Outcomes of HIV Positive Children and Adolescents Initiated on Antiretroviral Treatment in Nigeria (2007-2016).

Background: This manuscript aimed to examine treatment outcomes of HIV-positive children and adolescents. Methods: We retrospectively analyzed data of a sample of patients aged 0-19 years who initiated ART (October 2007-September 2016) in participating sites in 30 states and the Federal Capital Territory in Nigeria. Results: Among 4006 patients alive at the end of the follow up period, 138 (3.4%) were LTFU. Adolescents had a significantly higher risk of being LTFU than children aged 3-5 years (HR 2.47 [95% CI 1.40-4.34]). Patients with advanced disease had a significantly higher risk of being LTFU (Stage IV HR, 3.66 [95% CI: 2.00-6.68]). On average, optimal ART refill adherence was met by 67.3% of patients. Conclusion: Our findings suggest that focusing on preventing and managing advanced disease and interventions supporting adolescents when transferring to adult care is warranted.

Expanding access to HIV services during the COVID-19 pandemic-Nigeria, 2020.

BACKGROUND: To accelerate progress toward the UNAIDS 90-90-90 targets, US Centers for Disease Control and Prevention Nigeria country office (CDC Nigeria) initiated an Antiretroviral Treatment (ART) Surge in 2019 to identify and link 340,000 people living with HIV/AIDS (PLHIV) to ART. Coronavirus disease 2019 (COVID-19) threatened to interrupt ART Surge progress following the detection of the first case in Nigeria in February 2020. To overcome this disruption, CDC Nigeria designed and implemented adapted ART Surge strategies during February-September 2020. METHODS: Adapted ART Surge strategies focused on continuing expansion of HIV services while mitigating COVID-19 transmission. Key strategies included an intensified focus on community-based, rather than facility-based, HIV case-finding; immediate initiation of newly-diagnosed PLHIV on 3-month ART starter packs (first ART dispense of 3 months of ART); expansion of ART distribution through community refill sites; and broadened access to multi-month dispensing (MMD) (3-6 months ART) among PLHIV established in care. State-level weekly data reporting through an Excel-based dashboard and individual PLHIV-level data from the Nigeria National Data Repository facilitated program monitoring. RESULTS: During February-September 2020, the reported number of PLHIV initiating ART per month increased from 11,407 to 25,560, with the proportion found in the community increasing from 59 to 75%. The percentage of newly-identified PLHIV initiating ART with a 3-month ART starter pack increased from 60 to 98%. The percentage of on-time ART refill pick-ups increased from 89 to 100%. The percentage of PLHIV established in care receiving at least 3-month MMD increased from 77 to 93%. Among PLHIV initiating ART, 6-month retention increased from 74 to 92%. CONCLUSIONS: A rapid and flexible HIV program response, focused on reducing facility-based interactions while ensuring delivery of lifesaving ART, was critical in overcoming COVID-19-related service disruptions to expand access to HIV services in Nigeria during the first eight months of the pandemic. High retention on ART among PLHIV initiating treatment indicates immediate MMD in this population may be a sustainable practice. HIV program infrastructure can be leveraged and adapted to respond to the COVID-19 pandemic.

Optimizing community linkage to care and antiretroviral therapy Initiation: Lessons from the Nigeria HIV/AIDS Indicator and Impact Survey (NAIIS) and their adaptation in Nigeria ART Surge.

BACKGROUND: Ineffective linkage to care (LTC) is a known challenge for community HIV testing. To overcome this challenge, a robust linkage to care strategy was adopted by the 2018 Nigeria HIV/AIDS Indicator and Impact Survey (NAIIS). The NAIIS linkage to care strategy was further adapted to improve Nigeria's programmatic efforts to achieve the 1st 90 as part of the Nigeria Antiretroviral Therapy (ART) Surge initiative, which also included targeted community testing. In this paper we provide an overview of the NAIIS LTC strategy and describe the impact of this strategy on both the NAIIS and the Surge initiatives. METHODS: The NAIIS collaborated with community-based organizations (CBOs) and deployed mobile health (mHealth) technology with real-time dashboards to manage and optimize community LTC for people living with HIV (PLHIV) diagnosed during the survey. In NAIIS, CBOs' role was to facilitate linkage of identified PLHIV in community to facility of their choice. For the ART Surge, we modified the NAIIS LTC strategy by empowering both CBOs and mobile community teams as responsible for not only active LTC but also for community testing, ART initiation, and retention in care. RESULTS: Of the 2,739 PLHIV 15 years and above identified in NAIIS, 1,975 (72.1%) were either unaware of their HIV-positive status (N = 1890) or were aware of their HIV-positive status but not receiving treatment (N = 85). Of these, 1,342 (67.9%) were linked to care, of which 952 (70.9%) were initiated on ART. Among 1,890 newly diagnosed PLHIV, 1,278 (67.6%) were linked to care, 33.7% self-linked and 66.3% were linked by CBOs. Among 85 known PLHIV not on treatment, 64 (75.3%) were linked; 32.8% self-linked and 67.2% were linked by a CBO. In the ART Surge, LTC and treatment initiation rates were 98% and 100%, respectively. Three-month retention for monthly treatment initiation cohorts improved from 76% to 90% over 6 months. CONCLUSIONS: Active LTC strategies by local CBOs and mobile community teams improved LTC and ART initiation in the ART Surge initiative. The use of mHealth technology resulted in timely and accurate documentation of results in NAIIS. By deploying mHealth in addition to active LTC, CBOs and mobile community teams could effectively scale up ART with real-time documentation of client-level outcomes.

Rapid Scale-up of an Antiretroviral Therapy Program Before and During the COVID-19 Pandemic - Nine States, Nigeria, March 31, 2019-September 30, 2020.

In 2018, an estimated 1.8 million persons living in Nigeria had HIV infection (1.3% of the total population), including 1.1 million (64%) who were receiving antiretroviral therapy (ART) (1). Effective ART reduces morbidity and mortality rates among persons with HIV infection and prevents HIV transmission once viral load is suppressed to undetectable levels (2,3). In April 2019, through the U.S. President's Emergency Plan for AIDS Relief (PEPFAR),* CDC launched an 18-month ART Surge program in nine Nigerian states to rapidly increase the number of persons with HIV infection receiving ART. CDC analyzed programmatic data gathered during March 31, 2019-September 30, 2020, to describe the ART Surge program's progress on case finding, ART initiation, patient retention, and ART Surge program growth. Overall, the weekly number of newly identified persons with HIV infection who initiated ART increased approximately eightfold, from 587 (week ending May 4, 2019) to 5,329 (week ending September 26, 2020). The ART Surge program resulted in 208,202 more HIV-infected persons receiving PEPFAR-supported ART despite the COVID-19 pandemic (97,387 more persons during March 31, 2019-March 31, 2020 and an additional 110,815 persons during April 2020-September 2020). Comprehensive, data-guided, locally adapted interventions and the use of incident command structures can help increase the number of persons with HIV infection who receive ART, reducing HIV-related morbidity and mortality as well as decreasing HIV transmission.

Increasing pediatric HIV testing positivity rates through focused testing in high-yield points of service in health facilities-Nigeria, 2016-2017.

BACKGROUND: In 2017, UNAIDS estimated that 140,000 children aged 0-14 years are living with HIV in Nigeria, but only 35% have been diagnosed and are receiving antiretroviral therapy. Children are tested primarily in outpatient clinics, which show low HIV-positive rates. To demonstrate efficient facility-based HIV testing among children aged 0-14 years, we evaluated pediatric HIV-positivity rates in points of service in select health facilities in Nigeria. METHODS: We conducted a retrospective analysis of HIV testing and case identification among children aged 0-14 years at all points of service at nine purposively sampled hospitals (November 2016-March 2017). Points of service included family index testing, pediatric outpatient department (POPD), tuberculosis (TB) clinics, immunization clinics, and pediatric inpatient ward. Eligibility for testing at POPD was done using a screening tool while all children with unknown status were eligible for HIV test at other points of service. The main outcome was HIV positivity rates stratified by the testing point of service and by age group. Predictors of an HIV-positive result were assessed using logistic regression. All analyses were done using Stata 15 statistical software. RESULTS: Of 2,180 children seen at all facility points of service with unknown HIV status, 1,822 (83.6%) were tested for HIV, of whom 43 (2.4%) tested HIV positive. The numbers of children tested by age group were <1 years = 230 (12.6%); 1-4 years = 752 (41.3%); 5-9 years = 520 (28.5%); and 10-14 years = 320 (17.6%). The number of children tested by point of service were POPD = 906 (49.7%); family index testing = 693 (38.0%); pediatric inpatient ward = 192 (10.5%); immunization clinic = 16 (0.9%); and TB clinic = 15 (0.8%). HIV positivity rates by point of service were TB clinic = 6.7% (95% Confidence Interval (CI): 0.9-35.2%); pediatric inpatient ward = 4.7% (95%CI: 2.5-8.8%); family index testing = 3.5% (95%CI: 2.3-5.1%); POPD = 1.0% (95%CI: 0.5-1.9%); and immunization clinic = 0%. The percentage contribution to total HIV positive children found by point of services was: family index testing = 55.8% (95%CI: 40.9-69.8%); POPD = 20.9% (95%CI: 11.3-35.6%); inpatient ward = 20.9 (95%CI: 11.3-35.6%) and TB Clinic = 2.3% (95%CI: 0.3-14.8%). Compared with the POPD, the adjusted odds ratio (95% CI) for finding an HIV positive child by point of service were TB clinic = 7.2 (95% CI: 0.9-60.9); pediatric inpatient ward = 4.9 (95% CI: 1.9-12.8); and family index testing = 3.7 (95% CI: 1.5-8.8). HIV-positivity rates did not significantly differ by age group. CONCLUSION: In Nigeria, to improve facility-based HIV positivity rates among children aged 0-14 years, an increased focus on HIV testing among children seeking care in pediatric inpatient wards, through family index testing, and perhaps TB clinics is appropriate.

Health Workers' Perspectives on the Outcomes, Enablers, and Barriers to the Implementation of HIV "Test and Treat" Guidelines in Abuja, Nigeria.

We evaluated health workers' perspectives on the implementation of the 2016 HIV "Test and Treat" guidelines in Nigeria. Using semi-structured interviews, qualitative data was collected from twenty health workers meeting inclusion criteria in six study sites. Data exploration was conducted using thematic content analysis. Participants perceived that the "Test and Treat" guidelines improved care for PLHIV, though they also perceived possible congested clinics. Perceived key factors enabling guidelines use were perceived patient benefits, availability of policy document and trainings. Perceived key barriers to guidelines use were poverty among patients, inadequate human resources and stock-outs of HIV testing kits. Further improvements in uptake of guidelines could be achieved by effecting an efficient supply chain system for HIV testing kits, and improved guidelines distribution and capacity building prior to implementation. Additionally, implementing differentiated approaches that decongest clinics, and programs that economically empower patients, could improve guidelines use, as Nigeria scales "Test and Treat" nationwide.