Women speak out

By Sola Ogundipe

At most PMTCT sites in Nigeria, family planning services are offered as part of the PMTCT programme centred on antenatal care and maternal and child health services. Part of the package is family planning counselling and information on contraceptive methods.

Generally, family planning counselling and services are part of PMTCT routine care services for all pregnant women, irrespective of their HIV status clients.

At the PMTCT sites visited in Lagos, family planning is clearly articulated as an important strategy to reduce mother-to-child transmission. Healthcare providers explained that opportunities are not missed to provide clients with family planning counselling.

Most of the women encountered by Good Health Weekly said they were using injectable contraceptives. From the findings, women that are living with HIV are just as likely to use family planning methods as the women that are HIV negative.

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One of the big challenges faced by Nigerian women for the uptake and consistent use of modern family planning methods is partner consent. Even for female-oriented contraceptive methods such as the female condom, diaphragm, or vaginal gel, some women still need their male partners’ approval.

Partner opposition to family planning and contraceptive use is increasing the unmet need for contraception either through the prohibition of, or negative attitudes towards, women using any modern contraceptive method.

For women that are living with HIV, the situation may be appreciably worse as negotiating family planning methods and the use of contraceptives is often more challenging because the women are more disadvantaged.

Experts say preventing unintended pregnancies among women living with, or at risk of contracting HIV is a key component of the global HIV prevention strategy.

In Nigeria, it is well known that the use of modern contraception is an effective way of preventing unintended pregnancy. However, findings show that not all women that are in need of contraception have access to quality family planning services.

Uptake of contraceptive methods by women generally has been shown to be dependent on factors such as availability of contraceptive methods, fear of side effects, low perception of pregnancy risk, and partner opposition, among others.

Many Nigerian women that are of reproductive age and are living with HIV say they are not intending to conceive soon after giving birth to their last child.

From findings, women that are living with HIV and want to have more children are likely to desire to have reliable family planning methods as much as women that are HIV-negative.

Some of these women who spoke to Good Health Weekly said their position is based on the desire for adequate spacing of their children and also to promote their own health.

When asked when she planned to get pregnant and have another child, Funke Adaramola, a 34-year-old Lagos housewife expressed mixed feelings.

Although she was affirmative that she desired to space the births of her children by a minimum of two or three years, she noted that the choice wasn’t really hers to make.

A few days earlier, Funke who is living with HIV, had just been delivered of her first child – a healthy 2.8 kilograms baby girl after a successful Cesarean Section in a public hospital. She, however, said it was her husband that had the final say over the matter.

“I am not on family planning yet and I don’t intend to adopt any method except my husband says I should, ” she declared.

Another woman that is living with HIV, Gbemi Olatunde, who is 28 and a mother of two said she planned to get pregnant again as soon as her second child clocked three.

“I desire to have another child, but I want to wait a bit so that I am stronger and my baby is at least three years old but I am not on any family planning method. My husband doesn’t agree that I should use it because he wants me to quickly have another child, but . HIV adversely affected their desire to have further children.

For 32-year-old Joy who said she is okay after having three children, family planning is a lifesaver. The married mother of three said as a person living with HIV, she is convinced that having too many children could jeopardise her health.

“I don’t want more children, I am comfortable with the ones I have. Being a person living with HIV, if I go on giving birth I might get sicker.  When you are HIV-positive and pregnant you lose strength. My husband and I have discussed it so I have adopted a family planning method.

 “I am healthy enough to give birth to more children, but we have embraced family planning so that I don’t get pregnant and get more children unintentionally, ” she explained.

Male involvement in reproductive health services has long been accepted as key to family acceptance and adherence and may play important role in the uptake of family planning/HIV integrated services.

In Nigeria, men are generally favoured as the decision-makers in the household and family size and reproductive health decisions are often made mainly by the male partners.

As much as the typical Nigerian man tends to want a large family size for various reasons, but experts say recognising the role of gender in reproductive health service utilization is crucial in the Nigerian context as it can promote improved reproductive health outcomes for both men and women.

Dr Abiola Davies, UNICEF focal person for PMTCT in Nigeria says a woman that is living with HIV can transmit the virus to her baby during pregnancy, childbirth, or breastfeeding. She adds that if such a woman is given treatment with antiretroviral therapy, ART, it can help to prevent transmission of HIV to her baby and protect her own health.

According to Davies, there are several steps a woman can take to reduce the risk of transmitting HIV to her baby

“The first thing she should do is to get tested as soon as possible to know her status. If she has HIV, the sooner she starts treatment the better—for her own health and her baby’s health and to prevent transmitting HIV to her partner.

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“If she doesn’t have HIV, but if either she or her  partner engages in behaviour that puts her at risk for HIV, she should get tested again in her third trimester and she should also encourage her partner to get tested for HIV.”

The World Health Organisation, WHO says that women that are considering getting pregnant, but have partners who are living with HIV should to be given pre-exposure prophylaxis or PrEP, which may be an option to help protect the woman and her baby from getting HIV while she is trying to get pregnant, during pregnancy, or while breastfeeding.

“If you have HIV and take HIV medicine as prescribed throughout pregnancy and childbirth, and give HIV medicine to your baby for the recommended 4 to 6 weeks after giving birth, your risk of transmitting HIV to your baby can become lower than 1 per cent.”

Experts proffer a way forward to say an effective way to improve the coverage and reach of services is through the integration of family planning services with other health services. The integration of family planning services into HIV services is one such way that has the potential to reach both men and women with information on  family planning and HIV services at the same time—increasing

However, unwanted or unplanned pregnancies among HIV positive women are not uncommon. While the majority of the PMTCT efforts have focused on the delivery of antiretroviral therapy (ART) to mothers and their infants, modelling efforts have shown that preventing unintended pregnancies through the provision of family planning services is more cost-effective compared to ART alone.

According to UNAIDS, an estimated 20-30 per cent of HIV infections in newborns will be averted if unintended pregnancies are prevented among women living with HIV.

Experts argue that the integration of family planning into HIV services increases access to information and services on modern contraception. They point out that an increase in access to health services will translate to the uptake of these services, but in most cases, this is not the case.

Improving women’s capability to use modern contraception may result in decreased unwanted fertility, decrease maternal deaths from unsafe abortions, and prevention of HIV incidence especially through heterosexual and vertical transmission.

With the second-largest burden of maternal to child transmission of HIV (MTCT) in the world at a rate of 30 per cent as well as the largest burden of paediatric HIV infection globally at the rate of 10 per cent, there is cause for concern over the HIV/AIDS elimination goal in Nigeria.

According to UNICEF, the effective prevention of mother to child transmission of HIV (PMTCT) can drastically reduce the paediatric HIV infection to 2 per cent, but findings show gaps in the PMTCT services in Nigeria, where out of estimated 9.2 million pregnancies, only about 3 million received HIV counselling and testing (HCT). The unmet needs for PMTCT of HIV services in Nigeria.

There are unmet needs for PMTCT of HIV services in Nigeria due to challenges like low HCT/PMTCT service uptake low service delivery facilities, and low antenatal services among others.

 The National Agency for the Control of AIDS, NACA, says there are over 6,300  PMTCT sites nationwide. 

The national PMTCT programme was introduced in 2001 in Nigeria with the overall goal of contributing towards the reduction of HIV and AIDS incidences.

According to the National HIV/AIDS Strategic plan 2017-2021, the goal is to ensure at least 95 per cent of all HIV-positive pregnant women and HIV-exposed infants have access to effective antiretroviral (ARV) prophylaxis by end of 2021.  It also aimed towards ensuring at least 80 per cent of HIV positive pregnant women have access to quality infant feeding counselling and 95 per cent HIV exposed infants have access to Early Infant Diagnosis.

In the views of the NACA Director-General, Dr Sani Aliyu: “Through the PMTCT intervention, prevention of HIV from mother to child has definitely increased, however, we still have a large chunk of women who do not go to primary health care facilities to deliver. “

Preventing unintended pregnancy among HIV-positive women through family planning services is one of the four cornerstones of a comprehensive programme for the prevention of mother-to-child HIV transmission (PMTCT) in Nigeria.

The World Health Organisation says that a moderate reduction in the number of pregnancies among HIV-infected women would yield a reduction equivalent to the number of infections averted among infants of HIV-positive pregnant women.

A significant proportion of these women receive the full package of PMTCT interventions that include HIV counseling and testing to support safer infant feeding practices.

Reducing unintended pregnancies among HIV-positive women through family planning also reduces the number of children potentially orphaned when parents die of AIDS-related illnesses. It also reduces HIV-positive women’s vulnerability to morbidity and mortality related to pregnancy and lactation.

Provision of family planning services for all pregnant women irrespective of their HIV status helps to safeguard their health by enabling them to space the birth of their children.

Ultimately, the availability of HIV/AIDS Counseling and Testing (HCT) services and integrated PMTCT programmes address family planning, and vice versa.

Nigeria introduced efforts towards preventing mother-to-child transmission of HIV, several years ago, but despite significant progress in reducing new HIV infections among children, the country is not preventing or eliminating HIV infection in children fast enough.

Between 2010 and 2020, there was a massive scale-up of HCT and dedicated PMTCT sites in Nigeria from less than 700 to over 8,000.

The prevention and elimination of Mother-to-child Transmission HIV programmes, have provided antiretroviral treatment and other forms of HCT services to pregnant women living with HIV to stop their infants from acquiring the virus.

During the period, more pregnant women received counselling and testing even as more HIV positive women were placed on treatment and antiretroviral drugs

However, the reduction has not been fast enough to meet up with global targets towards the elimination of new HIV infections among children.

Findings show that while Nigeria has advanced in HIV prevention and elimination,  it is not on track to meet the Global Plan target of reducing mother-to-child transmission by 90 per cent.

The gaps in prevention strategies include high transmission rates among women of reproductive age (15-49), widespread unmet need for family planning, lack of access to antiretroviral medicines to prevent mother-to-child transmission, and high treatment drop-out rates among women who are pregnant and breastfeeding.

Good Health Weekly gathered many more pregnant women living with HIV  need to be accessing  PMTCT services during antenatal care.

In the view of UNICEF HIV/AIDS Specialist, Dr. Abiola Davies, HIV can be transmitted from an HIV-positive woman to her child during pregnancy, childbirth, and breastfeeding.

“Mother-to-child transmission, also known as vertical transmission, accounts for the vast majority of new infections in children.”

Davies said without intervention, the likelihood of HIV passing from mother to child is 15-45 per cent, but with antiretroviral therapy, ART, family planning/contraception, and other effective interventions the risk drops to below five per cent.

Davies noted that elimination of HIV is desirable as a reduction of transmission to low levels such that it no longer constitutes a public health problem.

Family planning is one of the most important PMTCT measures. When women living with HIV are supported to plan when they do and do not have children, the number of children being born with HIV reduces. HIV-positive women are also at greater risk of dying from pregnancy-related complications than women who are not living with HIV.

Integrating family planning services into HIV services has been one approach to making both more accessible to women and couples living with HIV, and significant progress has been made in the past decade. In 2017, a systematic review of the evidence found overall integration of family planning into HIV care and treatment programmes with modern methods including contraceptive use and knowledge among women living with HIV. However, it found the difference it made in meeting unmet need for family planning was more limited, with the level of need extremely high, even at the integrated sites.

Contraception for PMTCT The potential contribution of family planning and contraception in preventing HIV-positive births is well established.

From studies, even modest decreases in the number of pregnancies to HIV-positive women—ranging from 6 percent to 35 percent— could avert HIV-positive births at the same rates as the use of antiretrovirals for PMTCT.

Family planning and HIV integration is an important strategy for addressing the reproductive health rights and needs of women living with and at risk of HIV.

 Many women are simultaneously at risk for both unintended pregnancy and HIV infection and unsurprisingly, countries with the greatest burden of HIV also have high levels of unmet need for family planning.

 Like all women, HIV-positive women have a right to make reproductive decisions free of coercion. For women with HIV who want to become pregnant, use of antiretroviral prophylaxis during pregnancy can reduce mother-to-child transmission of HIV and  after delivery, family planning services that promote healthy timing and spacing of pregnancies are important in reducing the risk of adverse pregnancy outcomes such as low birth weight, preterm birth, and infant mortality.

For women with HIV who do not wish to become pregnant, family planning is a proven, cost-effective strategy for PMTCT, and therefore in reducing the number of children needing HIV treatment, care, and support.

According to Prof Oliver Ezechi, the head of HIV Research and Clinics in NIMR, the family planning services provide an opportunity to reach women and men at risk of and living with HIV with family planning information and services.

” Family planning services provide an opportunity to increase access to HIV counseling and testing and other HIV services. Since clients that are seeking HIV services and those seeking family planning services share many needs and concerns, integrating services enables providers to address them efficiently and comprehensively.

But experts say the implementstion is not as easy. Rates of unintended pregnancies remain high among women with HIV, and family planning interventions have been underutilized in HIV prevention, care, and treatment programmes.

Findings reveal that meeting the  contraceptive needs of women living with HIV is one of the key elements to prevent mother-to-child HIV transmission. The number of infant HIV infections prevented by contraception in the era of increased HIV treatment coverage and the additional HIV benefits of preventing unintended births to women living with HIV remains significant.

Out of the estimated 43,559 new infant HIV infections averted by contraception across 70 countries annually according to UNAIDS, an average of 4,195  occur in Nigeria with additional  2,770 new infant infections could be averted per year in the country

Contraception continues to play an integral role in global HIV prevention efforts in the era of increasing HIV treatment coverage, and factors like broad contraceptive availability is a key component to preventing unintended births and ending new infant HIV infections in Nigeria.

As such, reducing mother-to-child transmission remains a major target area. According to UNAIDS, Nigeria is among priority countries for PMTCT – being one of the nations with the highest HIV burden yet low levels of treatment coverage during pregnancy.

“When we see the women pregnant, we enroll them and provide them with drugs, because we don’t have in-patient facilities and then refer them to other hospitals for delivery and they are supposed to us return in six weeks. “Till date, out of all the pregnant women who received ARV drugs in NIMR who visit our facilities and returned,  33 out of the 641 babies that were returned to the HIV clinic were positive. What this means is that our mother-to-child- transmission rate is less than 1.5 per cent,” Ezechi stated.

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