Nadia A. Sam-Agudu

TLR9 Polymorphisms Are Associated with Altered IFN-γ Levels in Children with Cerebral Malaria

Toll-like receptor (TLR) polymorphisms have been associated with disease severity in malaria infection, but mechanisms for this association have not been characterized. The TLR2, 4, and 9 single nucleotide polymorphism (SNP) frequencies and serum interferon-gamma (IFN-gamma) and tumor necrosis factor-alpha (TNF-alpha) levels were assessed in Ugandan children with cerebral malaria (CM, N = 65) and uncomplicated malaria (UM, N = 52). The TLR9 C allele at -1237 and G allele at 1174 were strongly linked, and among children with CM, those with the C allele at -1237 or the G allele at 1174 had higher levels of IFN-gamma than those without these alleles (P = 0.03 and 0.008, respectively). The TLR9 SNPs were not associated with altered IFN-gamma levels in children with UM or altered TNF-alpha levels in either group. We present the first human data that TLR SNPs are associated with altered cytokine production in parasitic infection.

The Impact of Mentor Mother Programs on PMTCT Service Uptake and Retention-in-Care at Primary Health Care Facilities in Nigeria: A Prospective Cohort Study (MoMent Nigeria)

Background:Nigeria is a key target country in the global effort toward elimination of mother-to-child transmission of HIV. Low coverage of prevention of mother-to-child transmission (PMTCT) interventions, adherence, and retention-in-care rates in HIV-positive pregnant women are contributing factors to high mother-to-child transmission of HIV (MTCT) rates. In Nigeria, rural areas, served largely by primary health care facilities, have particularly poor indicators of PMTCT coverage. Mentor Mothers are HIV-positive women who serve as peer counselors for PMTCT clients, provide guidance, and support in keeping appointments and promoting antiretroviral adherence and retention-in-care. The Mother Mentor (MoMent) study aims to investigate the impact of structured Mentor Mother programs on PMTCT outcomes in rural Nigeria. Design and Methods:A prospective cohort study will compare rates of retention-in-care among PMTCT clients who are supported by formally-trained supervised Mentor Mothers versus clients who receive standard-of-care, informal peer support. Study sites are 20 primary health care centers (10 intervention, 10 control) in rural North-Central Nigeria. The study population is HIV-positive mothers and exposed infant pairs (MIPs) (N = 480; 240 MIPs per study arm). Primary outcome measures are the proportion of exposed infants receiving early HIV testing by age 2 months, and the proportion of MIPs retained in care at 6 months postpartum. Secondary outcome measures examine antiretroviral adherence, 12-month postpartum MIP retention, and MTCT rates. This article presents details of the study design, the structured Mentor Mother programs, and how their impact on PMTCT outcomes will be assessed.

The Impact of Structured Mentor Mother Programs on 6-month Postpartum Retention and Viral Suppression among Hiv-positive Women in Rural Nigeria: A Prospective Paired Cohort Study

Background: Peer support (PS) has reportedly improved Prevention of mother-to-child transmission (PMTCT) outcomes in high HIV-burden settings; however, evidence of impact on retention in care is limited. Retention in care implies consistent engagement and treatment adherence. The MoMent study evaluated the impact of structured vs unstructured PS on postpartum retention and viral load suppression among rural Nigerian women. Methods: A total of 497 HIV-positive pregnant women were consecutively enrolled at 10 primary health care centers with structured mentor mother (MM) support, and at 10 pair-matched primary health care centers with routine, ad hoc PS. The structured MM intervention comprised an outcome-specific scope of work, close MM supervision, standardized documentation, performance evaluations, and retraining as appropriate. Retention was defined by clinic attendance during the first 6-month postpartum. Participants with ≥3 of 6 expected monthly visits were considered retained. Women with a 6-month postpartum plasma viral load of <20 copies/mL were considered suppressed. A logistic regression model with generalized estimating equation was used to assess the effect of MMs on retention and viral suppression. Results: Exposure to structured MM support was associated with higher odds of retention than routine PS (adjusted odds ratio = 5.9, 95% confidence interval: 3.0 to 11.6). Similarly, the odds of viral suppression at 6-month postpartum were higher for MM-supported women (adjusted odds ratio = 4.9, 95% confidence interval: 2.6 to 9.2). Conclusions: Structured PS significantly improved postpartum PMTCT retention and viral suppression rates among women in rural Nigeria. Introduction of structure can enhance the impact of PS interventions on PMTCT outcomes.

Linkage to care early infant diagnosis and perinatal transmission among infants born to HIV-infected Nigerian mothers: Evidence from the Healthy Beginning Initiative.

Background:In 2014, Nigeria accounted for 33% of all new childhood HIV infections that occurred among the 22 Global Plan priority countries where 80% of HIV-infected women reside. Even with a vertical HIV transmission rate of 27%, only 6% of infants born to HIV-infected women in Nigeria receive early infant diagnosis (EID). This article reports rates of antiretroviral prophylaxis, EID, and mother-to-child transmission in a congregation-based Healthy Beginning Initiative (HBI) designed to increase HIV testing among pregnant women in southeast Nigeria. Methods:This is a nested cohort study of HIV-exposed infants (HEI) within the HBI trial originally designed as a 2-arm cluster randomized trial. HIV-infected mothers and infants were followed between January 2013 and August 2014. Results:Across both arms of the study, 72 HIV-infected women delivered 69 live infants (1 set of twins) and 4 had miscarriages. Of the 69 live-born HEI, HIV status was known for 71% (49/69), 16% (11/69) died before sample collection, and 13% (9/69) were lost to follow-up. Complete information was available for 84% of HEI (58/69), of which 64% (37/58) received antiretroviral prophylaxis. Among the 49 infants tested for HIV, 88% (43/49) received EID within 2 months and 12% (6/49) received antibody testing after 18 months. The mother-to-child transmission rate was 8.2% (4/49). Conclusions:EID was higher and HIV transmission rate was lower among the HBI participants compared to reported rates in 2014. However, further progress is needed to achieve goals of elimination of infant HIV infection.

Evaluating Religious Influences on the Utilization of Maternal Health Services among Muslim and Christian Women in North-Central Nigeria.

Introduction. Uptake of antenatal services is low in Nigeria; however, indicators in the Christian-dominated South have been better than in the Muslim-dominated North. This study evaluated religious influences on utilization of general and HIV-related maternal health services among women in rural and periurban North-Central Nigeria. Materials and Methods. Targeted participants were HIV-positive, pregnant, or of reproductive age in the Federal Capital Territory and Nasarawa. Themes explored were utilization of facility-based services, provider gender preferences, and Mentor Mother acceptability. Thematic and content approaches were applied to manual data analysis. Results. Sixty-eight (68) women were recruited, 72% Christian and 28% Muslim. There were no significant religious influences identified among barriers to maternal service uptake. All participants stated preference for facility-based services. Uptake limitations were mainly distance from clinic and socioeconomic dependence on male partners rather than religious restrictions. Neither Muslim nor Christian women had provider gender preferences; competence and positive attitude were more important. All women found Mentor Mothers highly acceptable. Conclusion. Barriers to uptake of maternal health services appear to be minimally influenced by religion. ANC/PMTCT uptake interventions should target male partner buy-in and support, healthcare provider training to improve attitudes, and Mentor Mother program strengthening and impact assessment.

The Impact of Structured Mentor Mother Programs on Presentation for Early Infant Diagnosis Testing in Rural North-Central Nigeria: A Prospective Paired Cohort Study

Background: Early infant diagnosis (EID) by 2 months of age is an important prevention of mother-to-child cascade step that serves as an early postpartum indicator of program success. Uptake and timely presentation for infant HIV diagnosis are significant challenges in resource-limited settings. Few studies on maternal peer support (PS) have demonstrated impact on EID. The MoMent study evaluated the impact of structured PS on timely presentation for EID testing in rural North-Central Nigeria. Methods: A total of 497 HIV-positive pregnant women were consecutively recruited at 10 primary health care centers with structured, closely supervised Mentor Mother (MM) support, and 10 pair-matched primary health care centers with routine but ad hoc PS. EID was assessed among HIV-exposed infants delivered to recruited women, and was defined by presentation for DNA polymerase chain reaction testing between 35 and 62 days of life. A logistic regression model with generalized estimating equation to account for clustering was used to assess the effect of MMs on EID presentation. Results: Data from 408 live-born infants were available for analysis. Exposure to MM support was associated with higher odds of timely EID presentation among infants, compared with routine PS (adjusted odds ratios = 3.7, 95% confidence interval: 2.8 to 5.0). Conclusions: Closely supervised, organized MM support significantly improved presentation for EID among HIV-exposed infants in a rural Nigerian setting. Structured PS can improve rates of timely EID presentation and potentially the uptake of EID testing in resource-limited settings.

A Socio-Ecological Examination of Treatment Access, Uptake and Adherence Issues Encountered By HIV-Positive Women in Rural North-Central Nigeria

ABSTRACT Background: In spite of the global decline in HIV infections, sub-Saharan Africa still accounts for a non-proportional majority of global new infections. While many studies have documented the importance of facilitating access to anti-retroviral therapy (ART) as a means of reducing infections, the relationship between interpersonal, community, healthcare facility, and policy-level factors and treatment adherence in Africa have not been well-described. The authors examined these factors in the context of prevention of mother-to-child transmission (PMTCT) of HIV in rural north-central Nigeria, where HIV burden is high and service coverage is low. Methods: Eleven focus groups (n = 105) were conducted among PMTCT clients, male partners, young women, and other community members from 39 rural and semi-rural communities to explore factors related to HIV and antenatal care service use. Data were analyzed using the Constant Comparative Method. Results: Irrespective of HIV status, participants reported barriers to access including long clinic wait times, transportation availability and cost, and the lack of HIV treatment medications. For HIV-positive women, stigma from family members, providers, and the local community affected their ability to obtain care and remain ART-adherent. In the face of these barriers, these women reflected on the importance of peer and community support, as well as the passage of laws to combat barriers to treatment access, uptake, and adherence. Conclusions: Facilitating treatment adherence may require not only focusing on the medical treatment needs of these women but also structural issues, such as the availability of providers and drugs, and systemic stigmatization of HIV-positive patients.

Exploring the acceptability of Option B plus among HIV-positive Nigerian women engaged and not engaged in the prevention of mother-to-child transmission of HIV cascade: a qualitative study

ABSTRACT The acceptability of lifelong antiretroviral therapy (ART) among HIV-positive women in high-burden Nigeria, is not well-known. We explored readiness of users and providers of prevention of mother-to-child transmission of HIV (PMTCT) services to accept lifelong ART -before Option B plus was implemented in Nigeria. We conducted 142 key informant interviews among 100 PMTCT users (25 pregnant-newly-diagnosed, 26 pregnant-in-care, 28 lost-to-follow-up (LTFU) and 21 postpartum women living with HIV) and 42 PMTCT providers in rural North-Central Nigeria. Qualitative data were manually analyzed via Grounded Theory. PMTCT users had mixed views about lifelong ART, strongly influenced by motivation to prevent infant HIV and by presence or absence of maternal illness. Newly-diagnosed women were most enthusiastic about lifelong ART, however postpartum and LTFU women expressed conditionalities for acceptance and adherence, including minimal ART side effects and potentially serious maternal illness. Providers corroborated user findings, identifying the postpartum period as problematic for lifelong ART acceptability/adherence. Option B plus scale-up in Nigeria will require proactively addressing PMTCT user fears about ART side effects, and continuous education on long-term maternal and infant benefits. Structural barriers such as the availability of trained providers, long clinic wait times and patient access to ART should also be addressed.

Pediatric to Adult Healthcare Transitioning for Adolescents Living with HIV in Nigeria: A National Survey

Introduction The period of transition from pediatric to adult care has been associated with poor health outcomes among 10–19 year old adolescents living with HIV (ALHIV). This has prompted a focus on the quality of transition services, especially in high ALHIV-burden countries. Due to lack of guidelines, there are no healthcare transition standards for Nigeria’s estimated 240,000 ALHIV. We conducted a nationwide survey to characterize routine transition procedures for Nigerian ALHIV. Materials and methods This cross-sectional survey was conducted at public healthcare facilities supported by five local HIV service implementing partners. Comprehensive HIV treatment facilities with ≥1 year of HIV service provision and ≥20 ALHIVs enrolled were selected. A structured questionnaire assessed availability of treatment, care and transition services for ALHIV. Transition was defined as a preparatory process catering to the medical, psychosocial, and educational needs of adolescents moving from pediatric to adult care. Comprehensive transition services were defined by 6 core elements: policy, tracking and monitoring, readiness evaluation, planning, transfer of care, and follow-up. Results All 152 eligible facilities were surveyed and comprised 106 (69.7%) secondary and 46 (30.3%) tertiary centers at which 17,662 ALHIV were enrolled. The majority (73, 48.3%) of the 151 facilities responding to the “clinic type” question were family-centered and saw all clients together regardless of age. Only 42 (27.8%) facilities had an adolescent-specific HIV clinic; 53 (35.1%) had separate pediatric/adolescent and adult HIV clinics, of which 39 (73.6%) reported having a transfer/transition policy. Only 6 (15.4%) of these 39 facilities reported having a written protocol. There was a bimodal peak at 15 and 18 years for age of ALHIV transfer to adult care. No surveyed facility met the study definition for comprehensive transition services. Conclusions Facilities surveyed were more likely to have non-specialized HIV treatment services and had loosely-defined, abrupt transfer versus transition practices, which lacked the core transition elements. Evidence-based standards of transitional care tailored to non-specialized HIV treatment programs need to be established to optimize transition outcomes among ALHIV in Nigeria and in similar settings.

P-E2 The Impact of structured mentor mother support on retention during the first 12 months postpartum among HIV positive women in rural Nigeria

Introduction: With the advent of lifelong therapy, interventions that sustain long-term engagement with PMTCT services are needed. We evaluated the impact of a structured peer support program on postpartum PMTCT retention among rural Nigerian women. Methods: This prospective cohort study enrolled HIV+ pregnant women from 20 primary healthcare centers (PHCs). Ten PHCs with structured mentor mother (MM) support (training, supervision, client tracking, standard documentation and performance evaluation) were pair-matched with 10 routine unstructured peer support (PS) PHCs. Participants received viral load at 6 months and were followed up to 12 months postpartum. Viral suppression was defined as <20 copies/mL. Retention assessment was based on monthly and bi-monthly clinic visits in the first and second 6 month postpartum periods respectively. Participants with ≥5 of 9 expected visits were considered retained. A logistic regression model with generalized estimating equation was used to evaluate the effect of PS and other factors on retention. Results: Of 497 women enrolled, 260 and 237 were exposed to MM and routine PS respectively. Women with MM support (aOR = 6.6, 95% CI 3.4 to 13.1) and viral suppression at 6 months (aOR = 3.1, 95% CI 1.8 to 5.6) had higher odds of retention during the 12 month postpartum period. Age, distance from PHC, religion, gravidity, disclosure & time of diagnosis had no effect on retention. Discussion: Structure in peer support programs improved retention. Also, viral suppression had an independent effect on retention, indicating a strong link between adherence and sustained engagement; both being essential for PMTCT. Conclusion: Built-in structure can significantly enhance the impact of PS interventions on PMTCT outcomes.