Factors associated with viral load non-suppression in people living with HIV on ART in Nigeria: cross-sectional analysis from 2017 to 2021.

OBJECTIVES: Identify factors (demographic and clinical) associated with a non-suppressed viral load (VL) of people living with HIV (PLHIV) on antiretroviral therapy (ART) in Nigeria. DESIGN: Cross-sectional study. SETTING: Sixteen US Agency for International Development supported states in Nigeria. PARTICIPANTS: 585 632 PLHIV on ART. PRIMARY OUTCOME MEASURES: VL non-suppression (defined as having a VL of at least 1000 HIV RNA copies per mL of plasma). χ2 testing and multivariable modified Poisson regression with robust variance estimates were conducted on routinely collected ART programme data. RESULTS: Sixty-six per cent of the study population were females. The largest age groups were 25-34 and 35-44, accounting for 32.1% and 31.1%, respectively. Males had a 9% greater likelihood (adjusted prevalence ratio, APR=1.09) of being non-suppressed. The age groups below 60+ (APR=0.67) had a higher likelihood of a non-suppressed VL, with the highest in the 0-14 age group (APR=2.38). Clients enrolled at tertiary and secondary level facilities had the greatest likelihood of a non-suppressed VL. Clients who started ART between 2010 and 2015 had the greatest likelihood of viral non-suppression (APR=6.19). A shorter time on ART (<1 year (APR=3.92)) was associated with a higher likelihood of a non-suppressed VL. Clients receiving care at private facilities had a lower likelihood of viral non-suppression in the adjusted model. Clients in the Edo (APR=2.66) and Niger (APR=2.54) states had the greatest likelihood of viral non-suppression. CONCLUSIONS: Targeting males, clients of younger age, those on treatment for less than 3 years, clients at tertiary and secondary health facilities, small and medium facilities, and clients in the Edo, Niger and Borno states for interventions could lead to improvements in VL suppression in Nigeria. The independent factors associated with a non-suppressed VL can guide improvements in ART programme development and VL suppression of PLHIV on ART in Nigeria.

Factors associated with an interruption in treatment of people living with HIV in USAID-supported states in Nigeria: a retrospective study from 2000-2020.

BACKGROUND: Patient interruption of antiretroviral therapy (ART) continues to limit HIV programs' progress toward epidemic control. Multiple factors have been associated with client interruption in treatment (IIT)- including age, gender, CD4 count, and education level. In this paper, we explore the factors associated with IIT in people living with HIV (PLHIV) in United States Agency for International Development (USAID)-supported facilities under the U.S. President's Emergency Plan for AIDS Relief (PEPFAR) program in Nigeria. METHODS: We conducted cross-sectional analyses on data obtained from Nigeria's National Data Repository (NDR), representing a summarized record of 573 630 ART clients that received care at 484 PEPFAR/USAID-supported facilities in 16 states from 2000-2020. IIT was defined as no clinical contact for 28 days or more after the last expected clinical contact. Univariate and multivariate logistic regression models were computed to explore the factors associated with IIT. The variables included in the analysis were sex, age group, zone, facility level, regimen line, multi-month dispensing (MMD), and viral load category. RESULTS: Of the 573 630 clients analysed in this study, 32% have been recorded as having interrupted treatment. Of the clients investigated, 66% were female (32% had interrupted treatment), 39% were aged 25-34 at their last ART pick-up date (with 32% of them interrupted treatment), 59% received care at secondary level facilities (37% interrupted treatment) and 38% were last receiving between three- to five-month MMD (with 10% of these interrupted treatment). Those less likely to interrupt ART were males (aOR = 0.91), clients on six-month MMD (aOR = 0.01), adults on 2nd line regimen (aOR = 0.09), and paediatrics on salvage regimen (aOR = 0.02). Clients most likely to interrupt ART were located in the South West Zone (aOR = 1.99), received treatment at a tertiary level (aOR = 12.34) or secondary level facilities (aOR = 4.01), and had no viral load (VL) on record (aOR =10.02). Age group was not significantly associated with IIT. CONCLUSIONS: Sex, zone, facility level, regimen line, MMD, and VL were significantly associated with IIT. MMD of three months and longer (especially six months) had better retention on ART than those on shorter MMD. Not having a VL on record was associated with a considerable risk of IIT.

The experience of men who participated in interventions to improve demand for and utilization of maternal and child health services in northern Nigeria: a qualitative comparative study.

BACKGROUND: Men in northern Nigeria are considered the leaders and ultimate decision makers, including decisions about health-related behaviours of their wives and children. Yet many men in the region consider pregnancy and childbirth to be in the woman's domain (even if she cannot make related decisions), and may not see a need to educate themselves on the issues. These dynamics directly influence demand for, and utilization of, maternal, newborn, and child health services. This study examines an intervention that educated married men in northern Nigeria about health issues related to pregnancy, labour, delivery, and the postpartum period, as well as newborn and child health, through participation in male support groups. The curriculum also included interpersonal relationship and household decision making, with an emphasis on the need for men to give their wives standing approval to seek health services as needed, for themselves and their children. METHODS: We conducted 12 focus group discussions with married men in Kaduna and Katsina states in northern Nigeria - half with men who had participated in the male support groups and half with men from areas that the intervention had not reached. Analysis was thematic, focusing on participants' perceptions of the male support groups, the benefits of the intervention, and enablers and barriers to support group participation. RESULTS: Perceptions of the male support groups were overwhelmingly positive. Participants internalized important messages they learned, which influenced their decisions related to the health of their wives and children. Some take it upon themselves to educate others in their communities about what they learned, and many say they see changes at the community level, with more utilization of maternal, newborn, and child health services. CONCLUSIONS: In the northern Nigeria context, educating men about danger signs of pregnancy, labour, delivery, newborn, and child health, is crucial to improving maternal and newborn health outcomes. Our intervention was successful not only in educating men, but also in converting some into advocates such that the effect of the intervention went beyond participants to the community. Programmes that aim to improve health-service utilization in northern Nigeria should consider scaling up this, or similar, interventions.

Factors associated with knowledge of obstetric danger signs and perceptions of the need for obstetric care among married men in northern Nigeria: a cross-sectional survey.

BACKGROUND: Male involvement in maternal, newborn and child health contributes to better health outcomes for women and their children, especially in restrictive societies. There is evidence that when men have better understanding of women's health needs, attitudes toward utilization of maternal and child health services, of both women and men, are improved. Given the role of men as the ultimate decision makers in families in northern Nigerian society, this study assessed the determinants of men's knowledge of danger signs in pregnancy and the continuum of obstetric care, and their perceptions of the importance of antenatal care utilization and health facility delivery. METHODS: This was a cross-sectional descriptive study. Structured questionnaires with close ended questions were administered to 1627 married men who had at least one wife younger than 25 years in communities in Nigeria northern states of Kaduna and Katsina. We use crosstabulations and means to compare characteristics of study respondents in the two states, assessing statistical significance of the differences with χ2-square and Anova tests as appropriate, and logistic regressions to assess the determinants of knowledge and perceptions. RESULTS: Knowledge of obstetric danger signs, especially during the postpartum period, was poor overall, but respondents were relatively more knowledgeable about danger signs during pregnancy and delivery compared with the postpartum period. Most perceived that antenatal care can reduce the risk of complications. Literate men were twice more likely to have positive health-behaviour perceptions. Wealth was positively associated with the perception that women should deliver in a health facility or hospital but did not have a statistically significant effect on the perception that antenatal care can reduce the risk of complications. CONCLUSIONS: While knowledge of obstetric danger signs was poor, literacy and household wealth significantly influenced knowledge of obstetric danger signs and perceptions that women should deliver at a health facility. Male involvement programmes need to ensure that men are empowered to understand obstetric danger signs along the continuum of obstetric care to improve perception and utilization of maternal health services for better maternal and newborn health outcomes.

Emergency transport for obstetric emergencies: integrating community-level demand creation activities for improved access to maternal, newborn, and child health services in northern Nigeria.

PURPOSE: Ensuring adequate access to skilled birth attendants during and after childbirth is a key strategy to reducing maternal and newborn mortalities. Transportation difficulties in emergency situations continue to be a significant barrier to accessing emergency obstetric care, especially in rural and hard-to-reach areas. Emergency transport schemes (ETS) have been introduced in various settings to increase access to emergency care and reduce the second obstetric delay with varying degrees of success. This qualitative study assessed the perceptions of stakeholders and beneficiaries of ETS in two states in northern Nigeria, comparing two models of ETS: one in which the ETS were introduced as a stand-alone intervention, and another in which ETS were part of a package of interventions for increasing demand and improving utilization of maternal and newborn health services. METHODS: We carried out focus group discussions with ETS drivers, mothers who delivered in the past year and utilized ETS, husbands of women who benefited from the schemes in the past year, health care providers, traditional birth attendants, and religious leaders, supplemented by in-depth interviews with program focal persons. RESULTS: Demand creation activities - especially working with traditional birth attendants and religious leaders - provided a strong linkage between the ETS and families of women in need of emergency transport services. Community members perceived the ETS model that included demand-generating activities as being more reliable and responsive to women's needs. CONCLUSION: ETS remain a key solution to lack of transport as a barrier to utilizing maternal and newborn health services in emergency situations in many rural and hard-to-reach communities. Programs utilizing ETS to improve access to emergency obstetric care should explore the potential of increasing their utility and reach by integrating the schemes with additional demand-side interventions, especially engagement with traditional birth attendants and religious leaders.

Overcoming barriers to access and utilization of maternal, newborn and child health services in northern Nigeria: an evaluation of facility health committees.

BACKGROUND: Poor quality of health services and socio-cultural dynamics may severely limit utilization of health services. Facility health committees were established in several states in northern Nigeria to reduce these barriers. The committees were charged with mobilizing communities, improving quality of health services, and promoting utilization of maternal and child health services. This study assessed this intervention. METHODS: To obtain a comprehensive picture of facility health committees' influence on maternal and child health services, we selected 33 facilities in three states in northern Nigeria (Jigawa, Kaduna, Kano) where the intervention was active. For each of these facilities we interviewed committee members (n = 399), conducted focus group discussions with a subset of committee members (18 focus groups), interviewed facility health providers (two providers from each facility), and conducted client exit interviews (n = 501). RESULTS: Facility health committees appear to have a positive influence on quality of maternal and child health services in the selected facilities. Committee members, health providers, and facility clients all agree that the committees have a tangible positive effect. The most important roles of the committees are to mobilize the community and increase demand for maternal and child health services, in a region where demand is very low. Committee activities further improve health services in many ways, including advocacy, community-facility coordination, fund raising, money donation, and problem mitigation. CONCLUSION: Facility health committees can be invaluable in contributing to improved demand for and access to quality maternal and child health services in health facilities in northern Nigeria. They provide strong linkages between community members and the health facilities, directly work to increase demand for services, and address supply-side challenges that often limit utilization of services in health facilities. The intervention can be improved by more broadly communicating committee activities in the community, and by incentivizing facility health committee members.