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1.1  Background Information

Over 78 million people have been infected with HIV since the start of the epidemic in the early 1980s. [1] In 2012, AIDS-related illnesses were the 6th leading cause of death worldwide. [2] HIV statistics for the end of 2013 indicate that around 35 million people are currently living with HIV worldwide, 38 percent less than in 2001. [3] In the same year, around 2.1 million people became infected with HIV and 1.5 million died of AIDS-related illnesses. HIV and AIDS are found in all parts of the world; however some areas are more affected than others.

Globally, at the end of 2011, 34.0 million (31.4 million-35.9 million) people were living with HIV, including 3.4 million (3,000,000-3,800,000) children less than 15 years of age. [4] In that same year, 330,000 {280,000-390,000] children acquired human immunodeficiency virus (HIV) infection. [5] This represents a 43% decline since 2003 and a 24% drop since 2009. [5] In 2010, about 250,000 (220,000-290,000) children, aged less than 15 years, died from acquired immunodeficiency disease syndrome (AIDS) related causes. [4] Sub-Saharan Africa continues to bear the burden of the HIV pandemic, with Nigeria as one of the countries with the highest burdens of paediatric AIDS. [5] In 2011, Nigeria had an estimated 440,000 children, less than 15 years, living with HIV. [5]

So, the emergence of the Human Immune Deficiency Virus (HIV) infection has increased the already heavy burden of disease and death among women and children in low and middle-income countries. [6] Pregnant women living with HIV are at high risk of transmitting HIV to their infants during pregnancy, birth or through breastfeeding and without any interventions, between 20% and 45% of infants may become infected with an estimated risk of 5- 10% during pregnancy, 10-20% during labour and delivery, and 5-20% through breastfeeding. Following the above developments, Mother-to-child transmission (MTCT) accounts for 90% of HIV infections in children under the age of 15 years. [4] Prevention of mother-to-child transmission (PMTCT) has become a key public health priority in Nigeria, a country faced with 56,681 annual HIV-positive births and


more than 210,000 women living with HIV. [7] Prevention of mother to child transmission (PMTCT) of HIV is a global interventional program initiated by the United Nations Organization to protect the children of the world from the scourge of the HIV pandemic.


The national PMTCT programme in Nigeria commenced in 2002 with supports from the World Health Organisation (WHO) and The United Nations Children's Fund (UNICEF). [9] An estimated 430,000 children were newly infected with HIV in 2008, over 90% of them through mother-to-child transmission (MTCT). Without treatment, about half of these infected children will die before their second birthday. Without intervention, the risk of MTCT ranges from 20% to 45%. With specific interventions in non-breastfeeding populations, the risk of MTCT can be reduced to less than 2%, and to 5% or less in breastfeeding populations. In 2008, MTCT of HIV was reported as the most common route of transmission among the paediatric age group in the National Hospital Abuja. [10] The importance of PMTCT in reducing paediatric morbidity and mortality cannot therefore, be overemphasised.

Nigeria was adjudged the country with the highest burden of MTCT in the world

[11] ; 210,000 HIV positive women are pregnant every year. Contributing to that high MTCT burden in Nigeria is high population size, HIV prevalence in general population and among pregnant women. More than 3.6 million adults and children were estimated to be living with HIV in 2005 and the 2010 national sentinel survey report estimated the HIV prevalence among pregnant women attending antenatal care services (ANC) at 4.1%.

Owhonola stated that out of 2.1 million children living with HIV globally in 2008, Nigeria accounted for 220,000 or over 10 percent. Most of these children were infected through MTCT. Pregnant women across the developing country must be tested for HIV.

[12]Prevention of mother to child transmission of HIV/AID programmes must be scaled up to include all mothers and babies no matter how impoverished or geographically isolated they may be, and where prevention of mother to child HIV transmission is accessible, it must be delivered consistently and with the most effective drugs available. The best chance for a child to survive is to have healthy parents. Medical, psychological and social support should thus be improved for infected mothers and other families. [13] There is

[13]            [20, 21]

[14]           [17-19]


relatively low antenatal attendance – only 58% of pregnant women attend at least one antenatal clinic visit and only 35% deliver in health facilities. [11,14]

The initial target date of 2010 was reviewed with a new dateline and targets set. These were, to provide access to at least 90% of all pregnant women to quality HIV counselling and testing by 2015, to provide access to at least 90% of all HIV positive pregnant women to more efficacious prophylaxis by 2015 and to provide access to at least 90% of HIV exposed infants to more efficacious ARV prophylaxis by 2015. Other goals were to provide access to at least 90% of HIV positive pregnant women to quality infant feeding counselling by 2015 and to provide access to at least 90% of all HIV exposed infants to early infant diagnosis services by 2015.

There are about 1,216 PMTCT service points across the Nigeria presently. [15] In 2009, 18.7% of pregnant women living with HIV received antiretroviral (ARV) agents to reduce the risk of MTCT, showing a significant increase in PMTCT coverage from 5.3% in 2007, although the coverage for ARV prophylaxis during the breastfeeding period has still remained low. [16] Providing ARV prophylaxis to pregnant women living with HIV has prevented more than 350,000 children from acquiring HIV infection since 1995 and resulted in a 24% decline in newly infected children since 2004. [4]

Historically, the discovery of human immunodeficiency virus (HIV) infection in 1981 and its subsequent emergence as a leading global epidemic are well documented. HIV is transmitted from an infected person to an uninfected person by two major

modes, namely, horizontal transmission and vertical transmission (or mother to child

transmission (MTCT)).

Horizontal transmission refers to transmission between two individuals who exist separately. It covers the commonly known routes of transmission in the adult such as through unprotected sex with an infected person, transfusion with infected blood and blood products, sharing of contaminated needles and other contaminated instruments, among others. This mode accounts for 90% of all HIV infections and is the sole mode of infection in the adults.

[22, 23]


Vertical (or mother to child) transmission refers to the situation where an infant of an HIV-infected mother acquires the HIV infection from the mother at one or more of the following stages: Transplacentally in the uterus during pregnancy, perinatally during

the process of labour and delivery, and postnatally during breastfeeding.                                                 Strategies

to reduce MTCT focus on these periods of exposure and include the use of ARVs, caesarean section before onset of labour or rupture of membranes, and complete avoidance of breastfeeding. [16] These combined interventions when followed effectively, reduce the risk of MTCT to as low as 1-2%. [24] Without intervention 30-45% of all infants born to HIV positive mothers will be infected and 10-20% will be infected through breastfeeding. [25] Early infant diagnosis (EID) programs can be used to evaluate the impact of PMTCT, as well as substantially improve the survival rates. [24]

“Prevention” refers to helping people avoid getting sick or identifying diseases early so treatment can begin. There are two types of preventive services:

Clinical preventive services are immunizations, disease screenings and behavioural counselling interventions delivered to individuals in clinical settings. These services are designed to prevent disease or to detect conditions that are not yet apparent to the patient, allowing for early treatment. [26]

Community preventive services are policies, programs and services that aim to improve the health of the entire population or specific sub populations. Examples of community preventive services are programs that: increase the amount of time students spend in primary education (PE) class, provide diabetes self-management education in community gathering places or increase the price of harmful products, such as tobacco.

Therefore, PMTCT of HIV and AIDS is the act of stopping a mother from transmitting or passing HIV and AIDS to her child during pregnancy, labour, delivery and breastfeeding. In response to the MTCT threat and in line with the global declaration of commitment to universal access to HIV prevention, treatment, care, and support and global efforts to reduce paediatric HIV infections, the Nigerian National PMTCT program was launched in 2002 employing a comprehensive four-pronged approach:


1.      Primary prevention of HIV infection among women of reproductive age group and their partners,

2.       Prevention of unintended pregnancies among women infected with HIV,

3.      Prevention of HIV transmission from women infected with HIV to their infants and

4.      Provision of treatment, care, and support to women infected with HIV, their infants and their families.

Global HIV/AIDS Initiative Nigeria (GHAIN) supported all aspects of the “Four-Prong” approach using evidence-based strategies. Primary prevention was a core program area in GHAIN, featuring abstinence and being faithful messages, condom use, HIV testing and counselling (HTC). Offer of FP services to prevent unintended pregnancies among women infected with HIV as well as prevention of prenatal transmission services were integrated within the Maternal and Child Health (MCH) services. Women infected with HIV, their infants and their families’ accessed treatment, care and support through integration, referral and linkages to care and treatment services.

The approach for primary prevention included advocacy, community mobilization and dialogue, focused group discussion, electronic media intervention, distribution of related media material and peer education. Guided by the principle of integrating PMTCT into MCH services, GHAIN articulated its support around increasing access to and quality of PMTCT. Existing MCH structure and human resources constituted the platform of GHAIN support to PMTCT. To be selected as a PMTCT site, a health facility has to have a pre-existing and functional ANC, maternity, child welfare and pharmacy services pre-existing.

Improving Access to PMTCT MCH service delivery points were carefully selected, taking into account the PMTCT roll out provision in the national and state strategic plans, the patient load and the state specific HIV prevalence when available. The phased support to health facilities was agreed with state health authorities. Facilities with high ANC and maternity patient load were prioritized. GHAIN pioneered the implementation of PMTCT in secondary level hospitals in Nigeria and later supported decentralization to primary health centres and in communities. Upon selection of health facilities, GHAIN


strengthened the capacity to deliver existing routine MCH services and to add on PMTCT interventions. [27]

The mother-to-child transmission (MTCT) of HIV, however, refers to the transmission of HIV from an HIV-positive woman to her child during pregnancy, labour, delivery or breastfeeding. MTCT is by far the most common way that children become infected with HIV (90 percent). [28]

Without treatment, the likelihood of HIV passing from mother-to-child is 15-45 percent. However, antiretroviral treatment (ART) and other effective interventions like; voluntary counselling, (VC), HIV testing, Obstetric intervention or caesarean section (CS) and safe infant breast feeding; for the prevention of mother-to-child transmission (PMTCT) can reduce this risk to below 5 percent. [29]

Effective PMTCT programmes require women and their infants to receive a cascade of interventions including uptake of antenatal services and HIV testing during pregnancy, use of antiretroviral treatment (ART) by pregnant women living with HIV, safe childbirth practices and appropriate infant feeding, uptake of infant HIV testing and other post-natal healthcare services. [30]

The World Health Organisation (WHO) promotes a comprehensive approach to

PMTCT programmes which includes:

§  Prevention of new HIV infections among women of childbearing age

§  Preventing unintended pregnancies among women living with HIV

§  Preventing HIV transmission from a woman living with HIV to her baby

§  Providing appropriate treatment, care and support to mothers living with HIV and their children and families. [31]

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