HIV: Nonchalance, Ignorance, TBAs, others threaten Nigeria’s efforts to end mother-to-child transmission

On the morning of 11 April, 2008, Rakiya Ibrahim walked into Dalhatu Specialist Hospital in Lafia, Nasarawa State, to access ante-natal services. She had gone to the hospital following advice from her pregnant neighbour on the benefits of ante-natal care for her and her unborn child.
Ms Ibrahim was already 18 weeks pregnant at the time she made the decision she later considered a life-changing one.

At the hospital, as is done for every pregnant woman, Ms Ibrahim’s blood sample was taken for regular screening.

“About 30 minutes later, a female nurse dressed in a combination of white and blue uniform called the women into her office one after the other, until it got to my turn,” Ms Ibrahim, who resides in the Angwan Gayam area of the state, narrated to this reporter in Hausa.

“After giving a lengthy preamble speech, the nurse said I have contracted a disease called HIV,” she said.

According to Ms Ibrahim, the nurse further explained the implication of living with the Human Immunodeficiency Virus (HIV) and its effect on her unborn child which by the way, was her first child.

When the child was eventually born, he tested negative for the virus.

“Receiving the news that my son Umar was not infected with the virus is probably the happiest news of my life,” she said.

Rakiya Ibrahim, her first child Umar and Sixth child, Asmau resides at Angwan Gayam area of Nasarawa stateRakiya Ibrahim, her first child Umar and Sixth child, Asmau resides at Angwan Gayam area of Nasarawa state

The reason for this happy ending is not far-fetched. She began her anti-retroviral treatment immediately after the diagnosis and also followed up at the health facility until delivery.

In the absence of intervention, Ms Ibrahim had a 15 to 45 per cent chance of passing the virus on to her child, according to the World Health Organisation (WHO).

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After Umar, Ms Ibrahim delivered five more children. Sadly, her last child, Asmau, tested positive for HIV, due to Ms Ibrahim’s actions. Of all six children, Asmau is the only one born positive for HIV and the reason for this is obvious.

While pregnant with Asmau, Ms Ibrahim shunned the health facility and opted for the help of a Traditional Birth Attendant (TBA). This means she never enjoyed pre-natal services throughout her pregnancy.

She also stopped taking her medications in the mistaken belief that she was no longer living with the virus.

“I thought the virus was no longer in my blood since I was feeling good and all my first five children were born negative,” Ms Ibrahim said.

That one wrong move by Ms Ibrahim not only put her life at risk but also jeopardised the life of little Asmau.

Pregnant women prefer TBAs

According to WHO, TBA is a person who assists a mother during childbirth and who initially acquired her skills by delivering babies herself or through an apprenticeship with other TBAs.

Before the advent of modern obstetric services, TBAs were popularly known to render services to pregnant women, especially in the African region.

With major progress made around the globe, it is anticipated that women will give birth in approved health clinics, but some women, especially those in rural communities, still patronise TBAs.

Like in many low and middle-income countries, many pregnant women in Nigeria continue to give birth at home with the help of TBAs, putting their lives and that of the child at risk. Ms Ibrahim, while carrying Asmau’s pregnancy, fits into this category.

Nonchalance as was the case when Ms Ibrahim was pregnant with Asmau is not the only reason some pregnant women prefer to use TBAs.

Deborah Yakubu, a woman living with HIV and residing in Igu, a community in Bwari, a suburb of the FCT, said she prefers the TBA in her community to health workers at the Primary Health Centre (PHC).

Ms Yakubu’s reason is that health workers most times make pregnant women feel neglected. She initially commenced ante-natal at the health facility but stopped halfway due ‘to ill-treatment’ from the nurses.

She also said it is far cheaper going to a TBA because they mostly accept wrappers or food items as a form of payment.

“It is easier to communicate with the TBA than those nurses, although I regret infecting my child with the virus,” she said.

Ms Yakubu also said at the health centres, “we are forced to make payment for different forms and antenatal services/requirements. I can’t always afford that,” she said.

Research has shown that the obsession of pregnant women with TBAs contributes majorly to increased maternal and child mortality rates. It has also frustrated the efforts to Eliminate Mother to Child Transmission of HIV (EMTCT) in Nigeria.

Despite proven medical interventions in place to prevent a mother from transmitting the virus to her child, many children are still born with HIV every year.

“A large number of these babies contracted the virus because their mothers failed to access health facilities for ante-natal care,” the National Prevention of Mother to Child Transmission (PMTCT) lead at the National AIDS and STIs Control Programme (NASCP), Gbenga Ijaodola, said.

The National Prevention of Mother to Child Transmission (PMTCT) lead at the National AIDS and STIs Control Programme (NASCP), Gbenga IjaodolaThe National Prevention of Mother to Child Transmission (PMTCT) lead at the National AIDS and STIs Control Programme (NASCP), Gbenga Ijaodola

Mr Ijaodola said some pregnant women opt to deliver at home or other birthing locations instead of approved health centres.

He said data from the 2018 National Demographic Health Survey (NDHS) indicates that a larger percentage of pregnant women still patronise TBAs.

He said this is due to some factors, which include socioeconomic status, long distances to the health facility, and the current economic situation in Nigeria.

“The preference of TBAs by pregnant women is mostly based on information they got from their grandmothers, mothers and other family or community members. It’s like a tradition,” he said.

However, a TBA called Mama Aisha residing in the Angwan Gayam area of Nasarawa State said women in her community prefer her for child delivery because of the connection she has built over time.

Mama Aisha said she is considered a great help to the community due to the number of children she has successfully delivered.

“The intention is not to harm any mother or child but just to help them deliver safely,” Mama Aisha said in Hausa. Helping pregnant women deliver their children is what Mama Aisha knows how to do best. But she is ignorant of HIV or any implication it may have on the child.

One of many

Four years old Asmau is one of the millions of children born with HIV globally every year. At least one child globally was infected with HIV every two minutes in 2020, according to the United Nations Children’s Fund (UNICEF).

Data from UNICEF also shows that 120,000 children died from AIDS-related diseases in 2020, or one child every five minutes.

In Africa’s most populous country, Nigeria, many children are born with the virus every year. This is despite various programmes and interventions in place to prevent MTCT.

A report by the National AIDS and STIs Control Programme (NASCP) indicates that 3,409 babies born in Nigeria in the past four years tested positive for HIV.

A UNICEF report also shows that at least one child between the ages of 0-9 years was infected with HIV every 30 minutes in 2020. This means that about 20,695 children in Nigeria were newly infected with HIV in 2020.

About 30 per cent of AIDS-related deaths in 2020 also occurred in children, according to the report.

MTCT is one of the many challenges to Nigeria’s efforts toward ending the HIV epidemic.

Nigeria contributes the largest burden of babies born with HIV in the world. In 2016 alone, the country accounted for 37,000 of the world’s 160,000 new cases of babies born with HIV.

“The statistics don’t lie, the numbers keep increasing,” Mr Ijaodola said.

Born with the virus

Like Asmau, six years old Hajara was also born with the virus.

Hajara’s mother, Maimuna Adamu, said she never visited the hospital throughout her pregnancy. making her ignorant of the implication of her status on the child.

Maimuna Adamu and her daughter Hajara, resides in Angwan Alhamdu, Nasarawa eggon in Nasarawa stateMaimuna Adamu and her daughter Hajara, resides in Angwan Alhamdu, Nasarawa eggon in Nasarawa state

Ms Adamu, who resides in Angwan Alhamdu, Nasarawa eggon in Nasarawa State, said she delivered Hajara at home with the help of a TBA popularly called ‘Mama’ in the community.

She, however, regrets her decision of avoiding the health facility. “Whenever I remember my child is infected with HIV because of me, I cry,” she said in Hausa.

More than one million women globally infected with HIV are estimated to deliver babies without professional help each year. Asmau and Hajara’s mothers contribute to this figure.

Estimates from the Joint United Nations Programme on HIV/AIDS also show that 21.58 per cent of HIV-infected pregnant Nigerian women transmitted the virus to their children in 2016 because they failed to seek prenatal services.

The assistant director of NASCP, Jamiyu Ganiyu, said MTCT is preventable through tracking the delivery of a proven set of health interventions but nothing can be done when pregnant women fail to present at the health facility.

Mr Ganiyu said the preference for TBA is a major challenge as more than 50 per cent of women who attend antenatal care end up delivering at home.

He said most pregnant women opt for TBAs majorly due to the high cost of healthcare services and distance to health facilities.

Integrating TBAs

Although TBAs play an important role in the provision of care to pregnant women, especially in rural communities, they are barely recognised by the formal health sector.

Health experts have repeatedly advocated the integration of TBAs into health services by providing them with HIV counselling and other training.

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“Engaging these women in activities lined up to fight HIV will ensure the country records a high success rate in PMTCT,” Wale Akinboboye, a public health expert, said.

Mr Akinboboye explained that TBAs are described as unskilled individuals because they are yet to receive a form of training to carry out certain procedures.

He said their presence and activities in communities cannot be overlooked as many communities in Nigeria have the tradition of using TBAs.

He said TBAs have a large clientele base and better access to pregnant women in rural communities. “This is because they are trusted by pregnant women in the community they serve.

“It will be a safe option integrating them into the PMTCT programmes,” he said.

The public health expert explained that some African countries are already engaging TBAs and recording success stories.

“The government must recognise the role of TBAs, identify and register the TBAs, educate and train the TBAs on HIV/AIDS, PMTCT and encourage them to always make referrals to PHCs for HIV counselling and make testing a part of their routine,” he said.

Mr Akinboboye said the government must also encourage TBAs by providing incentives for every referral made to health facilities.

“This will empower them to provide basic ante-natal care and refer those at high-risk pregnancies to the health facility,” he said.

Mr Akinboboye ultimately believes that getting women to attend antenatal clinics in established health facilities will be key to stopping MTCT in Nigeria.

The Chief Programme officer, Community Prevention and care services of the National Agency for the Control of AIDS (NACA), Babayemi Olakunde, said there are ongoing efforts to identify TBAs and the numbers of women that visit them within a period of time.

Mr Olakunde said this will ensure the government engages them strategically to meet the needs of pregnant women.

“We are working on a framework that can guide the engagements with TBAs so we can bring them on board to provide PMTCT services,” he said.

Only if the TBAs that delivered Asmau and Hajara had background knowledge on HIV and its implications, they would have been HIV-free today.

But it’s not too late to prevent more children from being born with HIV, Mr Akinboboye, the public health expert, said.

Low awareness, Access to PMTCT services

PMTCT programmes have focused primarily on preventing transmission from an HIV-infected woman to her infant. But not much attention has been given to improving the knowledge and awareness of HIV transmission and prevention among pregnant women, especially in rural communities.

Around the globe, persons living with HIV, including pregnant women, are treated with daily combinations of powerful ARVs.

When treatment suppresses the virus in pregnant women, their newborn babies also receive ARVs for six weeks, which makes transmission rates drop to less than one per cent. This method has worked in many developed countries as the MTCT rate has become low.

But in Nigeria, cases are on the increase because the regimen cannot be given if pregnant women do not know their status.

Mr Ijaodola said the majority of pregnant women do not know their HIV status and those who are aware, do not know the virus can be transmitted to the child.

He said some women are also ignorant of the importance of ante-natal care to them and their children.

“These are the major issues in eliminating mother-to-child transmission,” he said.

According to the 2018 NDHS, only about half of the population of women know that HIV can be transmitted during pregnancy, labour/delivery, or breastfeeding.

And only a little more than half of women know that the risk can be averted by the mother taking special drugs, the report stated.

If Ms Adamu had had access to professional health services during her pregnancy, Hajara would have been saved from contracting the virus.

She also contributes to the percentage of pregnant women in Nigeria who are unable to access PMTCT services.

“We are working to engage various key players at the community level to ensure they provide the right information for all women of reproductive age,” Mr Ijaodola said.

During a media dialogue on PMTCT held in Calabar, Mr Ijaodola said some stakeholders are working with the ministry of health to ensure women present their babies at facilities to undergo HIV testing at birth, and after six weeks for a retest of both positive and negative newborns.

He said the government is highly interested in the global drive for the elimination of Mother-to-Child Transmission.

He noted that this is in line with the global target which mandates that 95 per cent of all HIV-positive pregnant and breastfeeding mothers receive antiretroviral therapy; 95 per cent of all HIV-exposed infants receive antiretroviral prophylaxis and 95 per cent of all HIV-exposed infants have early infant diagnosis within 6-8 weeks of birth.

Mr Ijaodola said to achieve this set target, more awareness is needed among all populations and with special attention to pregnant women.

“What determines the health of every nation is how they take care of their women and children. And the joy of every mother is that her baby comes out clean devoid of any infection, HIV inclusive,” he said.

The Lafia state coordinator of Association of Women living with HIV/AIDs in Nigeria (ASWHAN), Ruth YakubuThe Lafia state coordinator of Association of Women living with HIV/AIDs in Nigeria (ASWHAN), Ruth Yakubu

The Lafia state coordinator of the Association of Women Living with HIV/AIDs in Nigeria (ASWHAN), Ruth Yakubu, said there are ongoing awareness exercises in Nasarawa State to highlight the importance of attending antenatal during pregnancy.

Ms Yakubu said this will ensure women know their HIV status and also make effort to protect the child.

If these awareness creations are effective, more Nigerian children will be born free of HIV.

NOTE: Names of persons Living with HIV were changed to protect their identities.

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