ABSTRACT
Introduction
Mother to child transmission (MTCT) of HIV is a preventable
route of HIV transmission in Nigeria. The federal government
of Nigeria introduced the prevention of mother to child
transmission (PMTCT) of HIV programme in NAUTH Nnewi in
2002. This study was carried out to assess the effects of the
PMTCT services on the health of mothers and children who
accessed these services in NAUTH Nnewi, SE Nigeria.
Methods
This is a cross-sectional descriptive study. 288 mother-child
pairs who had accessed the PMTCT services and attending the
paediatric follow-up clinic were recruited into the study by a
systematic sampling method using the daily clinic register of
exposed babies. Data was collected using a structured
interviewer-administered questionnaire and analyzed using
SPSS version 16. A p-value <0.05 was considered significant.
viii
Results
The mean age of all the respondents was 30+4.86 years. Most
(89.2%) were married, 10.1% had less than secondary
education while 4.2% had no formal education. 55.2% were
traders while 18.4% were unemployed. Median parity was 2.
Partner notification was 87.2%. 99% of the pregnancies was
carried to term while mean birth weight was 3.02+0.49kg.
Mother to child HIV transmission rate was 1%. Majority of the
mothers had good knowledge of routes of HIV transmission.
99% of mothers identified MTCT as main mode of
transmission. 93.4% did not perceive risk of transmission in
homosexuals and bisexuals. 75.8% used contraceptive
methods. 94.7% did not breastfeed while breastfeeding was
associated with MTCT of HIV (X
2=9.16; p<0.02). Infant
formula was associated with impaired baby’s current health
status. Majority of mothers reported excellent health status.
Conclusion
The PMTCT programme has resulted in good knowledge of
routes of HIV transmission and modes of prevention of MTCT
ix
of HIV, low MTCT rate, high rate of contraceptive use and
excellent health status among participating mothers and
children.
x
TABLE OF CONTENTS
Page
Title page
Declaration ii
Approval iii
Dedication iv
Acknowledgement v
Abstract vii
Table of content x
List of tables xi
List of acronyms xiii
Chapter one
Introduction 1
Chapter two
Literature review 34
Chapter three
Methodology 45
Chapter four
Results 52
Chapter five
Discussion 78
Conclusion 87
Recommendations 89
References 91
Appendix 1 – Informed consent form 110
Appendix 2 – Questionnaire 112
Appendix 3 – ethical Review Board Approval 126
xi
LIST OF TABLES
Page
Table 1: Socio-demographic characteristics of
all the respondents 39
Table 2: PMTCT ante-natal clinic activities outcome 41
Table 3: PMTCT programme outcome for infants 42
Table 4: Knowledge of route of transmission, PMTCT
programs & condom use 43
Table 5: Perception of HIV risk by participants 45
Table 6: Degree of perception concerning HIV
transmission 46
Table 7: Relationship between infant’s current
health status & some selected variables 47
Table 8: Correlation of receipt of replacement feed
with baby’s current health status 48
Table 9: Relationship between infant’s result of HIV
test and some selected variables 49
Table 10: Effect of breastfeeding infant any time on
result of baby’s HIV test 50
xii
Table 11: Breastfeeding infant any time versus
result of baby’s HIV test (further confirmed) 51
Table 12: Relationship between duration of breastfeeding
and result of baby’s HIV test (further confirmed) 52
Table 13: Mother’s current health status according
to ART intake 53
Table 14: Mother’s use of family planning method 54
Table 15: Mother’s current health status by
contraceptive use 55
Table 16: Mother’s current health status according to
type of contraception 56
Table 17: Mother’s current health status according to
participation in social support group 57
Table 18: Mother’s current health status according to
what is done to remain healthy/prevent infection 58
Table 19: Cross tabulation of comments on PMTCT
program with how treated at the clinic 59
Table 20: How treated at the hospital versus feeling
about HIV status confidentiality in the facility 60
xiii
ACRONYMS
3TC Lamivudine
AIDS Acquired Immuno-deficiency Syndrome
ARM Artificial Rupture of Membrane
ART Antiretroviral Treatment
ARV Antiretroviral
C/S Caesarean Section
CD4 Cluster Differentiation 4
DBS Dried Blood Spot
E & U Electrolyte & Urea
ECV External Cephalic Version
EFZ Efavirenz
ELISA Enzyme-Linked Immuno-sorbent Assay
ERB Ethical Review Board
ESR Erythrocyte Sedimentation Rate
FBC Full Blood Count
FBS Fasting Blood Sugar
FMOH Federal Ministry of Health
HAART Highly Active Antiretroviral Treatment
HIV Human Immunodeficiency Virus
IHVN Institute for Human Virology Nigeria
xiv
IUCD Intra-uterine Contraceptive Device
IUD Intra-uterine Death
KABP Knowledge, Attitude, Beliefs, Practices
LAM Lactational Amenorrhoea
LFT Liver Function Test
MTCT Mother to Child Transmission
NAUTH Nnamdi Azikiwe University Teaching Hospital
NVP Nevirapine
PCR Polymerase Chain Reaction
PEPFAR President’s Emergency Plan for AIDS Relief
PI Principal Investigator
PLWHA People Living With HIV/AIDS
PMTCT Prevention of Mother to Child Transmission
RA Research Assistant
STI Sexually Transmitted Infections
TB Tuberculosis
TFR Total Fertility Rate
UNGASS United Nations General Assembly
WHO World Health Organisation
ZDV Zidovudine
xv
1
CHAPTER ONE
INTRODUCTION
Acquired immuno-deficiency syndrome (AIDS) is a disease
condition caused by infection of the human body by a
retrovirus called the human immunodeficiency virus (HIV) 1
.
On entry into the body, the virus invades the Cluster
differentiation 4 (CD4) cells in which it replicates. Its
successful multiplication leads to the destruction of the CD4
cells. Thus, the CD4 cells count reduces as the viral load
increases.
The CD4 cells are responsible for the protection of the human
body against numerous pathogenic organisms with which it
comes into contact in day to day living. Depletion of the CD4
cells leads to immune deficiency state and an increased
likelihood of the body being invaded by opportunistic
organisms. These organisms, which are ordinarily harmless to
the human body, then become pathogenic and cause what is
known as opportunistic infections 2
. It is the opportunistic
infections that persistently reduce the quality of life of the
2
individual and eventually result in death if treatment is not
promptly and adequately provided. Highly Active Antiretroviral Therapy (HAART), when promptly and adequately
provided and taken, reduces HIV morbidity and mortality 3, 4
.
Magnitude of the Problem of HIV/AIDS
The HIV and AIDS pandemic is one of the most serious health
crises in the world today. By the end of 2008, AIDS and AIDSrelated illnesses had killed more than 25 million people (2
million in 2008 alone including 280,000 children under 15
years) and an estimated 35.8million people were living with
HIV, out of which 15.7 and 2.1million were women and
children under 15 years respectively5
. Sub-Saharan Africa has
continued to bear the greatest burden of the HIV and AIDS
epidemic, with approximately 67% of the total number of
people living with HIV, 68% of the new infections and 72% of
AIDS-related deaths in 2008. Over the decades, the epidemic,
once dominated by infected males has become progressively
feminized and in sub-Saharan Africa approximately 60% of
adults living with the HIV are women6,7,8
.
3
Over 90% of infection in children is acquired through motherto-child transmission (MTCT) and as more women contract the
virus, the number of children infected also increases9
.
Estimate of the Global HIV pandemic demonstrated that in
sub-Saharan Africa, more than 1200 children become infected
with HIV each day5
. In 2008 alone an estimated 2.1 million
children were living with HIV and up to 430,000 were newly
infected worldwide, with sub-Saharan Africa accounting for
about 90% of both of these figures5
.
Nigeria, with a population of 140 million10
, is the most
populous country in Africa and was ranked 2nd worst affected
by HIV/AIDS in the world in 2008 after South Africa5
. Since
the first case of HIV/AIDS in Nigeria was reported in 1986
involving a 13 year old girl who died of the disease11, there
has been progressive increase in the total number of people
living with HIV/AIDS (PLWHA). The national prevalence rose
from 1.8% in 1991 to 5.8% in 2001 but declined to 5% in
2003 and 4.4% in 2005 before rising again to 4.6% in 2008
with prevalence in Anambra State determined to be 5.6%12
.
4
The HIV prevalence rate is higher in the urban (5.4%) than
rural areas (3.4%). Among young persons, the highest
prevalence rate of 5.6% is in the age group 25 to 29 years13
.
The average number of adults living with HIV was 3,500,000
in 2005 at a time when number of women (15-49 years old)
living with HIV was 1,900,000, giving a female: male ratio of
1.2:1. Heterosexual transmission accounts for nearly 80% to
95% of all infections14. About 10% of HIV infections are
transmitted by MTCT, while another 10% is transmitted by the
use of unsterilized needles and surgical implements, infected
blood and blood products15
.
Mother-to-Child Transmission of HIV
Over 90% of HIV infections in children less than 15 years are
due to MTCT. In the absence of interventions, between 15%
and 45% of infants born to HIV-infected mothers acquire the
infection during pregnancy, delivery or through breastfeeding16
. The burden of MTCT of HIV is higher in subSaharan Africa than the rest of the world, because of higher
5
levels of hetero-sexual transmission, high female to male
ratio, high total fertility rate (TFR) and high rate of breastfeeding17,18
. Transmission of HIV in children has become a
critical health problem undermining the positive impact of
child survival strategies in the African continent19,20
.
Estimated magnitude of MTCT in Nigeria
Population 140 million
Birth rate per annum 42/ 1000
Birth per annum 5,900,000
HIV prevalence in ANC women 4.4%
Total number of infants born to
HIV infected women exposed to the
risk of MTCT assuming no multiple
pregnancy
260,000
Number of HIV positive infants per
annum
65,000 to 117,500
Source: FMOH. National Guidelines on Prevention of Motherto-Child Transmission of HIV, July 2007.
6
Risk Factors for MTCT of HIV
Factors associated with increased risk of MTCT of HIV
Factors strongly associated with MTCT of HIV include viral
characteristics and high viral load; maternal advanced disease,
immune deficiency and HIV infection acquired during
pregnancy or breastfeeding21,22
, obstetric practices like vaginal
delivery23, rupture of membranes for more than 4 hours
before delivery24; prematurity of the infant; and feeding
factors like prolonged breastfeeding, mixed feeding and breast
diseases like abscess, mastitis and cracked nipples during
breastfeeding25
.
Other factors associated with MTCT of HIV but with limited
evidence include viral resistance; maternal vitamin A
deficiency, anaemia, Chorioamnionitis, sexually transmitted
diseases, frequent unprotected sex, multiple sexual partners,
smoking and intravenous drug abuse; obstetric practices like
invasive or traumatic procedures, instrumental deliveries,
amniocentesis, episiotomy, external cephalic version and intrapartum haemorrhage; and foetal or infant lesions of the skin
or mucous membranes and genetic factors.
7
Prevention of Mother-to-Child Transmission of HIV
One of the goals of the June 2001 Declaration of Commitment
of the United Nations General Assembly Special Session on
HIV/AIDS (UNGASS)26 is to reduce the proportion of infants
infected with HIV by 20% by 2005 and 50% by 2010. The
Nigeria national goal for PMTCT as contained in the 2003
AIDS Policy is to reduce the transmission of the HIV through
MTCT by 50% by the year 2010 and to increase access to
quality voluntary confidential counseling and testing services
by 50% by the same year. To achieve this goal, a
comprehensive strategy to prevent HIV infection among
infants and young children has been developed, which
promotes implementation in an integrated manner within the
health care delivery system.
The NAUTH PMTCT programme started in 2003 as a national
programme implemented by the Federal Government of
Nigeria with NAUTH as one of the pilot sites. The NAUTH
programme was taken over by the Institute of Human
Virology Nigeria (IHVN) in 2005. NAUTH has 7 satellite sites,
8
including 3 private hospitals, for the PMTCT programme which
is implemented according to the National Guidelines on
Prevention of Mother-to-Child Transmission of HIV15
.
The PMTCT interventions consist of four strategic approaches
which include:
1. Primary prevention of HIV infection in women of
reproductive age group and their partners
This involves provision of early diagnosis and treatment
of STIs, making HIV testing and counseling widely
available and provision of suitable counseling for
women who are HIV negative.
2. Prevention of unintended pregnancies among
HIV positive women
The responsibility of the government and health services is to
provide HIV positive women and their partners with
comprehensive information and education about the risks
associated with child bearing as part of routine public
9
information about HIV and AIDS, to ensure that HIV positive
women and their partners have real choices of action, and to
respect and support the decisions they reach15. This means:
providing good quality, user-friendly, and easily accessible
family planning services so that HIV positive women can avoid
pregnancy if they choose, promoting condom use, either alone
or combined with a more effective method of contraception
(dual method) for dual protection from HIV and other STIs
and from unplanned pregnancies as an effective strategy to
prevent HIV transmission, integrating dual protection
messages into family planning counseling services and
offering contraception to replace the birth spacing effect of
exclusive breastfeeding in women who chose replacement
feeding because of their HIV status.
3. Antenatal Care for HIV Positive Women
Specific Modification of Obstetric Care for HIV Positive
Women
Health workers in the antenatal clinic are able to identify
women who have tested positive in order to treat them
10
appropriately. This is done in a way that respects the privacy
and rights of the HIV positive woman. As part of the initial
counseling, women are told why it is important that health
workers know their HIV status. NAUTH has a way of making
this available in the notes, without making it accessible to the
public, visitors or others. When a woman is known to be HIV
positive or is diagnosed as HIV positive during pregnancy, her
obstetric and medical care are strengthened and modified.
Post test counseling for HIV positive pregnant women is
conducted appropriately.
All HIV positive women are given optimal health care to
ensure their safe delivery. Additional visits are not required for
obstetric reasons, although she may need to attend for further
counseling sessions. To minimize the likelihood of MTCT of
HIV, care is taken to avoid invasive procedures such as
chronic villous sampling, amniocentesis or cordocentesis and
external cephalic version (ECV) which may carry a risk of HIV
transmission to the foetus. Care is individualized in special
circumstances such as premature rupture of membrane
11
(preterm and term) and ante-partum haemorrhage. Proper
and consistent use of the partograph in monitoring progress
of labour improves the management of labour and also
reduces the risk of prolonged labour in all women. Because
rupture of membranes of more than four (4) hours duration is
associated with an increased risk of HIV transmission, ARM is
reserved for those with foetal distress or abnormal progress
and is only done if cervical dilatation is 7 cm or more. Forceps
and vacuum delivery is avoided as they have been shown to
be associated with increased risk of MTCT. Vaginal cleansing
with chlorhexidine (0.25% solution) helps to reduce the risk of
puerperal and neonatal sepsis including HIV transmission
where membranes are ruptured for more than 4 hours. After
every vaginal examination, the birth canal is wiped with gauze
or cotton wool, soaked in chlorhexidine solution and the
number of vaginal examinations is kept to a minimum.
Episiotomies are used only for specific obstetric indications.
12
4. Prevention of HIV transmission from HIV
infected mothers to their unborn babies and
infants.
The Use of Antiretroviral Drugs in PMTCT of HIV
In addition to the normal criteria for initiation of antiretroviral
therapy (ART) in adults infected with HIV, pregnancy
constitutes another indication for ART or prophylaxis.
Treatment is indicated as per the WHO clinical staging and
eligibility criteria. When the HIV-positive mother does not
meet the criteria for treatment then prophylaxis is offered.
In HIV infected adult population, ART is initiated based on any
of the following criteria if CD4 cell count is available:
1. WHO Stage IV disease irrespective of CD4 cell count
2. WHO Stage III disease with CD4 cell count < 350
cells/mm3
3. WHO Stage I or II disease with CD4 cell count ≤ 200
cells/mm3
However, pregnancy in the HIV-seropositive woman is an
indication for prophylactic ART irrespective of CD4 count, viral
load or clinical stage of the disease. The time of
13
commencement and choice of ART in HIV-seropositive
pregnant woman depends on the clinical setting. Where
necessary, ART is provided in consultation with an
experienced physician.
Pre-treatment evaluation:
This includes complete history and physical examination,
checking laboratory parameters (FBC/ESR, FBS, LFT, E&U,
Serum lipids and CD4 count), WHO clinical and immunological
staging of the client, ensuring availability of supportive
measures (nutritional and psychosocial) and developing
patient-specific adherence strategy.
For ARV prophylaxis
All patients placed on ART are monitored clinically,
biochemically and immunologically. The regimens stated
below in different clinical settings are based on the 2007
National Guidelines on Prevention of Mother-to-Child
Transmission of HIV15 which was still in use during this study.
14
ART prophylaxis in different clinical settings
Clinical Setting I
For pregnant woman who is HAART eligible, but not
currently on ART, initiation of ART is delayed until after the
first trimester, unless benefits outweigh risks. ZDV is included
in the regimen unless the haemoglobin level is less than
8g/dL. ZDV, 3TC and NVP are given if CD4 count is less than
250 cells/mm3
. If CD4 count is more than 250 cells/mm3
, NVP
is avoided or if used, hepatotoxicity is monitored closely. NVP
is stopped for women commenced on HAART – (ZVD, 3TC and
NVP) before they became pregnant and found to react to NVP
in first trimester pregnancy but EFV + ZDV + 3TC can be
given in the second and third trimesters.
Infant
Single-dose NVP is given as soon as possible after birth
preferably within 72 hours because NVP given to the HIVexposed infant has been shown to prevent perinatal HIV
transmission to the infant27
. ZDV is also given for 6 weeks.
ZDV is avoided if haemoglobin is less than 8g/dl for the adult
and less than 10 g/dl for the infant.
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