Despite impressive health system-related achievements in the prevention of mother-to-child transmission of HIV (PMTCT) in the last decade, Nigeria contributes the greatest number of infants infected with HIV worldwide. Elimination of mother-to-child transmission of HIV in Nigeria requires the implementation of feasible, culturally acceptable and sustainable interventions and policies addressing a series of health system-related challenges, according to a review published in International Health.
An estimated 159,000 of the 180,000 new infections among children worldwide were in sub-Saharan Africa, with Nigeria alone accounting for 23% of the region’s total. Between 2009 and 2015, new infections among Nigerian children only fell by 21%. In 2017 only 32% of pregnant women living with HIV in Nigeria got antiretrovirals.
Identifying and addressing health system-related challenges to PMTCT is critical to implementing effective PMTCT programmes. The authors aimed to identify achievements and challenges in the elimination of mother-to-child transmission of HIV in Nigeria from a health system perspective. They drew on their experiences of implementing PMTCT programmes in Nigeria and reviewed policy documents and research papers.
The authors analysed progress and challenges using the World Health Organization’s (WHO) health system framework. This includes six essential building blocks (service delivery, health workforce, health information, medical products, health financing, and leadership and government) that make up a health system and are needed to improve health outcomes.
From 2009 to 2016 healthcare facilities providing PMTCT services increased by a significant 875% from 690 to 6729. In 2010 PMTCT services were decentralised to primary healthcare centres and have also been integrated into maternal healthcare services.
Despite these achievements only 20% of the estimated 34,423 healthcare facilities offer onsite PMTCT services. Within states, there is a rural-urban disparity in the distribution of facilities.
There is limited testing of pregnant women and their male partners. The increase in PMTCT facilities has not resulted in a corresponding increase in antiretroviral coverage for PMTCT. From 2012 to 2013, for example, PMTCT facilities increased by 486% yet the proportion of women getting antiretrovirals for PMTCT only increased by 48%. Such low numbers have been partially responsible for PEPFAR withdrawing funding from small PMTCT sites.
Retention in care and adherence are problematic. A study found that between 2004 and 2014 only 66% of 31,504 women enrolled into PMTCT care during the antenatal period completed the cascade of antenatal care, had an institutional delivery and had at least one infant follow-up visit. Another study found of the 368 pregnant women living with HIV in Anambra state, 22% reported non-adherence to their medication.
Basic requirements for HIV testing services are lacking and include: absence of a counselling room, pre- and post-testing counselling not performed, and national PMTCT guidelines for service delivery not available or not accessible.
Armed conflict, especially in the northeast, has also affected service delivery.
There is a dearth of skilled healthcare workers (doctors, nurses and midwives) available to deliver essential services including PMTCT in Nigeria, especially in some parts of the country. In 2014 the government developed a task shifting and task sharing policy to address this.
HIV programmes have added to the workload of an already sparse workforce. Continual industrial strikes due to poor remuneration, healthcare leadership, management issues, infrastructure failings and inter-professional disputes affect the response.
Knowledge gaps and discriminatory attitudes among some HIV service providers are prevalent. Close to 70% of healthcare workers providing PMTCT services in rural areas in Oyo state did not know when to start ART for pregnant women living with HIV and over 50% said they were scared to deliver an infant for fear of infection.
Health information and research
In terms of achievements, the health management information system has changed from a vertical reporting system to a more harmonised system with standardised indicators. Electronic medical record systems have been introduced in some facilities to improve data collection and management.
Research alliances have been formed to encourage implementation science in HIV service delivery. Some innovative approaches have been developed, such as a patient-held smartcard which embeds patients’ health-related information and allows healthcare workers to access it through a mobile phone app.
However, poor data quality and a low capacity for data management persist. Manual paper-based systems predominate. A national unique identifying system to efficiently track patients, regardless of where they have attended for care, is needed.
Inadequate funding and poor research infrastructure impede high-quality research.
Most medical products are obtained by donor partners, with supply chain managers distributing HIV products according to healthcare facilities requests. However, stockouts occasionally occur. While first-line antiretrovirals are available, there is limited availability of second- and third-line antiretrovirals.
Poor data management of commodities is one of the main causes of interrupted supplies. The supply chain systems have been unified for more effective HIV commodities management.
Over-reliance on dwindling external funding threatens the sustainability of the HIV response. The federal government has developed an alternative funding mechanism and two states, representing 81% of the national HIV burden, are now funded domestically.
While antiretrovirals are free, out-of-pocket expenses are common. The national health insurance system covers less than 10% of the eligible population.
Leadership and governance
The federal government has aligned with the global initiative of eliminating mother-to child-transmission, developed strategic plans and frameworks accordingly, and updated treatment guidelines.
Maintaining high political commitment for sustained funding and effective co-ordination is a crucial challenge. For example, infrequent PMTCT technical coordination meetings are due to ministries of health having insufficient funds.
There is limited accountability from donors and implementing partners to the co-ordinating government agencies – donors and partners decide their programme priorities that often do not align with the government’s.
“There is a need for stronger leadership and political will,” the authors say.
Olakunde B et al. Towards the elimination of mother-to-child transmission of HIV in Nigeria: a health system perspective of the achievements and challenges. International Health, doi:10.1093/inthealth/ihz018, 2019.