Medication-based Refill Adherence Among Pregnant Women Living With HIV in Nigeria.

PURPOSE: A major global public health challenge is the continuance of new pediatric HIV infections primarily because of mother to child transmission of HIV occurring mainly in sub-Saharan African countries. The purpose of this study was to examine antiretroviral therapy (ART) refill adherence and its determinants among pregnant women living with HIV in Nigeria. METHODS: A retrospective review of pharmacy refill records was undertaken to examine adherence data on 275 pregnant women undergoing ART in 4 high-volume HIV treatment sites in Nigeria. A pharmacy refill adherence measure was used to assess medication refill behavior of pregnant women living with HIV who had received an ART refill during a period of 3 months. Medication-based ART refill adherence was categorized as % adherence (100% adherence) or % nonadherence (<100% adherence) to the ART refill scheduled dates. Refill appointments were scheduled on a 28-day cycle. Multivariable logistic regression analysis was performed. FINDINGS: Of the 275 women, 59.3% (95% CI, 53.1%-65.5%) were adherent to their ART refill schedule. Women who initiated ART during the third trimester of their current pregnancy had the lowest adherence rate of 30.8% (95% CI, 7.7%-53.8%) compared with women who commenced ART before conception or during the first or second trimester. The availability of a treatment support person was significantly associated with ART refill adherence. The odds of medication-based refill adherence were 2.9 times higher for participants who had a treatment support person (odds ratio = 2.9; 95% CI, 1.6-5.2; p = 0.001). IMPLICATIONS: Results indicate that having a treatment support person could contribute to improving ART adherence in pregnant women living in Nigeria.

Perspectives of pregnant women, family members and health professionals on medication adherence in Nigeria.

ABSTRACT Nigeria has the highest burden of mother-to-child transmission of human immunodeficiency virus (HIV) worldwide. Pregnant women living with HIV in Nigeria face challenges adhering to antiretroviral therapy (ART). We explored the perspectives of pregnant women living with HIV, family members, friends and health professionals to understand adherence to ART. Pregnant women, family members, friends and health professionals recruited from four HIV treatment sites in Nigeria participated in semi-structured interviews and focus groups. Thematic analysis was conducted and themes and sub-themes were mapped against the Theory of Planned Behaviour comprising behavioural, normative and control beliefs. Overall, 74 participants took part in the study. Common behavioural beliefs comprised maintaining the mother's and unborn child's health and success of having HIV-negative children from previous pregnancies. Common normative beliefs involved partner and family support for medication taking and medication refill visits. Common control beliefs comprised fear of discrimination and stigmatisation. Results showed that adherence to ART in pregnancy is intricate. Hence, before interventions are developed to change adherence behaviours in pregnant women tailored strategies should be devised that address the salient beliefs that influence adherence during pregnancy.

Factors Associated With Success in Reducing HIV Mother-to-child Transmission in Sub-Saharan Africa: Interviews With Key Stakeholders.

PURPOSE: A key global health challenge is the persistence of new pediatric HIV infections due to mother-to-child transmission (MCTC), particularly in sub-Saharan Africa. The purpose of this study was to identify the key strategies that some sub-Saharan African countries have used to successfully reduce new pediatric HIV infections. METHODS: A qualitative study utilizing semistructured interviews with key stakeholders in 6 sub-Saharan African countries (Burundi, Malawi, Mozambique, South Africa, Swaziland, and Uganda) was conducted from September 2017 to September 2018. These stakeholders were situated in the National Department of Health or in international health-funding bodies relating to the provision of the HIV/AIDS implementation program in these countries. The countries were selected based on considerable success achieved with HIV treatment in pregnant women. Audio-recorded interviews were transcribed verbatim and thematic analysis was undertaken. FINDINGS: In all, 6 interviews were conducted, and the mean time of the interviews was 62 min. There were similar numbers of men and women, and most were in the 35- to 45-year age group. Five in six were either a medical doctor or held a doctorate degree. Four in six had >10 years of experience working in the prevention of HIV (PMTCT). Four key strategies that contributed to significant reductions in pediatric HIV infection in the respective countries were identified: (1) committed political leadership; (2) support structures within the community; (3) innovation in service delivery; and (4) robust monitoring and evaluation systems. Stakeholders spoke about how their governments played a leading role in engagement with communities, and in the dissemination of services. Innovative service delivery comprising task-shifting initiatives and the integration of maternal, newborn, and child health and HIV PMCTC services played an important role in reducing the burdens experienced by women and health care workers, leading to improved health outcomes. Peer support also helped mothers to adhere to their treatment during and after pregnancy. The capacity of national programs to monitor and evaluate the PMTCT services and the importance of regular viral-load monitoring were highlighted by the stakeholders. IMPLICATIONS: These strategies can be reviewed for possible implementation by other sub-Saharan African countries as possible means of reducing new pediatric HIV infections.

Post Option B+ implementation programme in Nigeria: Determinants of adherence of antiretroviral therapy among pregnant women with HIV.

OBJECTIVE: Nigeria has the highest rate of mother to child transmission of HIV (MTCT) in the world. By 2015, all Global Plan priority countries, except Nigeria, had adopted the Option B+ programme. Nigeria finally adopted Option B+ in 2016 with full implementation reported in 2017. We examined adherence to antiretroviral therapy (ART) among pregnant women since the rollout of Option B+ in Nigeria. METHODS: A cross sectional approach was adopted that involved dissemination of a survey (Adult AIDS Clinical Trial Groups [AACTG] standardised survey) to HIV positive pregnant women, to assess adherence to ART. This study was conducted from February to June, 2018 in four health care sites in Akwa Ibom State, in the South-South region of Nigeria. Bootstrapping was used to estimate the 95% confidence interval of the prevalence of adherence. Bivariate associations between patient demographic characteristics and medication taking behaviours, and the outcome variable of ART adherence were examined using Chi-square tests. Multivariable logistic regression was used to identify factors independently associated with adherence. RESULTS: Of the 275 women (response rate=92.6%), 32.7% (95% CI: 26.9-38.5) self-reported taking all ART doses in the past 96 hours. In the multivariable logistic regression analyses, there were positive associations between an increased education level (OR=1.7, p=0.006) and disclosure of HIV status (OR=2.3, p=0.024), and medication adherence. For women who had previous prevention of MTCT exposure, the odds of medication adherence were 2.5 times higher compared with those with no previous MTCT exposure (OR=2.5, p=0.005). CONCLUSION: Adherence to ART among pregnant women in Nigeria is low. There is a need to improve adherence during pregnancy under the Option B+ programme in Nigeria.

A meta-analysis of effectiveness of interventions to improve adherence in pregnant women receiving antiretroviral therapy in sub-Saharan Africa.

OBJECTIVE: We evaluated the effectiveness of interventions aimed at improving antiretroviral therapy (ART) adherence during pregnancy in sub-Saharan Africa. METHODS: For this meta-analysis, the following databases were searched: MEDLINE Complete, Embase, Global Health, CINAHL Complete, and Google Scholar. Randomized and nonrandomized studies were considered for inclusion if they involved an intervention with the intent of improving medication adherence among pregnant women taking ART in sub-Saharan Africa. Databases were searched from inception to the end of August 2017. The primary outcome assessed was adherence to ART, defined as the proportion of women adherent to treatment in the control and intervention groups. Risk ratios and random effect meta-analysis were undertaken, and heterogeneity was examined with the I2 statistic. RESULTS: The systematic search of databases yielded a total of 402 articles, of which 19 studies were selected for meta-analysis with a total of 27,974 participants. Nine types of interventions were identified in the 19 studies to improve ART adherence. The test for the subgroup differences showed that there was a statistically significant difference among the 9 subgroups of interventions, χ2 (8)=102.38; p=0.00001. Collectively, in the meta-analysis, the various intervention types made a significant impact on improving medication adherence. The overall effect estimate with 95% CI was as follows: 1.25 (95% CI=1.03, 1.52, p=0.03). The following risk ratio results for meta-analysis were obtained for the three interventions that showed significant impact on adherence; namely social support and structural support, 1.58 (95% CI=1.36, 1.84, p<0.00001); education, social support and structural support=2.60 (95% CI=1.95, 3.45, p<0.00001); and device reminder=1.13 (95% CI=1.05, 1.20, p=0.0004). The proportion of women who were adherent to ART as a result of the interventions was 59.3% compared with 22.5% in the control groups. CONCLUSION: The use of device reminder, a combination of social support and structural support, and education, social support and structural support has the potential to improve ART adherence during pregnancy. Good quality prospective observational studies and randomized control trials are needed in sub-Saharan Africa to determine the most effective interventions.

Medication adherence in pregnant women with human immunodeficiency virus receiving antiretroviral therapy in sub-Saharan Africa: a systematic review.

BACKGROUND: The use of antiretroviral therapy (ART) is a core strategy proposed by the World Health Organization in preventing mother to child transmission (MTCT) of HIV. This systematic review aimed to examine the enablers and barriers of medication adherence among HIV positive pregnant women in sub-Saharan Africa. METHODS: We used the following keywords: HIV AND (Pregnancy OR Pregnant*) AND (PMTCT OR "PMTCT Cascade" OR "Vertical Transmission" OR "Mother-to-Child") AND (Prevent OR Prevention) AND (HAART OR "Antiretroviral Therapy" OR "Triple Therapy") AND (Retention OR Concordance OR Adherence OR Compliance) to conduct electronic searches in the following databases: MEDLINE Complete (1916-Dec 2017), Embase (1947-Dec 2017), Global Health (1910-Dec 2017) and CINAHL Complete (1937-Dec 2017). Of the four databases searched, 401 studies were identified with 44 meeting the inclusion criteria. Seven studies were added after searching reference lists of included articles, resulting in 51 articles in total. RESULTS: The review demonstrated that stigma, cost of transportation, food deprivation and a woman's disclosure or non-disclosure of her HIV status to a partner, family and the community, could limit or define the extent of her adherence to prescribed antiretroviral drugs during pregnancy. Furthermore, the review indicated that knowledge of HIV status, either before or during pregnancy, was significantly associated with medication adherence. Women who knew their HIV status before pregnancy demonstrated good adherence while women who found out their HIV infection status during pregnancy were linked with non-adherence to ART. CONCLUSION: This review revealed several barriers and enablers of adherence among pregnant women taking ART in sub-Saharan Africa. Major barriers included the fear of HIV infection status disclosure to partners and family members, stigma and discrimination. A major enabler of adherence in women taking ART was women's knowledge of their HIV status prior to becoming pregnant. Enhanced effort is needed to facilitate women's knowledge of their HIV status before pregnancy to enable disease acceptance and management, and to support pregnant women and her partner and family in dealing with fear, stigma and discrimination about HIV.

Can simple mobile phone applications provide reliable counts of respiratory rates in sick infants and children? An initial evaluation of three new applications.

BACKGROUND: Respiratory rate is an important sign that is commonly either not recorded or recorded incorrectly. Mobile phone ownership is increasing even in resource-poor settings. Phone applications may improve the accuracy and ease of counting of respiratory rates. OBJECTIVES: The study assessed the reliability and initial users' impressions of four mobile phone respiratory timer approaches, compared to a 60-second count by the same participants. METHODS: Three mobile applications (applying four different counting approaches plus a standard 60-second count) were created using the Java Mobile Edition and tested on Nokia C1-01 phones. Apart from the 60-second timer application, the others included a counter based on the time for ten breaths, and three based on the time interval between breaths ('Once-per-Breath', in which the user presses for each breath and the application calculates the rate after 10 or 20 breaths, or after 60s). Nursing and physiotherapy students used the applications to count respiratory rates in a set of brief video recordings of children with different respiratory illnesses. Limits of agreement (compared to the same participant's standard 60-second count), intra-class correlation coefficients and standard errors of measurement were calculated to compare the reliability of the four approaches, and a usability questionnaire was completed by the participants. RESULTS: There was considerable variation in the counts, with large components of the variation related to the participants and the videos, as well as the methods. None of the methods was entirely reliable, with no limits of agreement better than -10 to +9 breaths/min. Some of the methods were superior to the others, with ICCs from 0.24 to 0.92. By ICC the Once-per-Breath 60-second count and the Once-per-Breath 20-breath count were the most consistent, better even than the 60-second count by the participants. The 10-breath approaches performed least well. Users' initial impressions were positive, with little difference between the applications found. CONCLUSIONS: This study provides evidence that applications running on simple phones can be used to count respiratory rates in children. The Once-per-Breath methods are the most reliable, outperforming the 60-second count. For children with raised respiratory rates the 20-breath version of the Once-per-Breath method is faster, so it is a more suitable option where health workers are under time pressure.