Impact of conditional economic incentives and motivational interviewing on health outcomes of adolescents living with HIV in Anambra State, Nigeria: A cluster-randomised trial.

Background: Adolescents living with HIV (ALHIV) have had worse outcomes compared to adults. They face enormous difficulty in accessing HIV care services. We hypothesize that conditional economic incentives (CEI) and motivational interviewing could increase retention in care, medication adherence and ultimately viral load suppression. Therefore, we evaluated the one-year impact of conditional economic incentives and motivational interviewing on the health outcomes of ALHIV in Anambra State, Nigeria. Methods: Using a cluster-randomised design, we examined the one-year (from December 1, 2018, to November 30, 2019), individual-level impact of an Incentive Scheme comprising conditional economic incentives and motivational interviewing on achieving undetectable viral load (primary outcome), CD4+ count, adherence to antiretroviral therapy and retention in care (secondary outcomes) by ALHIV in Anambra State, Nigeria. Twelve HIV treatment hospitals were stratified according to the type of clinic (secondary or tertiary) and randomly assigned to the intervention arm or control arm to receive the Incentive Scheme or routine care, respectively. ALHIV aged 10-19 years, initiated into HIV care for a minimum of 6 months, and who adhered poorly to medications (<100% adherence rate) were eligible for the study. Participants in the intervention arm received motivational interviewing at the study baseline and every visit. They also received US$5.6 when HIV viral load (VL) was <20 copies/mL at month 3, US$2.8 if the VL remained suppressed at months 6 and 9, and US$5.6 if the VL remained <20 copies/mL at month 12. Results: Of the 246 trial participants, 119 were in the intervention while 127 were in the control arm. There was no difference in the baseline characteristics of the participants between the intervention and control arm except for the number of participants with undetectable viral load and the number of participants with ≥95% adherence. Although participants in the intervention arm had a 10.1% increase while those in the control arm had a 1.6% decrease in proportion with undetectable viral load (≤20 copies/ml) after 12 months, the change in the primary outcome was not statistically significant. Similarly, the differences in the secondary outcomes were not statistically significant. Conclusion: The Incentive Scheme did not improve the virologic outcome of ALHIV after 12 months. Differences in the secondary outcomes after 12 months were also not significantly different from the baseline. Trial registration: We registered the trial retrospectively with The Pan African Clinical Trials Registry: https://pactr.samrc.ac.za/(PACTR201806003040425) on 2/2/2018.

Cost-effectiveness and feasibility of conditional economic incentives and motivational interviewing to improve HIV health outcomes of adolescents living with HIV in Anambra State, Nigeria.

BACKGROUND: In sub-Saharan Africa, there is increasing mortality and morbidity of adolescents due to poor linkage, retention in HIV care and adherence to antiretroviral therapy (ART). This is a result of limited adolescent-centred service delivery interventions. This cost-effectiveness and feasibility study were piggybacked on a cluster-randomized trial that assessed the impact of an adolescent-centred service delivery intervention. The service delivery intervention examined the impact of an incentive scheme consisting of conditional economic incentives and motivational interviewing on the health outcomes of adolescents living with HIV in Nigeria. METHOD: A cost-effectiveness analysis from the healthcare provider's perspective was performed to assess the cost per additional patient achieving undetected viral load through the proposed intervention. The cost-effectiveness of the incentive scheme over routine care was estimated using the incremental cost-effectiveness ratio (ICER), expressed as cost/patient who achieved an undetectable viral load. We performed a univariate sensitivity analysis to examine the effect of key parameters on the ICER. An in-depth interview was conducted on the healthcare personnel in the intervention arm to explore the feasibility of implementing the service delivery intervention in HIV treatment hospitals in Nigeria. RESULT: The ICER of the Incentive Scheme intervention compared to routine care was US$1419 per additional patient with undetectable viral load. Going by the cost-effectiveness threshold of US$1137 per quality-adjusted life-years suggested by Woods et al., 2016, the intervention was not cost-effective. The sensitivity test showed that the intervention will be cost-effective if the frequency of CD4 count and viral load tests are reduced from quarterly to triannually. Healthcare professionals reported that patients' acceptance of the intervention was very high. CONCLUSION: The conditional economic incentives and motivational interviewing was not cost-effective, but can become cost-effective if the frequency of HIV quality of life indicator tests are performed 1-3 times per annum. Patients' acceptance of the intervention was very high. However, healthcare professionals believed that sustaining the intervention may be difficult unless factors such as government commitment and healthcare provider diligence are duly addressed. TRIAL REGISTRATION: This trial is registered in the WHO International Clinical Trials Registry through the WHO International Registry Network ( PACTR201806003040425 ).

A systematic review of qualitative research on barriers and facilitators to exclusive breastfeeding practice in sub-Saharan African countries.

BACKGROUND: Studies reporting factors associated with exclusive breastfeeding are mostly quantitative. No study has performed a systematic qualitative summary to document the recurring constraints and facilitators to exclusive breastfeeding in sub-Saharan African countries from breastfeeding mothers' perspective. This study systematically reviews the literature reporting barriers and facilitators to exclusive breastfeeding from the breastfeeding mothers' perspective in sub-Saharan Africa to develop an educational intervention to optimize exclusive breastfeeding. METHODS: A systematic literature review of qualitative studies such as phenomenological studies, followed by a risk of bias and methodological assessment of the included studies' quality using the Critical Appraisal Skills Programme (CASP) tool was conducted. MEDLINE and Google Scholar were searched from January 1990 to October 2019 to retrieve studies of breastfeeding mothers who had infants aged between 0 and 12 months. Two authors independently carried out the review process and resolved disagreements through consensus. We analyzed the data thematically. RESULTS: After reviewing 92 studies, 20 studies involving 836 participants from 11 countries were eligible. Of the 72 studies excluded, 39 were not conducted in sub-Saharan Africa, and 33 included other participants such as fathers. Three themes emerged as barriers to exclusive breastfeeding (EBF) and five additional themes were identified with facilitators of maternal-infant factors being the most significant in both cases. Maternal employment and knowledge of the benefits of EBF were the most common maternal-infant factors that served as a barrier and a facilitator, respectively. The study's limitations were that the review involved only primary research among breastfeeding mothers living in sub-Saharan Africa and excluded studies not available in the English language. The information synthesized from this review could be used to develop communication strategies employed during individual and group patient education in the hospitals to improve breastfeeding mothers' understanding, acceptance, and practice of exclusive breastfeeding. This review was prospectively registered with the International Prospective Register of Systematic Reviews (PROSPERO), registration number CRD42020133761. CONCLUSIONS: This review found that maternal-infant factors have the most significant influence over the practice of exclusive breastfeeding. Therefore, interventions targeted towards maternal-infant factors will improve and optimize exclusive breastfeeding significantly and, ultimately, improve maternal-child health outcomes.

Conditional economic incentives and motivational interviewing to improve adolescents' retention in HIV care and adherence to antiretroviral therapy in Southeast Nigeria: study protocol for a cluster randomised trial.

BACKGROUND: Adolescent HIV patients face enormous difficulty in accessing HIV care services. Given their vulnerability to risk-taking behaviour, this group also have worse treatment outcomes compared to other age groups. Poor treatment outcomes will impact negatively on HIV/AIDS management and control particularly in sub-Saharan Africa (SSA) as more than eight out of ten of the world's HIV-infected adolescents live in this region of the world. Limited evidence exists on the effectiveness of service delivery interventions to support adolescents' retention on antiretroviral therapy (ART) and adherence to ART. This trial is designed to evaluate the impact of conditional economic incentive and motivational interviewing on adolescents' retention in HIV care and adherence to ART in Anambra State, Southeast Nigeria. METHODS/DESIGN: The study will be a cluster randomised controlled trial that will be conducted in selected HIV treatment hospitals in Anambra State, Nigeria. Based on sample size calculation, 12 HIV treatment hospitals from Anambra will be selected for the study. Six HIV treatment hospitals each will be randomised to either the intervention or the control arm. A structured adherence support scheme termed the 'Incentive Scheme' will be applied to the intervention arm while the control arm will receive routine HIV care (usual care). Additionally, patients in the intervention arm will receive motivational interviewing at baseline and following initiation of antiretroviral therapy (ART), they will receive a gift voucher of US$5.6 when HIV viral load (VL) is < 20 copies/mL at 12 weeks, a gift voucher of US$2.8 if the VL remains suppressed for the next 3 months, and the next 6 months, and finally a gift voucher of US$5.6 if the VL remains < 20 copies/mL at 1 year. All gift vouchers will be conditional not only on VL results but attending the motivational interviews. The primary outcome for the trial will be the difference between groups in the proportion with HIV VL suppression (≤ 20 copies/mL) by 12 months and then 24 months after withdrawal of incentive. DISCUSSION: The findings of this proposed trial will provide evidence on the feasibility of applying conditional economic incentives combined with motivational interviewing to improve retention and adherence to antiretroviral therapy of adolescents living with HIV in Nigeria and possibly in other sub-Saharan African countries. TRIAL REGISTRATION: Registered in the Pan African Clinical Trials Registry, ID: PACTR201806003040425 . Registered on 2 February 2018.

Expanding HIV/AIDS care service sites: a cross sectional survey of community pharmacists' views in South-East, Nigeria.

BACKGROUND: Community pharmacists are very accessible to most patients yet; they have been underutilized in the aspect of providing HIV care and services. The World Health Organisation recently recommended expanding community pharmacists' roles to address the increasing complexity of antiretroviral agents and co-infection drug regimen. This study therefore was designed to assess the readiness and willingness of community pharmacists in Nigeria to participate in the care of people living with HIV/AIDS and the possible inclusion of their pharmacy premises as sites for HIV care services. METHODS: A descriptive cross sectional survey was carried out among 205 community pharmacists in south east, Nigeria between October, 2016 and February, 2017. Two hundred and five self-administered questionnaires were distributed to conveniently selected community pharmacists in the region. Data collected were analysed using SPSS version 23. Descriptive statistics was conducted for the demographics and percentage mean scores for each domain were computed. The variables in each domain were categorised into groups and simple percentages were used to show the percentage distribution of the variables. Cross tabulation was also carried out to show the relationship between the variables and groups' differences were explored using analysis of variance and P-values <0.05 were considered significant. RESULTS: All distributed questionnaires were filled and retrieved. The overall knowledge of HIV among the surveyed pharmacists was seen to be high (70.41%). Although the percentage attitude score of the respondents towards HIV care services was on the average (57%), they were highly willing and ready to use their premise to offer HIV services with a percentage mean readiness score of 87.32%. However, their perceived skills in carrying out these services were observed to be low. CONCLUSION: Community pharmacists in the south eastern part of Nigeria have high knowledge of HIV and a somewhat attitude towards HIV care services with high willingness and readiness to be involved in HIV care and services. Despite efforts to engage community pharmacists in HIV services more is needed in the aspect of making adequate policies to further empower more community pharmacists in this aspect of care.

Knowledge and Implementation of Tertiary Institutions' Social Health Insurance Programme (TISHIP) in Nigeria: a case study of Nnamdi Azikiwe University, Awka.

INTRODUCTION: Tertiary Institutions' Social Health Insurance Programme (TISHIP) is an arm of the National Health Insurance Scheme (NHIS), which provides quality healthcare to students in Nigerian higher institutions. The success of this scheme depends on the students' knowledge and awareness of its existence as well as the level of its implementation by healthcare providers. This study was therefore designed to assess students' knowledge and attitude towards TISHIP and its implementation level among health workers in Nnamdi Azikiwe University Medical Centre. METHODS: Using a stratified random sampling technique, 420 undergraduate students of Nnamdi Azikiwe University, Awka were assessed on their level of awareness and general assessment of TISHIP through an adapted and validated questionnaire instrument. The level of implementation of the scheme was then assessed among 50 randomly selected staff of the University Medical Center. Data collected were analyzed using Statistical Package for Social Sciences (SPSS) version 20 software. RESULTS: Whereas the students in general, showed a high level of TISHIP awareness, more than half of them (56.3%) have never benefited from the scheme with 52.8% showing dissatisfaction with the quality of care offered with the scheme. However, an overwhelming number of the students (87.9%) opined that the scheme should continue. On the other hand, the University Medical Centre staff responses showed a satisfactory scheme implementation. CONCLUSION: The study found satisfactory TISHIP awareness with poor attitude among Nnamdi Azikiwe University students. Furthermore, the University Medical Centre health workers showed a strong commitment to the objectives of the scheme.