital. Among those sampled by questionnaires, it was found that (82.1%) of the women said they paid for ANC services. Such payments were made for drugs, registration and laboratory tests. While 8.2% of the women spent less than ₦200.00 for services, others (57.5%) expended between ₦200.00 and ₦2000.00 to obtain such services. However, about half (49.0%) of respondents said  in spite of these charges, that services were cheap. Added to the cost of services was the cost of transportation to the facility. Eight of 54 (14.8%) respondents indicated they spent above ₦500.00 from their homes to the hospital while half of them spent between ₦50.00 and ₦100.00. Two of the women spent no money for transportation as their homes were within walking distance to the hospital.

Quality of service
The effectiveness of the PMTCT programmes depends on quality of services provided to pregnant women and their families. Some of these services were assessed in this study. Only two of the 2,632 declined HIV testing thus giving acceptance level of 99.9%. Records also indicated that of those tested,  2,437 (92.7%)received test results same day while  others returned for their results another day. Close to three-quarters  (72.7%) of the respondents (with HIV infected women receiving one-on-one post test counseling) received information on infant feeding generally and in the context of mother to child transmission of HIV and the need to inform their partners of their test results.
The time respondents spent in hospital ranged from one to nine hours with a mean of four hours, twelve minutes. About a quarter of the women (23.2%) however said they spent three hours in the hospital for ANC services. On the whole, respondents assessed services they received to be good (58.9%), very good (17.9%) and excellent (21.4%).

Place of delivery
When asked where they were delivered of their babies, 14 (28%) of 50 who responded to this question, indicated it was the same hospital (General Hospital, Oron) while 34 (68%) were delivered in churches (40%), traditional birth attendants (22%) and homes (6%). Only two (4%) delivered in another hospital. The Apostolic and Mt. Zion churches  were the two most churches were the church deliveries took place. Some of the reasons for delivering outside the formal sector included advice from their church leaders, high cost of delivery materials required by hospital staff and “fear of witches and wizards”.
Respondents were asked to make suggestions on ways of improving services at the hospital.
All the women said there should be no “waste of time” at the facility during ANC visits; the services should be free while 34.5% said all drugs for ANC attendees should be available in the hospital.

DISCUSSION
Nigeria, like many other countries, has rapidly scaled up coverage of PMTCT programmes, but the impact is seldom measured. The global plan to eliminate mother-child transmission (MTCT) was launched in June 2011 setting ambitious international targets such as a reduction in new child HIV infections by 90% and a reduction in mother-to-child transmission to less than 5%[12]. Measuring the impact and effectiveness of PMTCT programmes is critical for national and state programme planning and the eventual elimination of MTCT. It has been said that there are no standardised, internationally recognised methods for measuring national and state mother-to-child transmission rates and PMTCT programme effectiveness[13]. A common approach therefore, is to use programme coverage[14]. This involves counting the number of mother-infant pairs in a population receiving PMTCT services.  This might involve administering a questionnaire and collecting dried blood samples for populations with high HIV prevalence[12]. This was the approach used for this evaluation especially considering that Oron recorded  a high HIV prevalence rate of 15.9% in the 2010 national ANC sentinel survey.

In this evaluation, 16 of the 398 exposed infants representing 4.0% were HIV infected at the age of 18 months even with the mothers practicing mixed feeding of their infants. Similar practice of mixed feeding especially in countries with high HIV prevalence has been reported elsewhere[15]. The finding here of a low HIV infection rate among mix-fed infants is at variance with other reports that indicate an HIV infected woman who takes ARVs and mix-feed her baby may still have a higher rate of transmission than a mother who exclusively breastfeed and takes ARVs[15].
A total of 2632 (average 220 a month) pregnant women attended the general hospital, Oron in 2010 with a mean gestational age of 24 weeks. The initiation of anti retroviral prophylaxis or treatment early in the pregnancies might have contributed to the observed outcome of low MTCT in this evaluation. This agrees with  the observation in South Africa that early booking at ANC, early HIV testing and a well implemented  PMTCT programme   contributes to reducing the number of HIV-infected babies born to HIV positive mothers[15]. Many of the respondents made four or more visits to the ANC before their deliveries. This is a best practice which is in conformity with the Nigerian national policy of focused ante natal care that recommends a minimum of four visits during ANC. Going by the Federal Ministry of Health, 15–45% (60 -180) of the exposed infants in this study were at risk of being infected[3]. An infection rate of 4% as observed here is not just significant but exciting for the Akwa Ibom state PMTCT programme and ministry of health policy officers as this is an indication of programme success. It also fits into the international momentum for the elimination of paediatric HIV by 2015 where targets to reduce new infections have been set at 90% service  coverage and population-level mother-to-child infection rates at under 5% at 18 months in a breastfeeding population like ours. The effectiveness of the PMTCT programme in this health facility could therefore become a strong and evidence-based advocacy tool for replication at other facilities within or outside the side.
Cost of services for ANC was an unexpected finding considering the free ANC policy of the state government. It will be good to explore this further to confirm if these charges were ‘official’ or “hidden charges” propagated without official approval. This is necessary as lack of access to resources and inequitable decision-making power mean that when poor women face out-of-pocket costs such as user fees when seeking health care, the cost of care may become out of reach to them[8].

One of the key measures of effectiveness of PMTCT programme is how many people complete the PMTCT cascade: from antenatal care, counseling and testing, through starting timely treatment, to returning to test the infant and follow-up care for the infant[12]. This evaluation indicated a 99.9% acceptance level for HIV testing and counseling with 92.7% receiving their test results same day. This is indicative of high quality of service provided to clients. In addition, all the HIV infected women initiated ARVs early in their pregnancies. Other relevant services including information on breast feeding, family planning and partner involvement were discussed. However, these quality services were provided at the expense of clients spending long (one to nine hours) at the facility. This calls for improvement, especially as many of these pregnant women are self employed and when this is juxtaposed to costs of services may further discourage service uptake.
Of great concern to the state, not just for PMTCT programme, but for maternal and child health generally, is the preference of many pregnant women to be delivered outside the formal health sector in spite of the high ANC attendance and a supposedly free state ANC policy.  This evaluation revealed only 48.6% of the women delivered in formal health sector. This is similar to the 48.1% obtained from the national demographic and health survey[8]. The fact that many of these women that preferred deliveries in churches tended to belong to certain religious denominations calls for more in-depth research to unearth the issues involved in guiding their decisions with a view to programming for denomination-specific interventions involving such churches/denominations.

CONCLUSION
Administration of ARVs to HIV infected mothers and their exposed infants was effective in reducing mother-to-child transmission from 15-45% to 4% in General Hospital, Iquita Oron in 2010 even in the presence of mixed infant feeding practices.

RECOMMENDATION
This evaluation has demonstrated the effectiveness of the PMTCT programme in a resource constraint setting. It is hereby recommended for replication in other health facilities of the state in particular and the nation generally.

LIMITATIONS OF THE STUDY
Limiting the period for evaluation to one year and one health facility might not provide enough data for PMTCT programme effectiveness in the state. In addition, the small number of respondents here may be inadequate to draw generalised conclusions on their characteristics and behaviours especially with regard to breast feeding. These should however, not invalidate the study as it will provide information on programme implementation and serve as a baseline for subsequent evaluations.

REFERENCES

  1. Rogers-Bloch and Quail (2002) Community perceptions of PMTCT services and safe male circumcision in six focal states in Nigeria, Arlington, VA: USAID’s support and technical assistance resources, AIDSTAR-One Task order 1; p.17, www.aidstar-one.com/focus_areas/prevention/resources/reports/nigeria_community_perceptions_pmtct_smc on 23 September, 2012
  2. UNAIDS (2011) Global plan towards the elimination of new HIV infections among children by 2015 and keep their mother alive. http://www.unaids.org/en/media/unaids/contentassets/documents/unaidspublication/2011/20110609_JC2137_Global-Plan-Elimination-HIV-Children-en.pdf accessed on 23 September, 2012
  3. Federal Ministry of Health (2005). Report of evaluation of the PMTCT pilot programme in Nigeria. Accessed from www.nascp.gov.ng/reports/Nigerian PMTCT evaluation report final .pdf on 23/09/2012
  4. UNICEF (2012) HIV and Infant Feeding: Breastfeeding and HIV transmission. Updated June 2012.  http://www.unicef.org/nutrition/index_24827.html, accessed on 7 November, 2012
  5. UNICEF (2010) Nigeria: PMTCT www.unicef.org/aids/files/Nigeria_PMTCTFactsheet_2010.pdf accessed on 10 October, 2012
  6. Federal Ministry of Health (2010). Technical report, National HIV sero-prevalence sentinel survey among pregnant women attending ante natal clinics in Nigeria; Dept of Public Health, National AIDS/STI control programme
  7. Federal Ministry of Health (2010) National guidelines for prevention of mother-to-child transmission of HIV 4th edition.
  8. National Population Commission (NPC) [Nigeria] and ICF Macro. 2009. Nigeria Demographic and Health Survey 2008. Abuja, Nigeria: National Population Commission and ICF Macro.
  9. Akwa Ibom state Action committee on AIDS (2010). Akwa Ibom State HIV/AIDS Epidemiology, Response and Policy Synthesis Report
  10. Family Health International (2004). Monitoring HIV/AIDS Programmes: Participant guide: A USAID resource for prevention, care and treatment, Module 9: Monitoring and evaluating PMTCT programme  www.gametlibrary.worldbank.org/FILES/547_Monitoring PMTCT -participant-FHI .pdf, accessed on 23 October, 2012
  11. Elizabeth M Stringer a, Benjamin H Chi a, Namwinga Chintu a, Tracy L Creek b, Didier K Ekouevi c, David Coetzee d, e, Andrew Boulle d, Francois Dabis f, Nathan Shaffer b, Catherine M Wilfert g, Jeffrey SA Stringer.  Monitoring effectiveness of programmes to prevent mother-to-child HIV transmission in lower-income countries. Bulletin of the World Health Organization Past issues: Volume 86, Number 1, January 2008, 1-80, www.who.int/bulletin/volunes/86/1/en/index.html accessed on 20 October, 2012 Pius Tih e, Andrew Boulle d, Francois Dabis f, Nathan Shaffer b, Catherine M Wilfert g, Jeffrey SA Stringer.  Monitoring effectiveness of programmes to prevent mother-to-child HIV transmission in lower-income countries. Bulletin of the World Health Organization Past issues: Volume 86, Number 1, January 2008, 1-80,  www.who.int/bulletin/volunes/86/1/en/index.html accessed on 20 October, 2012
  12. Neuman, Melissa (2011). PMTCT satellite sessions; Rapporteur reports, 6th IAS conference on HIV pathogenesis, treatment and prevention, 17-20 July, 2011. Accessed from http://pag.ias2011.org/session.aspx?s=23 accessed on 20 October, 2012
  13. Leach-Lemens, Carole (2011). South Africa’s PMTCT programme reduces MTCT under 4%. Presentation at the Sixth International AIDS society Conference in Rome.   http://www.aidsmap.com/South-Africas-PMTCT-programme-reduces-mother-to-child-transmission-to-under-4/page/1880446/ accessed 20 October, 2012
  14. UNICEF (2012) HIV and Infant Feeding: Breastfeeding and HIV transmission. Updated June 2012. http://www.unicef.org/nutrition/index_24827.html , accessed 7 November 2012
  15. Iryna Chaparanganda (2012) Effectiveness of PMTCT Programme at Mogwase Health centre, South Africa. Retrovirology, 2012, 9 (Suppl 1): p 114.  www.retrovirology.com/content/9/S1/p114, accessed on 21 October, 2012
  16. Nanda, Priva (2002) Gender Dimensions of User Fees: Implications for Women’s Utilization of Health Care. Reproductive Health Matters Volume 10, Issue 20 , Pages 127-134, November 2002. http://www.rhm-elsevier.com/article/S0968-8080(02)00083-6/abstract, accessed on 23 October, 2012