Generating evidence for health policy in challenging settings: lessons learned from four prevention of mother-to-child transmission of HIV implementation research studies in Nigeria.

BACKGROUND: Implementation research (IR) facilitates health systems strengthening and optimal patient outcomes by generating evidence for scale-up of efficacious strategies in context. Thus, difficulties in generating IR evidence, particularly in limited-resource settings with wide disease prevention and treatment gaps, need to be anticipated and addressed. Nigeria is a priority country for the prevention of mother-to-child transmission of HIV (PMTCT). This paper analyses the experiences of four PMTCT IR studies in Nigeria, and proffers solutions to major challenges encountered during implementation. STUDIES INCLUDED AND FINDINGS: Multicentre PMTCT IR studies conducted in Nigeria during the Global Plan's assessment period (2011 to 2015) were included. Four studies were identified, namely The Baby Shower Trial, Optimizing PMTCT, MoMent and Lafiyan Jikin Mata. Major common challenges encountered were categorised as 'External' (beyond the control of study teams) and 'Internal' (amenable to rectification by study teams). External challenges included healthcare worker strikes and turnover, acts and threats of ethnic and political violence and terrorism, and multiplicity of required local ethical reviews. Internal challenges included limited research capacity among study staff, research staff turnover and travel restrictions hindering study site visits. Deliberate research capacity-building was provided to study staff through multiple opportunities before and during study implementation. Post-study employment opportunities and pathways for further research career-building are suggested as incentives for study staff retention. Engagement of study community-resident personnel minimised research staff turnover in violence-prone areas. CONCLUSIONS: The IR environment in Nigeria is extremely diverse and challenging, yet, with local experience and anticipatory planning, innovative solutions can be implemented to modulate internal challenges. Issues still remain with healthcare worker strikes and often unpredictable insecurity. There is a dire need for cooperation between institutional review boards across Nigeria in order to minimise the multiplicity of reviews for multicentre studies. External challenges need to be addressed by high-level stakeholders, given Nigeria's crucial regional and global position in the fight against the HIV epidemic.

The Effect of a Continuous Quality Improvement Intervention on Retention-In-Care at 6 Months Postpartum in a PMTCT Program in Northern Nigeria: Results of a Cluster Randomized Controlled Study.

BACKGROUND: Retention in care is critical for improving HIV-infected maternal outcomes and reducing vertical transmission. Health systems' interventions such as continuous quality improvement (CQI) may support health services to address factors that affect the delivery of HIV-related care and thereby influence rates of retention-in-care. METHODOLOGY: We evaluated the effect of a CQI intervention on retention-in-care at 6 months postpartum of pregnant women and mothers living with HIV who had been started on lifelong antiretroviral treatment. Thirty-two health care facilities were randomized to either implement the intervention or not. We considered women fully retained in care when they attended the 6-month postpartum visit and did not miss any previous scheduled visit by more than 30 days. RESULTS: Five hundred eleven women living with HIV attending antenatal clinics at 26 facilities were included in the analysis. Median age at enrolment was 27 years and gestational age was 20 weeks. Seventy-one percent of women were seen at 6-month postpartum irrespective of missing any scheduled visit. However, 43% of women were fully retained at 6-month postpartum and did not miss any scheduled visit based on our stringent study definition of retention. There was no significant difference in retention at 6 months between the intervention and control arms [44% vs. 41%, relative risk: 1.08; 95% confidence interval (CI): 0.78 to 1.49]. Initiation of ARV prophylaxis among infants within 72 hours was not different by study arm (66.0% vs. 74.7%, relative risk = 0.95; 95% CI: 0.84 to 1.07) but rates of early infant testing at 4-6 weeks were higher in intervention sites (48.8% vs. 25.3%, adjusted relative risk: 1.76; 95% CI: 1.27 to 2.42). CONCLUSIONS: CQI as implemented in this study did not differ across study arms in the rates of retention. Several intervention design or implementation issues or other contextual constraints may explain the absence of effect.

Using Small Tests of Change to Improve PMTCT Services in Northern Nigeria: Experiences From Implementation of a Continuous Quality Improvement and Breakthrough Series Program.

BACKGROUND: Continuous Quality Improvement (CQI) is a process where health teams systematically collect and regularly reflect on local data to inform decisions and modify local practices and so improve delivery of services. We implemented a cluster randomized trial to examine the effects of CQI interventions on Prevention of Mother-to-Child Transmission (PMTCT) services. Here, we report our experiences and challenges establishing CQI in 2 high HIV prevalence states in northern Nigeria. METHODS: Facility-based teams were trained to implement CQI activities, including structured assessments, developing change packages, and participation in periodic collaborative learning sessions. Locally evolved solutions (change ideas) were tested and measured using process data and intermediate process indicators were agreed including overall time spent accessing services, client satisfaction, and quality of data. RESULTS: Health workers actively participated in clinic activities and in the collaborative learning sessions. During the study, the mean difference in time spent accessing services during clinic visits increased by 40 minutes (SD = 93.4) in the control arm and decreased by 44 minutes (SD = 73.7) in the intervention arm. No significant difference was recorded in the mean client satisfaction assessment score by study arm. The quality of data was assessed using a standardized tool scored out of 100; compared with baseline data, quality at the end of study had improved at intervention sites by 6 points (95% CI: 2.0 to 10.1). CONCLUSIONS: Health workers were receptive to CQI process. A compendium of "change ideas" compiled into a single change package can be used to improve health care delivery.

Assessing the level of preparedness of private health providers for clinical management of HIV/AIDS epidemic in Nassarawa State, Nigeria.

Very little information is available on the extent to which the private health sector is involved in clinical management of HIV/AIDS in Nigeria. This study assessed the potentials and existing capacity of 15 private health facilities in Nassarawa state for clinical management of HIV/AIDS. Information was obtained from 25 staff (15 proprietors and 10 professionals) of the randomly selected health facilities in the state using structured questionnaire. Of the 15 health facilities, three provided voluntary counselling and testing (VCT), seven had never admitted persons living with HIV/AIDS (PLWHA), two provided laboratory services, none provided home-based care for PLWHAs, two had anti-retro-viral drugs in stock, two had rooms for counselling, three had full-time doctors, and six had registered nurses. Of the 25 health workers, 5 had skills/training in conducting VCT, 15 had skills in the treatment of opportunistic infections, 14 were aware of anti-retro-viral drugs and 13 did not feel comfortable attending to PLWHAs. The study recommended capacity building on HIV/AIDS related services for the private health-workers.

Trends in female circumcision between 1933 and 2003 in Osun and Ogun States, Nigeria (a cohort analysis).

The international movement against female circumcision gained momentum in the past two decades. Although recent studies report decline in the practice none has studied the cohort effect or provided plausible explanation for such decline. Changes in female circumcision occurring in two southwestern States of Nigeria between 1933 and 2003 were tracked in a cross-sectional survey using cohort analysis. 1174 female live births to 413 women were included in the analysis. About fifty-three percent of all females were circumcised. The prevalence dropped from 64.9% during the period 1933-60 to 25.7% for the period 2000-2003. For first order births, the corresponding rates were 58.8% and 25.0%. The decline for first-born females comes a decade before other birth orders. Age and education of mother are two main factors of the decline. Global consensus or legal enforcement plays secondary roles. Understanding how modernisation affects the decline in female circumcision should receive greater attention.

Impact of an intervention to improve treatment-seeking behavior and prevent sexually transmitted diseases among Nigerian youths.

BACKGROUND: Interventions to treat STDs have been reported to reduce HIV incidence. Interventions to improve treatment-seeking for STDs may impact on the duration and prevalence of STDs. Nigeria has high rates of STDs and an increasing incidence of HIV. OBJECTIVE: To evaluate the impact of an intervention on STD treatment-seeking behavior and STD prevalence among Nigerian youth. METHODS: A randomized controlled trial in 12 schools in Edo State was conducted to evaluate an intervention to improve STD treatment-seeking and STD treatment provision. The intervention, based on formative research, consisted of community participation, peer education, public lectures, health clubs in the schools, and training of STD treatment providers, including those with no formal training. A questionnaire measured outcomes before and 10 months into the intervention. The effect of the intervention among four randomly selected intervention schools compared to eight randomly selected control schools was assessed using logistic regression with Huber's formula to account for school clusters. RESULTS: One thousand eight hundred and ninety-six and 1858 youths 14-20 years of age were enrolled in the pre- and post-intervention surveys. Youths in the intervention schools, compared to control schools, reported statistically significant improvements in knowledge of STDs, condom use, partner awareness that the youth had an STD, and STD treatment-seeking behavior. Treatment by private physicians increased (OR=2.1, 95% CI=1.1-4.0), and treatment by patent medicine dealers or pharmacists decreased (OR=0.44, 95% CI=0.22-0.88). The reported prevalence of STD symptoms in the past 6 months was significantly reduced in the intervention compared to control schools (OR=0.68, 95% CI=0.48-0.95). CONCLUSION: Significant improvements in treatment-seeking for STD symptoms can be effected among Nigerian youths. The prevalence of reported STD symptoms can be decreased by improving treatment-seeking for and awareness of STDs.

Increasing retention in care of HIV-positive women in PMTCT services through continuous quality improvement-breakthrough (CQI-BTS) series in primary and secondary health care facilities in Nigeria: a cluster randomized controlled trial. The Lafiyan Jikin Mata Study.

BACKGROUND: Rates of retention in care of HIV-positive pregnant women in care programs in Nigeria remain generally poor with rates around 40% reported for specific programs. Poor quality of services in health facilities and long waiting times are among the critical factors militating against retention of these women in care. The aim of the interventions in this study is to assess whether a continuous quality improvement intervention using a Breakthrough Series approach in local district hospitals and primary health care clinics will lead to improved retention of HIV-positive women and mothers. METHODS/DESIGN: A cluster randomized controlled trial with 32 health facilities randomized to receive a continuous quality improvement/Breakthrough Series intervention or not. The care protocol for HIV-infected pregnant women and mothers is the same in all sites. The quality improvement intervention started 4 months before enrollment of individual HIV-infected pregnant women and initially focused on reducing waiting times for women and also ensuring that antiretroviral drugs are dispensed on the same day as clinic attendance. The primary outcome measure is retention of HIV-positive mothers in care at 6 months postpartum. DISCUSSION: Results of this trial will inform whether quality improvement interventions are an effective means of improving retention in prevention of mother-to-child transmission of HIV programs and will also guide where health system interventions should focus to improve the quality of care for HIV-positive women. This will benefit policymakers and program managers as they seek to improve retention rates in HIV care programs.