|Year : 2018 | Volume
| Issue : 1 | Page : 27-31
Audit of prevention of mother-to-child transmission programme interventions in HIV-Exposed children at national hospital, Abuja, Nigeria
Mariya Mukhtar-Yola, Adekunle Tolulope Otuneye, Amsa Baba Mairami, Yewande Wey, Vincent Nwatah, Lamidi Isah Audu
Department of Paediatrics, National Hospital Abuja, Abuja, Nigeria
|Date of Web Publication||17-Apr-2018|
Dr. Mariya Mukhtar-Yola
National Hospital Abuja, Abuja
Source of Support: None, Conflict of Interest: None
Background: Ninety percentage of children acquire human immunodeficiency virus (HIV) infection in the form of Mother-to-child Transmission (MTCT). In the absence of interventions, transmission rates range from 15% to 45%. This can be reduced to below 5% with effective interventions. The last published national guideline (NG) on prevention of MTCT (PMTCT) was in 2010. Clinical audits are essential in improving the quality of care delivered to patients. Objectives: The study objectives were to determine the rate of MTCT of HIV in exposed infants at a follow-up clinic between 2011 and 2014 and to determine the level of adherence to 2010 NG on the use of highly active antiretroviral therapy (HAART), polymerase chain reaction (PCR) testing, feeding options, antiretroviral (ARV) prophylaxis and the use of co-trimoxazole (CTZ). Methods: A retrospective review of data was done over 4 years. The population consisted of babies delivered through PMTCT programme and those referred to the clinic from other centres. Data analysis was done using the Statistical Package for the Social Sciences (SPSS) version 21. Results: Out of 699 babies enrolled, MTCT occurred in 22 babies (3.2%) and PCR testing was done in 445 babies (64.7%), most in the 1–2 months' age group. Breastfeeding was practiced in 402 (58.2%) babies, while about 88.0% of them received post-exposure ARV prophylaxis (PEP). CTZ prophylaxis was offered to only 226 (34.6%) babies. The regression model showed that maternal use of HAART and PEP for babies was independently associated with a reduction in transmission rate. Conclusion: The MTCT rate was 3.2%. There is a need to strengthen service provision to adhere to NG, especially on breastfeeding and CTZ prophylaxis.
Keywords: Audit, human immunodeficiency virus-exposed infants, prevention of mother-to-child transmission interventions
|How to cite this article:|
Mukhtar-Yola M, Otuneye AT, Mairami AB, Wey Y, Nwatah V, Audu LI. Audit of prevention of mother-to-child transmission programme interventions in HIV-Exposed children at national hospital, Abuja, Nigeria. Niger Postgrad Med J 2018;25:27-31
|How to cite this URL:|
Mukhtar-Yola M, Otuneye AT, Mairami AB, Wey Y, Nwatah V, Audu LI. Audit of prevention of mother-to-child transmission programme interventions in HIV-Exposed children at national hospital, Abuja, Nigeria. Niger Postgrad Med J [serial online] 2018 [cited 2020 Apr 1];25:27-31. Available from: http://www.npmj.org/text.asp?2018/25/1/27/230221
| Introduction|| |
Globally, mother-to-child transmission (MTCT) of human immunodeficiency virus (HIV) is the major type of transmission to children accounting for up to 90% of cases. Although substantial progress has been made globally in reducing or even eliminating MTCT of HIV through effective prevention of mother-to-child transmission (PMTCT) interventions, sub-Saharan African has continued to record high transmission rates., The large population, high prevalence of HIV among pregnant women, high fertility rate, mixed feeding of babies, poor access to health facilities for antenatal and delivery purposes and loss to follow-up have contributed to the high rates of MTCT in Nigeria.
The PMTCT of HIV programme was initiated in Nigeria by the Federal Ministry of Health in 2001, with the aim of reducing vertical transmission of HIV. Subsequently, a guideline which provided the recommended standard of care for HIV-positive pregnant women and their babies was developed in 2003 and reviewed in 2005 and 2007 to reflect global trends in line with relevant scientific studies. Furthermore, following the rapid advice provided by the World Health Organization (WHO) on the use of antiretroviral (ARV) drugs for treating pregnant women and preventing HIV infection in infants, as well as revised HIV and infant feeding guidelines, a further review was done in 2010. The guideline emphasised identifying pregnant women in need of treatment for their own illness versus those who only require prophylaxis for their index pregnancy. The drug regimen of choice for prophylaxis to begin as early as 14 weeks of gestation was highly active antiretroviral therapy (HAART) with the option of the zidovudine- based regimen or dual therapy for the facilities that had limited capacity to monitor clients on triple therapy. The guideline also advocated breastfeeding as the preferred infant feeding option with ARVs taken by the mother, baby or both for a defined period. Early infant diagnosis of HIV by polymerase chain reaction (PCR) should be performed on infants on follow-up around 6 weeks after delivery, with a repeat 6 weeks after cessation of breastfeeding. HIV-positive infants are offered ART and further care.
This study set out to determine the rate of mother-to-child transmission of HIV amongst exposed infants attending a HIV follow-up clinic, as well as to investigate the level of adherence by prescribers and patients to the 2010 National Guideline (NG) on PCR testing, feeding option, ARV prophylaxis and use of co-trimoxazole (CTZ). The null hypothesis being tested is that there is no difference in the level of adherence to the 2010 PMTCT guideline on the use of HAART, PCR testing, feeding options, ARV prophylaxis and the use of CTZ.
| Methods|| |
The study setting was at the National Hospital Abuja, a 400-bedded tertiary centre, which serves as a referral hospital not only to the district hospitals within town but also to hospitals from neighbouring states and beyond. It is also one of the initial six pilot sites initiated by the government for PMTCT programme and treatment of children with HIV/AIDS. The Institute of Human Virology under the Presidential Emergency Plan for AIDS Relief initiative supports the HIV programme in the hospital.
A retrospective review of data was done covering a 4-year period from January 2011 to December 2014. The age, sex, final PCR result, type of HIV treatment or prophylaxis received by the mother, infant feeding choice, post-exposure prophylaxis (PEP) and use of CTZ prophylaxis were assessed.
Ethical approval was obtained from the Ethical Review Board of the National Hospital.
Participants were drawn from the follow-up clinic of HIV-exposed neonates, which runs within the newborn clinic. HIV-exposed infants are followed up to the age of 18 months in this clinic and all interventions during the study period were made according to the 2010 National PMTCT Guideline. Enrolled participants consisted of babies delivered through PMTCT programme in National Hospital Abuja and those referred to the clinic from other centres.
Data were validated and analysed using the Statistical Package for Social Sciences (SPSS) Version 21 (IBM Corp: Armonk, NY). Summaries were obtained using frequencies and percentages for categorical data, while means and standard deviations were obtained for numerical data.
The Chi-square test was used to determine any significant association between categorical variables (PCR result and various interventions), and P < 0.05 was considered significant. Binary logistic regression and multivariate regression analyses were done, with the PCR result as the independent variable and various interventions such as mother received HAART, infant received PEP and breastfeeding as the dependent variables. The standardised coefficients, F-statistic (which assesses multiple coefficients simultaneously), and significance levels were determined.
| Results|| |
A total of 699 babies were enrolled during the period under review of which 22 (3.2%) were PCR positive while 673 (96.2%) were negative and 4 results were not recorded. The indication for PCR was as a first test for a healthy exposed baby in 619 cases (88.6%) and as a first test for a sick baby in 80 cases (11.4%). There were records of 343 males and 341 females with a male-to-female ratio of 1.1:1. There was no difference between male and female infants who tested positive to PCR (χ2 = 0.194; P = 0.660). The year 2011 had the highest number of enrollees (198 [28.3%]), while 2012 had the highest number of positive cases (10 [5.3%]) as shown in [Figure 1]. PCR testing was done mostly in the 1–2 months' age group (445 [64.7%]) followed by the 2–6 months' age group (157 [22.8%]) as shown in [Figure 2].
|Figure 1: Distribution of human immunodeficiency virus test (polymerase chain reaction) across years under review|
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|Figure 2: Distribution of human immunodeficiency virus test by age category|
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The various interventions offered in pregnancy are shown in [Table 1]: 52 (7.5%) mothers did not receive HAART, while 102 (14.8%) started either HAART or received monotherapy during pregnancy and 532 (77.1%) received HAART before pregnancy. There were four (0.6%) patients who had no records if any medication was received. Only 402 (58.2%) babies were ever breastfed and 599 (87.7%) received PEP, majority of whom received nevirapine. Only 226 (34.6%) babies received CTZ prophylaxis.
Bivariate analysis of the association between various dependent variables and the final PCR result showed a statistically significant difference between whether the mother received HAART or not (χ2 = 93.54; P = 0.000) and if a baby received PEP or not (χ2 = 61.80; P = 0.000) [Table 2]. Furthermore, the regression model showed that the use of HAART by the mother and PEP for the baby were independently associated with a reduction in transmission rate, accounting for about 30% of the variability as shown in [Table 3] (coefficient of determination R2 = 0.271).
|Table 2: Distribution of polymerase chain reaction result versus interventions|
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|Table 3: Regression coefficients of polymerase chain reaction result versus various interventions|
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| Discussion|| |
This clinical audit showed a mother-to-child transmission rate of 3.2%. Vertical transmission remains the predominant mode of transmission in children, hence the need to reduce MTCT., This finding is similar to reports from several centres., Lower and higher rates of transmission have been reported depending on the level of adherence to WHO guideline recommendations.,,,
The finding from this study is higher than that from a previous report by Agboghoroma et al. from the same centre. Their study was done between 2006 and 2008 evaluating patients from National Hospital Abuja only where the overall MTCT was found to be 2.4%. They found the transmission rate to be lower in those who received HAART and breastmilk substitutes (BMSs) as compared to those on monotherapy and exclusive breastfeeding (EBF). During their study, the NG recommended BMS for infants and provided it free to parents, thus 95% of the enrolled babies were on BMS, probably reducing the risk of post-natal transmission, in contrast to the current status where about 43% of babies were on BMS. Morbidity and mortality were, however, not assessed in that series and infant follow-up was identified as a huge challenge. The elimination of post-natal transmission of HIV has been a major challenge in PMTCT programme in Nigeria and other African countries where breastfeeding is virtually universal. The 2013 National Demographic Health Survey in Nigeria reported that although 97% of Nigerian women breastfeed their babies, only 17% practice EBF, while the majority practice mixed feeding. There is a possibility that many of the mothers who claimed EBF in this study actually practiced mixed feeding. This has been associated with higher risk of HIV transmission compared with EBF. More recent reports show that infants on EBF and PEP have lower rates of post-natal transmission.,,
The current study period reflects a transition between guidelines stressing the important role of HAART versus monotherapy and the paradigm shift in infant feeding recommendation as well as PEP duration. The included participants were infants of mothers who received PMTCT at National Hospital as well as those referred from other hospitals who may have had limited access to ART provision and diagnostic facilities.
Since the last report, the number of mothers on ARV drugs and babies on PEP has greatly increased to 91.9% and 88%, respectively. Majority of the mothers received HAART prior to pregnancy, while others received either HAART or monotherapy during pregnancy and labour. However, 52 (7.5%) mothers did not receive ARVs prior to delivery, highlighting the fact that though services are available, uptake is still suboptimal perhaps for several reasons. Some of these include long-standing health system issues (such as staffing and staff attitude, service accessibility and availability); community-level factors (particularly stigma, fear of disclosure and lack of partner or family support); home delivery; poor adherence to medications and financial constraints., These factors were not examined for in this study. In a recent report by National Action Committee on AIDS, of the 75,885 HIV-positive pregnant women identified in 2015, about 70.8% received ARVs.
The follow-up rate of HIV-exposed infants was much higher and diagnosis was made much earlier in this study compared to earlier reports from the same centre., Those who had their PCR testing done within the first 2 months of life were predominantly those who had the PMTCT care offered at the National Hospital, while those referred from other hospitals and presented late mainly had testing done between 2 and 6 months. This has implications for initiating treatment early in those who turn out to be positive.
The 2010 NG  recommends breastfeeding for all HIV-exposed infants; however, in this study, only 402 (58.2%) babies were ever breastfed while 289 (41.8%) were being fed on BMS. Although the rate of breastfeeding may appear low considering the guideline recommendation, it is well documented that changing the attitude and behavior of people is a very gradual process, especially as the earlier guidelines had recommended feeding with BMS., Mothers who had used BMS in an earlier pregnancy from which the baby turned out HIV negative may be unwilling to breastfeed the next baby for the remote fear of transmission. There is a need to provide training to healthcare workers and ongoing counselling to parents.
Several studies have proven that mothers who received HAART prior to delivery, followed by prophylaxis in their infants, have less chances of transmitting the HIV virus to their infants.,, The regression analysis showed a statistically significant difference and reduction in transmission rates between those who had pre-natal HAART and PEP compared to those who did not.
Overall, this audit has revealed that the adherence to the recommendations of the 2010 NG on the use of HAART in mothers, PCR testing and PEP in babies was good. However, there was a low adherence to guideline recommendation on EBF and CTZ prophylaxis as only 226 (34.6%) babies received CTZ prophylaxis. These interventions have been found to be cost-effective in reducing long-term morbidity and mortality., Infant feeding counselling and prescription of CTZ need to be strengthened as we look forward to the adaptation of the 2016 WHO guideline by the government which recommends treatment for all positives.
Limitation of study
The study was not without limitations, being a retrospective review of data, certain variables could not be assessed such as prevalence of mixed feeding and indeed there were incomplete data on some variables.
| Conclusion|| |
PMTCT interventions, especially the use of HAART in mothers and PEP, reduced transmission rate to 3.2%. However, there is a need to strengthen service provision to adhere to NGs, especially on breastfeeding and CTZ prophylaxis. Nigeria signed up to the global plan for the elimination of new HIV infections among children and keeping their mothers alive. Significant strides have been made, in partnership with development partners, to decentralise PMTCT services to primary healthcare centres and rural settings in order to increase coverage. In 2015, 7265 sites offered PMTCT services. The quality of services must, however, be maintained and regular audits must be done to improve service provision.
The authors would like to thank Mr. Olukayode, medical laboratory scientist, at the National Hospital Abuja for helping with data storage.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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