Modelling the impact and cost-effectiveness of combination prevention amongst HIV serodiscordant couples in Nigeria.

OBJECTIVE: To estimate the impact and cost-effectiveness of treatment as prevention (TasP), pre-exposure prophylaxis (PrEP) and condom promotion for serodiscordant couples in Nigeria. DESIGN: Mathematical and cost modelling. METHODS: A deterministic model of HIV-1 transmission within a cohort of serodiscordant couples and to/from external partners was parameterized using data from Nigeria and other African settings. The impact and cost-effectiveness were estimated for condom promotion, PrEP and/or TasP, compared with a baseline where antiretroviral therapy (ART) was offered according to 2010 national guidelines (CD4 <350 cells/μl) to all HIV-positive partners. The impact was additionally compared with a baseline of current ART coverage (35% of those with CD4 <350 cells/μl). Full costs (in US $2012) of programme introduction and implementation were estimated from a provider perspective. RESULTS: Substantial benefits came from scaling up ART to all HIV-positive partners according to 2010 national guidelines, with additional smaller benefits of providing TasP, PrEP or condom promotion. Compared with a baseline of offering ART to all HIV-positive partners at the 2010 national guidelines, condom promotion was the most cost-effective strategy [US$1206/disability-adjusted-life-year (DALY)], the next most cost-effective intervention was to additionally give TasP to HIV-positive partners (incremental cost-effectiveness ratio US $1607/DALY), followed by additionally giving PrEP to HIV-negative partners until their HIV-positive partners initiate ART (US$7870/DALY). When impact was measured in terms of infections averted, PrEP with condom promotion prevented double the number of infections as condom promotion alone. CONCLUSIONS: The first priority intervention for serodiscordant couples in Nigeria should be scaled up ART access for HIV-positive partners. Subsequent incremental benefits are greatest with condom promotion and TasP, followed by PrEP

The pattern of attrition from an antiretroviral treatment program in Nigeria.

To evaluate the rate and factors associated with attrition of patients receiving ART in tertiary and secondary hospitals in Nigeria.We reviewed patient level data collected between 2007 and 2010 from 11 hospitals across Nigeria. Kaplan-Meier product-limit and Cox regression were used to determine probability of retention in care and risk factors for attrition respectively. Of 6,408 patients in the cohort, 3,839 (59.9%) were females, median age of study population was 33years (IQR: 27-40) and 4,415 (69%) were from secondary health facilities. The NRTI backbone was Stavudine (D4T) in 3708 (57.9%) and Zidovudine (ZDV) in 2613 (40.8%) of patients. Patients lost to follow up accounted for 62.7% of all attrition followed by treatment stops (25.3%) and deaths (12.0%). Attrition was 14.1 (N = 624) and 15.1% (N = 300) in secondary and tertiary hospitals respectively (p = 0.169) in the first 12 months on follow up. During the 13 to 24 months follow up period, attrition was 10.7% (N = 407) and 19.6% (N = 332) in secondary and tertiary facilities respectively (p<0.001). Median time to lost to follow up was 11.1 (IQR: 6.1 to 18.5) months in secondary compared with 13.6 (IQR: 9.9 to 17.0) months in tertiary sites (p = 0.002). At 24 months follow up, male gender [AHR 1.18, 95% CI: 1.01-1.37, P = 0.038]; WHO clinical stage III [AHR 1.30, 95%CI: 1.03-1.66, P = 0.03] and clinical stage IV [AHR 1.90, 95%CI: 1.20-3.02, p = 0.007] and care in a tertiary hospital [AHR 2.21, 95% CI: 1.83-2.67, p<0.001], were associated with attrition.Attrition could potentially be reduced by decentralizing patients on ART after the first 12 months on therapy to lower level facilities, earlier initiation on treatment and strengthening adherence counseling amongst males

The effects of centering pregnancy on maternal and fetal outcomes in northern Nigeria; a prospective cohort analysis

Abstract Background Maternal and infant mortality remains high in Nigeria primarily due to low use of skilled birth attendants. Huge disparities exist between southern and northen Nigeria on use of skilled birth attendants with south significantly higher than the north. We assessed the effect of centering pregnancy group (CPG) antenatal care on the uptake of antenatal care (ANC), facility delivery and immunization rates for infants in Kano state. Methods Between December 2012 and May 2014, pregnant women with similar sociodemographics and obstetric history were enrolled into intervention (CPG) and control groups and followed up prospectively. Chi-square tests were conducted to compare the differences between the intervention and the control groups with respect to background characteristics and intervention outcomes. Logistic regression was used to measure the associations between CPG and uptake of services for mother-baby pairs in care. Results A total of 517 (260 in the control group and 257 in the CPG) pregnant women enrolled and participated in the study. Thirty-six percent of women in the control group attended ANC at least once in 2nd and 3nd trimester compared to 49% of respondents in the CPG (p < 0.01). Health facility delivery was higher among CPG (13% vs. 8%; p < 0.01). When controlled for age, number of previous pregnancies, number of term deliveries, number of children alive and occupation of respondent or their spouses, respondents who participated in the CPGs compared to those who did not, were more likely to attend at least one antenatal care (ANC) session in the third trimester [adjusted risk ratio (ARR):1.52; 95% CI:1.36–1.69], more likely to immunize their babies at six weeks [ARR: 2.23; 95% CI: 1.16–4.29] and fourteen weeks [ARR: 3.46; 95% CI: 1.19–10.01] and more likely to use health services [ARR: 1.50; 95% CI: 1.06–2.13]. Conclusion Centering or group pregnancy showed a positive effect on the use of antenatal services, facility delivery and postnatal services and thus is a promising intervention to increase uptake of maternal health care services in northern Nigeria. The low facility delivery remains a cause for alarm and requires further investigation to improve facility delivery in northern Nigeria

Performance evaluation of BD FACSPresto™ point of care CD4 analyzer to enumerate CD4 counts for monitoring HIV infected individuals in Nigeria.

Despite the upsurge in support and intervention of donor agencies in HIV care and treatment programing in Sub-Sahara African, antiretroviral (ART) programs are still confronted with access and coverage challenges which influence enrolment of new patients. This study investigated the validity of point of care BD FACSPresto™ CD4 analyzer for CD4+ cell count, overall agreement, correlation, sensitivity, and specificity in comparison to a reference standard flow cytometry method. We also assessed the feasibility of use among non-laboratorians.Blood samples from 300 HIV infected individuals were analyzed for CD4+ T cell and CD4%, using finger prick capillary sample from 150 PMTCT clients and 150 ART clients at Murtala Mohammed Specialist Hospital, Kano, Nigeria. Their venous samples were compared on a flow cytometry reference method using BD FACSCount CD4+ count system. The accuracy of the BD FACSPresto machine in comparison to BD FACSCount was evaluated. Statistical analysis was carried out using STATA (version 12). Bland-Altman method and correlation analysis were used to analyze agreement between both measurements. In addition, sensitivity and specificity of both measurements were determined. Statistical significance was set at p-value <0.05.The mean bias and limit of agreement for CD4+ count between BD FACSPresto and BD FACS count machine were 7.49 (95% CI: 2.44 to 12.54) and -8.14 to 96.39 respectively. Further analysis revealed close agreement between BD FACSPresto and BD FACSCount with no significant difference between the two methods (p = .0.95). Using a threshold of 500 cells/μL, sensitivity and specificity of BD FACSPresto were 95.1% and 97.1% respectively, compared to BD FACSCount. There was no statistically significant difference in the misclassification between BD FACSPresto and BD FACSCount results (p = 0.23). Furthermore, sensitivity and specificity were similar when BD FACSPresto machine was operated by a nurse or laboratory scientist, there was no substantial difference in testing variability observed between laboratory and non-laboratory operators using the BD FACSPresto analyzer.Overall, BD FACSPresto Point of Care CD4+ count finger stick capillary blood results is a reliable method in comparison to venous sample cytometry method and no significant difference variability observed between laboratory personnel and non-laboratory operators. The BD FACSPresto is simple, more robust and easy to use equipment without significant variability in reliability by non-laboratory health care workers hence will be a valuable instrument in increasing access and coverage of CD4 estimations in developing countries. The introduction of the BD FACSPresto POC analyzer has a high potential in reducing patients waiting time and improving the overall quality of ART service and clients' satisfaction especially in rural settings

Improved access to HIV diagnosis and linkage to antiretroviral therapy among children in Southern Nigeria: a before-after study

Abstract Background Globally, two out of five children living with HIV (CLHIV) are unaware of their HIV status, and a little more than 50% are receiving antiretroviral therapy (ART). This paper describes case-finding strategies and their contribution to identifying CLHIV and linking them to ART in Nigeria. Methods This before-after study used program data abstracted during the implementation of different paediatric-focused strategies (provider-initiated testing and counselling, orphans and vulnerable children testing, family-based index testing, early infant diagnosis (EID), community-driven EID, and community-based testing) delivered in health facilities and in communities to improve HIV case identification. Data were abstracted for children (0 to 14 years) who received HIV testing services and were initiated on ART in Akwa Ibom State, Nigeria during the pre-implementation period (April–June 2021) and during the implementation period (July–September 2021). Descriptive statistics were used to describe the testing coverage, positivity rate (proportion of tests that were positive for HIV), linkage to ART, and ART coverage, by age, sex, and testing modality. Interrupted time series analysis (ITSA) on STATA 14 was used to estimate the effect of the implementation of these strategies on HIV testing uptake and positivity rate at a 0.05 significance level. Results A total of 70,210 children were tested for HIV within the six-month period, and 1,012 CLHIV were identified. A total of 78% (n = 54,821) of the tests and 83.4% (n = 844) CLHIV were diagnosed during the implementation period. During implementation, the HIV positivity rate increased from 1.09% (168/15,389) to 1.54% (844/54,821), while linkage to ART increased from 99.4% (167/168) to 99.8% (842/844). The contribution from community-based modalities to CLHIV identified increased from 63% (106/168) to 84% (709/844) during the implementation, with the majority, 60.8% (431/709), from community-based index testing. Overall, ART coverage increased from 39.7 to 55.6% at the end of the intervention period. Conclusion The findings show that expanding differentiated HIV testing approaches provided mostly in the community significantly increased pediatric case identification. However, ART coverage remains low, especially for younger age groups, and requires further efforts

Akwa Ibom AIDS indicator survey: Key findings and lessons learnt.

BackgroundThe burden of HIV/AIDS epidemic is huge, but this varies widely by population in Nigeria. Data that could be used to guide the scale up of HIV prevention and control strategies has significant gaps. The study sought to estimate the prevalence of HIV and its associated determinants in Akwa Ibom state.MethodsAkwa Ibom AIDS Indicator Survey (AKAIS) is a population based cross-sectional survey, with a two-stage probability sampling. The survey had both behavioural and biological components. Tablet-based questionnaire was used to collect data on participant's household information, demographics, socio-economic, and behavioral risk factors associated with HIV; while the biological component involved collection of venous blood samples for participants who were over 19months. For children aged 18months on less, capillary blood from finger prick sample was used. Participants were tested for HIV. Other biomarker tests for HIV positive participants included CD4, HIV-1 RNA viral load and incidence assays.ResultsIn all 15,609 people (8,963 adults aged 15 years and older (55% females), 6,646 individuals less than 15 years (51% males), from 4,313 households, participated in AKAIS. Overall, 2.8% (423 persons; 422 HIV-1 and 1 HIV-2) were found to be HIV positive. HIV prevalence was 4.8% in adults (15 years and above) and 0.4% in pediatric (ConclusionsHIV prevalence among adults was 4.8% with an overall incidence of 0.41%. These estimates are essential to inform strategic control and prevention of HIV epidemic in Akwa Ibom state targeting the affected populations

High Prevalence of HIV Drug Resistance Among Newly Diagnosed Infants Aged <18 Months: Results From a Nationwide Surveillance in Nigeria

BACKGROUND: WHO recommends protease-inhibitor-based first-line regimen in infants because of risk of drug resistance from failed prophylaxis used in prevention of mother-to-child transmission (PMTCT). However, cost and logistics impede implementation in sub-Saharan Africa, and >75% of children still receive nonnucleoside reverse transcriptase inhibitor-based regimen (NNRTI) used in PMTCT. METHODS: We assessed the national pretreatment drug resistance prevalence of HIV-infected children aged <18 months in Nigeria, using WHO-recommended HIV drug resistance surveillance protocol. We used remnant dried blood spots collected between June 2014 and July 2015 from 15 early infant diagnosis facilities spread across all the 6 geopolitical regions of Nigeria. Sampling was through a probability proportional-to-size approach. HIV drug resistance was determined by population-based sequencing. RESULTS: Overall, in 48% of infants (205 of 430) drug resistance mutations (DRM) were detected, conferring resistance to predominantly NNRTIs (45%). NRTI and multiclass NRTI/NNRTI resistance were present at 22% and 20%, respectively, while resistance to protease inhibitors was at 2%. Among 204 infants with exposure to drugs for PMTCT, 57% had DRMs, conferring NNRTI resistance in 54% and multiclass NRTI/NNRTI resistance in 29%. DRMs were also detected in 34% of 132 PMTCT unexposed infants. CONCLUSION: A high frequency of PDR, mainly NNRTI-associated, was observed in a nationwide surveillance among newly diagnosed HIV-infected children in Nigeria. PDR prevalence was equally high in PMTCT-unexposed infants. Our results support the use of protease inhibitor-based first-line regimens in HIV-infected young children regardless of PMTCT history and underscore the need to accelerate implementation of the newly disseminated guideline in Nigeria

Improving access to HIV testing for pregnant women in community birth centres in Nigeria: an evaluation of the Prevention of Mother-to-Child Transmission program

Background: The elimination of mother-to-child HIV transmission requires access to HIV testing services (HTS) for pregnant women. In Akwa Ibom, Nigeria, 76% of pregnant women receive antenatal care from traditional birth attendants and may not have access to HIV testing. Objectives: This study examines the contribution of traditional birth attendants and other healthcare workers in community birth centres in improving access to HTS among pregnant women and their HIV-exposed infants. Design: A retrospective cross-sectional study of previously collected programme data at two points in time to evaluate the prevention of mother-to-child transmission (PMTCT) programme. Methods: We assessed programme records before and after introducing an intervention that engaged traditional birth attendants and other healthcare workers in community birth centres to expand access to HTS among pregnant women and their HIV-exposed infants in Akwa Ibom State, Nigeria. Data were abstracted from the programme database for the preintervention period (April 2019 to September 2020) and the intervention period (October 2020 to March 2022). Data abstracted include the number of pregnant women tested for HIV, those diagnosed with HIV, the number of HIV-exposed infants who had samples collected for early infant diagnosis and those diagnosed with HIV. The data were analysed descriptively and inferentially. Results: Before the intervention, 39,305 pregnant women and 2248 HIV-exposed infants were tested for HIV. After the intervention, the number of pregnant women tested increased to 127,005 and the number of HIV-exposed infants tested increased to 2490. Among pregnant women, the postintervention testing increased by 3.2-fold, with community birth centres reporting 63% of all tests. The intervention also resulted in an 11% increase in HIV-exposed infants benefitting from early infant diagnosis with community birth centres reporting 5% of all tests. Of those diagnosed with HIV, 24% of pregnant women and 12% of infants were diagnosed at community birth centres. Conclusion: Community-based HIV testing for pregnant women can reduce mother-to-child transmission and improve early diagnosis and treatment of exposed infants. Collaboration with birth attendants is crucial to ensure testing opportunities are not missed. Prospective research is needed to understand the clinical outcomes of intervention programmes in the community

Increasing multimonth dispensing of antiretrovirals and assessing the effect on viral load suppression among children and adolescents receiving HIV services in Nigeria.

IntroductionMultimonth dispensing (MMD) enables less frequent clinic visits and improved outcomes for people living with HIV, but few children and adolescents living with HIV (CALHIV) are on MMD. At the end of the October-December 2019 quarter, only 23% of CALHIV receiving antiretroviral therapy (ART) through SIDHAS project sites in Akwa Ibom and Cross River states, Nigeria, were receiving MMD. In March 2020, during COVID-19, the government expanded MMD eligibility to include children and recommended rapid implementation to minimize clinic visits. SIDHAS provided technical assistance to 36 "high-volume" facilities-≥5 CALHIV on treatment-in Akwa Ibom and Cross River to increase MMD and viral load suppression (VLS) among CALHIV, toward PEPFAR's 80% benchmark for people currently on ART. We present change in MMD, viral load (VL) testing coverage, VLS, optimized regimen coverage, and community-based ART group enrollment among CALHIV from the October-December 2019 quarter (baseline) to January-March 2021 (endline) based on retrospective analysis of routinely collected program data.Materials and methodsWe compared MMD coverage (primary objective), and optimized regimen coverage, community-based ART group enrollment, VL testing coverage, and VLS (secondary objectives), among CALHIV 18 years and younger pre-/post-intervention (baseline/endline) at the 36 facilities. We excluded children younger than two years, who are not recommended for or routinely offered MMD. The extracted data included age, sex, ART regimen, months of ART dispensed at last refill, most recent VL test results, and community ART group enrollment. Data on MMD-three or more months of ARVs dispensed at one time-were disaggregated into three to five months (3-5-MMD) vs. six or more months (6-MMD). VLS was defined as ≤1,000 copies. We documented MMD coverage by site, optimized regimen, and VL testing and suppression. Using descriptive statistics, we summarized the characteristics of CALHIV on MMD and non-MMD, number of CALHIV on optimized regimens, and proportion enrolled in differentiated service delivery models and community-based ART refill groups. For the intervention, SIDHAS technical assistance was data driven: weekly data analysis/review, site-prioritization scoring, provider mentoring, line listing eligible CALHIV, pediatric regimen calculator, child-optimized regimen transitioning, and community ART models.ResultsThe proportion of CALHIV ages 2-18 receiving MMD increased from 23% (620/2,647; baseline) to 88% (3,992/4,541; endline), while the proportion of sites reporting suboptimal MMD coverage among CALHIV (ConclusionsMMD was feasible among CALHIV without compromising VLS. Expanded eligibility criteria, line listing eligible children, monitoring pediatric antiretroviral stock, and data use contributed to positive results. Future efforts should address low 6-MMD uptake related to stock limitations and synchronize antiretroviral refill pickup with VL sample collection