Increasing PMTCT uptake through integrated faith-based activities
Authors: Benjamin H Chi, Elizabeth M Stringer
Journal: The Lancet Global Health (2015)

Scientific discovery and forward-thinking health policies have fuelled efforts to expand prevention of mother-to-child HIV transmission (PMTCT) services across sub-Saharan Africa.1Chi BH Stringer JS Moodley D Antiretroviral drug regimens to prevent mother-to-child transmission of HIV: a review of scientific, program, and policy advances for sub-saharan africa.Curr HIV/AIDS Rep. 2013; 10: 124-133Crossref PubMed Scopus (49) Google Scholar However, nearly a third of HIV-infected women still do not start antiretroviral therapy (ART) during pregnancy,2Joint United Nations Programme on HIV/AIDS2014 Progress Report on the Global Plan Towards the Elimination of New HIV Infections Among Children by 2015 and Keeping Their Mothers Alive.http://www.unaids.org/sites/default/files/media_asset/JC2385_ProgressReportGlobalPlan_en_0.pdfGoogle Scholar thus exposing their newborns to an unacceptably high risk of HIV infection. If we are to eliminate paediatric HIV and reach the ambitious 90-90-90 goals set forth by the United Nations,3UNAIDS90–90–90 - An ambitious treatment target to help end the AIDS epidemic.http://www.unaids.org/en/resources/documents/2014/90-90-90Google Scholar new strategies for expanding access are urgently needed. In this issue of The Lancet Global Health, Echezona Ezeanolue and colleagues4Ezeanolue EE Obiefune MC Ezeanolue CO et al.Effect of a congregation-based intervention on uptake of HIV testing and linkage to care in pregnant women in Nigeria (Baby Shower): a cluster randomised trial.Lancet Glob Health. 2015; 3: e692-e700Summary Full Text Full Text PDF Scopus (52) Google Scholar describe the results of the Baby Shower Trial, a large cluster-randomised study of congregation-based approaches to increase PMTCT uptake. The primary intervention occurred at a monthly baby shower (a reception held in honour of a pregnant women where she plays pregnancy-related games and receives gifts from friends, usually, items she would need during delivery or immediately after birth)sponsored by each participating church. All women received basic health education and a Mama Pack of essential clinical supplies. Women at intervention sites were additionally offered antenatal screening on-site (including for HIV, haemoglobin, malaria, sickle-cell genotype, hepatitis B, and syphilis), locally packaged as part of the Healthy Beginning Initiative. By contrast, women in the control arm sites were encouraged to access antenatal care at local health facilities for routine screening. The primary outcome was HIV testing, confirmed by record review at the participant's antenatal clinic in the control arm and by results at the baby shower in the intervention arm. In HIV-infected women, the initiation of ART was also included as a secondary outcome measure. The results of the study are highly encouraging. HIV testing rates were significantly higher in the intervention arm than in the control arm (92% vs 55%). In multivariable models, the likelihood of not receiving an HIV test was more than 11-fold greater (adjusted odds ratio 11·2, 95% CI 8·8–14·3; p<0·0001) in the control arm. The overall prevalence of HIV in the 3002 study participants was only 2%, lower than regional estimates of 4–8%. Despite the smaller-than-anticipated number of HIV-positive women, significant increases in linkage to HIV care and initiation of ART were noted at intervention sites. As in many places worldwide, religious institutions are highly influential across Africa, and religious leaders command a powerful voice in the fight against AIDS. Faith-based organisations have been integral to the expansion of HIV services across the region, but the Baby Shower Trial is among the first to show how health services integrated into church-sponsored activities can produce measurable increases in PMTCT uptake. This study was well designed and showed promising results—but can its success be replicated elsewhere? Nigeria ranked first among more than 50 countries in church attendance,5Swanbrow D Study of worldwide rates of religiosity, church attendance.http://ns.umich.edu/Releases/1997/Dec97/chr121097a.htmlDate: 1997Google Scholar a characteristic that probably distinguishes it from many settings. The Healthy Beginning Initiative leveraged this substantial church infrastructure to integrate HIV testing and promote specific health behaviours around PMTCT. How the congregation-based intervention would perform in settings where a lower proportion of the population attends church regularly or where HIV prevalence is higher is not known. Plans are already underway to adapt and extend the initiative to mosques in northern Nigeria and Hindu temples in India. Such pilot programmes are needed to confirm the intervention's effectiveness and to help inform broader implementation efforts. By design, the intervention was available only to congregation members in participating churches. When compared with regional HIV prevalence estimates, study participants seemed to be at lower risk of HIV infection. A low perception of personal HIV risk could increase a woman's willingness to undergo HIV testing,6Thierman S Chi BH Levy JW Sinkala M Goldenberg RL Stringer JS Individual-level predictors for HIV testing among antenatal attendees in Lusaka, Zambia.Am J Med Sci. 2006; 332: 13-17Summary Full Text Full Text PDF PubMed Scopus (16) Google Scholar which might partly explain the high testing rates reported with the intervention. Programme adaptions that target high-risk groups (eg, adolescents, commercial sex workers, and intravenous drug users) deserve further investigation. Congregation-based strategies could play an important part in their identification and engagement. The strong emphasis on male involvement in the Healthy Beginning Initiative could have important benefits, both directly and indirectly. The family-centred approach provides an important entry point for male partners to be tested for HIV as well and, if diagnosed, to access long-term care and treatment services. Additionally, couples-based HIV testing has been associated with increased levels of maternal engagement in PMTCT and with improved infant outcomes.7Farquhar C Kiarie JN Richardson BA et al.Antenatal couple counseling increases uptake of interventions to prevent HIV-1 transmission.J Acquir Immune Defic Syndr. 2004; 37: 1620-1626Crossref PubMed Scopus (327) Google Scholar, 8Aluisio A Richardson BA Bosire R John-Stewart G Mbori-Ngacha D Farquhar C Male antenatal attendance and HIV testing are associated with decreased infant HIV infection and increased HIV-free survival.J Acquir Immune Defic Syndr. 2011; 56: 76-82Crossref PubMed Scopus (174) Google Scholar Such collateral benefits of the congregation-based intervention should be thoroughly explored. Finally, with the introduction of lifelong ART for all HIV-infected pregnant and breastfeeding women, programmes should identify and address key gaps along an increasingly complex PMTCT cascade.9Stringer EM Chi BH Chintu N et al.Monitoring effectiveness of programmes to prevent mother-to-child HIV transmission in lower-income countries.Bull World Health Organ. 2008; 86: 57-62Crossref PubMed Scopus (106) Google Scholar HIV testing and ART initiation represent crucial steps along this continuum, but they are only the beginning. Studies show considerable attrition after ART initiation and then again after delivery.10Tenthani L Haas AD Tweya H et al.Retention in care under universal antiretroviral therapy for HIV-infected pregnant and breastfeeding women (‘Option B+’) in Malawi.AIDS. 2014; 28: 589-598Crossref PubMed Scopus (279) Google Scholar, 11Nachega JB Uthman OA Anderson J et al.Adherence to antiretroviral therapy during and after pregnancy in low-income, middle-income, and high-income countries: a systematic review and meta-analysis.AIDS. 2012; 26: 2039-2052Crossref PubMed Scopus (327) Google Scholar Without effective interventions, many of the purported benefits for PMTCT and maternal health will not be realised. The Healthy Beginning Initiative provides an evidence-based blueprint for how churches and health clinics can collaborate to produce measurable programmatic benefits. By extending such strategies from HIV testing to long-term adherence and retention, these programmes can further deliver on their promise and meaningfully contribute to the elimination of paediatric HIV in the region. We declare no competing interests. Effect of a congregation-based intervention on uptake of HIV testing and linkage to care in pregnant women in Nigeria (Baby Shower): a cluster randomised trialCulturally adapted, community-based programmes such as the Healthy Beginning Initiative can be effective in increasing HIV screening in pregnant women in resource-limited settings. Full-Text PDF Open Access