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The Impact of Structured Mentor Mother Programs on 6-Month Postpartum Retention and Viral Suppression among HIV-Positive Women in Rural Nigeria: A Prospective Paired Cohort Study

Sam-Agudu, Nadia A. MD*,†; Ramadhani, Habib O. MD, MPH, PhD; Isah, Christopher HND*; Anaba, Udochisom MPH*; Erekaha, Salome MPH*; Fan-Osuala, Chinenye MPH*; Galadanci, Hadiza MBBS, MSc; Charurat, Manhattan PhD

Author Information
JAIDS Journal of Acquired Immune Deficiency Syndromes: June 1, 2017 - Volume 75 - Issue - p S173-S181
doi: 10.1097/QAI.0000000000001346



Because of high HIV burden and challenges in its prevention of mother-to-child transmission of HIV (PMTCT) response, Nigeria remains a priority country for the Global Plan for the elimination of new HIV infections among children and keeping their mothers alive.1,2 With >200,000 HIV-positive pregnant women delivering annually, Nigeria has the second highest PMTCT burden globally.3 Nigeria's early infant diagnosis (EID) coverage (9%), maternal drug coverage (30%), and decline in child HIV infections (21%) were the lowest among the Global Plan priority countries.1 In the context of its large PMTCT burden, these low achievements make the optimization of Nigeria's PMTCT outcomes especially important.

In Nigeria, as in many countries, PMTCT services are primarily facility based,4 requiring clients to continuously access health care facilities to access care and treatment. Retention of the HIV-positive woman has been used as a surrogate for maternal adherence to treatment.5 It is known that poor maternal adherence to antiretroviral therapy (ART) leads to increased viral load (VL) and increased risk of MTCT. Therefore, retention in care, reflected by continued interaction of clients with services, is important for optimal maternal–infant outcomes in PMTCT.

Nigeria's PMTCT program implementation has been especially challenging in rural areas. Utilization of maternal health services, including PMTCT, is low in rural communities,6,7 where only 47% of women access skilled antenatal care (ANC), compared with 86% of their urban counterparts.7 Given that health-seeking behavior is poor in rural areas, behavior-modifying interventions are appealing for improvements in PMTCT service uptake, compliance with clinical visits, and to achieve overall better outcomes.

Mentor mothers (MMs) are HIV-positive women with PMTCT experience who are trained to provide education and psychosocial support to other HIV-positive women.8–11 MMs guide clients to access services, keep appointments, and maintain drug adherence.8,10,11 Peer support (PS) by women living with HIV has been demonstrated to have positive impact on PMTCT service uptake, including receipt of tests and antiretroviral drugs as well as adoption of recommended infant feeding practices among clients in several African countries.9,12,13

Locally feasible and effective interventions are needed to improve the uptake and coverage of HIV-related care and treatment, especially in areas where gaps are greatest. The MoMent (Mother Mentor) study protocol14 was designed to investigate the impact of a structured PS intervention on maternal retention and uptake of EID within PMTCT programs in rural North Central Nigeria. The impact on MTCT rate and maternal VL suppression were secondary outcomes. This article reports the effect of the MM intervention on postpartum maternal retention and VL suppression. EID and MTCT rate outcomes are reported elsewhere.


Study Design and Setting

This was a prospective paired cohort study conducted in the Federal Capital Territory and Nasarawa states in North Central Nigeria, at rural primary health care centers (PHCs). Because of programmatic standards and expectations to provide trained PS among some potential study sites, randomization was not possible. MM intervention sites were matched with routine care sites in for comparison. Details on the site selection process have been published elsewhere.14 Briefly, based on 4-site characteristics (monthly new antenatal clinic bookings, HIV prevalence among pregnant women, and number of staff providing EID sampling and clinical PMTCT services), 10 sites with routine PS were matched with 10 of 16 enhanced support-appropriate sites (Fig. 1). Data used for site matching were based on facility-documented historical data from the immediate preceding 6 months. HIV-positive pregnant women enrolled consecutively at MM sites received enhanced PS from closely supervised MMs within a structured program; women at routine sites received routine PS in a loosely organized program. The table (see table, Supplemental Digital Content 1, presents descriptions of the PS program and peer counselor roles for each arm of the study. Although peer counselors in both study arms were required to be HIV positive, MM supervisors in the intervention arm were not required to be HIV positive. An average of 2 peer counselors was assigned to each study site to maintain a peer counselor-to-study client ratio of no more than 1:15. PMTCT and other HIV services at all study sites were supported by the Institute of Human Virology Nigeria (IHVN).

CONSORT flow diagram for site selection and participant recruitment.

Study Participants and Recruitment Procedures

Study participants were mother–infant pairs (MIPs): HIV-positive women and their live-born HIV-exposed infants. ART-naive and ART-experienced women, and those of all gestational ages, were eligible for recruitment; only those presenting in labor were excluded. Detailed patient recruitment and data collection procedures have been described elsewhere.14 Because of poor program documentation and poor patient recall, we could not obtain reliable or verifiable data on duration of ART for women who were already on ART. Recruitment was completed between April 2014 and September 2015 and follow-up was conducted up to 6-month postpartum for each MIP. Women experiencing miscarriage or stillbirth maintained enrollment status and were followed until the study endpoints. All study participants received routine Option B PMTCT services per national guidelines15,16 during recruitment and follow-up, including initiation of maternal ART regardless of CD4 count at booking.

Ethical Approvals

The study was approved by the Nigerian National Health Research Ethics Committee, the Ethics Review Committee of the World Health Organization, and the Institutional Review Board of the University of Maryland Baltimore. Written informed consent was obtained from all study participants.

VL Sample Collection and Testing

Twenty milliliters of whole blood was collected from participants at 6-month postpartum. Samples were centrifuged and multiple plasma aliquots were obtained. VL was determined with the COBAS AmpliPrep/TaqMan HIV-1 assay (Roche Diagnostics, Indianapolis, IN) at a limit of detection of 20 copies/mL. VL suppression was defined as VL below the detection threshold of the assay,17 at <20 copies/mL.

Sample Size Estimation

The primary outcome addressed by this article is maternal retention at 6-month postpartum.14 It was estimated that 6-month retention in the nonintervention arm would be 30%. With an intracluster correlation of 0.05, type II error (1−β) = 0.8 and type I error α = 0.05, a minimum of 21 MIPs per site would provide 80% power to detect a difference of 20% in retention rate (30% routine PS vs 50% MM). Allowing for maternal and infant mortality, a final sample size of 24 MIPs per PHC (480 MIPs total at 20 PHCs) was determined.14 Because of lower-than-projected recruitment over the first 12 months, the smallest absolute difference was increased to 30% (30% routine PS vs 60% MM), with all other assumptions unchanged, to arrive at a sample size of 220 MIPs, while maintaining power at 80%.

Statistical Analysis

Variables and Definitions

National PMTCT guidelines in effect during the study did not recommend a specific postpartum schedule of visits for mothers or infants beyond 6 weeks presentation for EID and 18-month infant HIV antibody testing.15 Therefore, the approach to evaluating impact of the intervention on postpartum retention was to assess patterns of attendance based on a once monthly visit expectation, derived from routine HIV drug pick-up patterns in the PMTCT program. Retention in care was defined according to the number of 30-day periods of a maximum of 6, during which each enrolled woman had at least 1 clinic visit, between date of delivery and 180 days postpartum. Women who had ≥3 of 6 expected visits were considered retained. Any maternal “made” facility visit for any reason (eg, routine clinical care, laboratory tests, and drug pick-ups) was eligible for retention assessment per the study definition. Maternal viral suppression was assessed at 6-month postpartum and defined as the proportion of HIV-positive women with VL samples collected at 6 months ± 2 weeks postpartum who had results of <20 copies/mL.

Data Analyses

Descriptive comparisons of participant characteristics in both arms were performed. Attendance and retention outcomes were analyzed per intention-to-treat procedure. The effect of MM on retention was examined using a multivariate logistic regression model with generalized estimating equation (GEE) to account for clusters. First, univariate models for associations between retention, type of PS, and individual characteristics were developed. To minimize bias on account of the nonrandomized design, biologically plausible confounders and variables that changed crude estimate by ≥5% were sequentially added to the multivariate model. This was stopped when addition did not result in further change in estimate. Covariates included maternal characteristics such as age, gestational age at booking, marital status, education, religious affiliation, number of previous pregnancies, number of living children, HIV disclosure status, new or previously HIV-diagnosed, and whether new or previously on ART. Facility-level covariates were HIV prevalence, number of PMTCT staff, and number of DNA polymerase chain reaction sample collection–trained staff.

For sensitivity analysis, a 4-level ordinal scale for patterns of attendance was used to demonstrate dose response; 0, 1–2, 3–4, and 5–6 thirty-day periods with at least one “made” postpartum visit represented “No,” “Poor,” “Fair,” and “Good” attendance. In this case, 3 separate GEE models were fit keeping the “No attendance” category as the reference group. A multivariate logistic regression model with GEE was used to assess the MM intervention effect on viral suppression. To ensure all study participant data were used in all analyses, indicator variables for the missing data were imputed. All associations were presented as adjusted odds ratios (aORs) with 95% confidence intervals (CIs). Statistical analyses were conducted using SAS version 9.3 (SAS Institute Inc., Cary, NC).


After pair matching the 20 study sites, the average matching criteria values for routine PS vs MM sites were as follows: monthly ANC bookings 103 vs 81; site HIV prevalence 4.4% vs 5.0%; number of PMTCT service providers 5 vs 5; number of DNA polymerase chain reaction collection–trained staff 1 vs 2; respectively. A total of 497 HIV-positive pregnant women were enrolled from the 20 matched sites (Fig. 1). Intervention sites had lower ANC flow than control sites during enrollment (8941 vs 14,354). Overall, HIV prevalence among women in ANC care was higher at intervention vs control sites (5.5% vs 2.8%, P < 0.0001). Similar proportions of women (36/298, 12% vs 45/283, 16%) declined enrollment in the MM vs routine PS arm, respectively. Ultimately, 260 pregnant women were enrolled in the MM arm and 237 in the routine PS arm. In the antenatal period, there was 1 loss to follow-up and no deaths in the MM arm compared with 51 women lost to follow-up and 2 deaths in the routine PS arm. Three women died during the 6-month postpartum follow-up. Table 1 presents baseline maternal characteristics. Women recruited in the MM arm were more likely to be Christian (77.7% vs 49.4%, P < 0.01) and to have had secondary level or greater education (57.7% vs 40.1%, P < 0.01).

Baseline Characteristics of Enrolled HIV-Positive Pregnant Women

Intensity of PS provided during follow-up was evaluated by peer counselor-to-study client ratio and number of visits made per client from prenatal engagement until 6-month postpartum. In this period, average MM-to-client ratio was 1:12, compared with routine PS-to-client ratio of 1:14, and mean number of visits (SD) made per client per 30-day month was 3.6 (±2.6) for routine PS vs 4.2 (±1.9) for MMs (P = 0.4).

Retention Among Postpartum Women

Table 2 presents an analysis of factors associated with postpartum retention, including type of PS. Overall, 24.9% (59/237) and 61.9% (161/260) of women were retained in the routine PS and MM arms, respectively, with an absolute difference of +37%. In multivariate analysis, compared with routine PS, exposure to MM support was significantly associated with increased likelihood of retention (aOR = 5.9, 95% CI, 3.0 to 11.6). Sensitivity analysis (Table 3) demonstrated a robust dose response for greater likelihood of retention with higher levels of attendance for MM-supported women. No other maternal factors, including education, religion, distance to facility, or disclosure status were associated with retention.

Factors Associated With Maternal Retention at 6-Month Postpartum
Sensitivity Analysis of Association Between MM Support and Visit Attendance

Viral Suppression at 6-Month Postpartum

Table 4 presents maternal VL results for samples collected at 6-month postpartum. For this analysis, women who never presented for sample collection were considered nonsuppressed. Overall, 45.1% (224/497) of enrolled women had VL results available—176 (78.6%) from the MM arm and 48 (21.4%) from the routine PS arm (not shown). Of the 224 women with VL results available, 130 (58.0%) were suppressed. In multivariate analysis, MM support was associated with higher odds of viral suppression, compared with routine PS (aOR = 4.9, 95% CI: 2.6 to 9.2) (Table 4). In addition, retained status (aOR = 2.1, 95% CI: 1.2 to 3.5) and receiving a boosted protease inhibitor (lopinavir) (aOR = 3.7, 95% CI: 1.0 to 13.2) were also found to be independently associated with viral suppression. No other factors evaluated, including education, religion, and distance from facility were associated with viral suppression.

Factors Associated With Postpartum Maternal Viral Suppression


Our results indicate that compared with routine PS, the structured MM intervention was associated with a 6-fold improvement and >35% absolute difference in retention of mothers living with HIV at 6-month postpartum. Sensitivity analysis further demonstrated impact of MM support at low-to-high levels of attendance, showing the advantage of the intervention for even low-level visit compliance, over none. Although MMs and similar PS interventions have demonstrated impact on PMTCT outcomes in comparable settings,9,12,13 our study shows that built-in structure and supervision for PS can significantly improve health outcomes—in this case, retention in care. Few other studies have reported impact of PS on retention in PMTCT care18; one published study did not show effect following 6 months of follow-up.8 PS has however improved rates of retention in ART programs among nonpregnant adults.19,20

Although ART programs have widely applied loss-to-follow-up21 and retention22 definitions, there is currently no standard or widely applied definition for PMTCT retention.5 As a result, comparisons of PMTCT retention interventions are difficult to perform. Two recent reviews reported retention rates of 20%–100% from studies applying definitions largely based on scheduled clinic visits in follow-up periods between 6 weeks and 18-month postpartum.18,23 Rawizza et al24 retrospectively analyzed retention outcomes for >30,000 Nigerian women from a broad mix of settings and facilities over a 10-year period. Using 1 expected visit during each of the antenatal, delivery, and postpartum periods, retention was calculated at 66% for up to 18 months of follow-up.24

Yet, Nigeria's PMTCT appointment scheduling is typically based on facility-designated PMTCT service or drug pick-up day(s), rather than individually scheduled visits. Even so, these visit schedules are not uniformly adhered to across facilities; therefore, individual appointments may not be an accurate retention measure. Program experience has shown that drug pick-ups are the best adhered to recurring PMTCT service among postpartum mothers. In our study, we assumed that postpartum mothers would follow a minimum drug pick-up frequency of once monthly, which is the typical practice across health care facilities in our study setting. Ultimately, monthly postpartum drug pick-ups provided a fairly sensitive measure of retention in our study population. Thus, we argue that PMTCT retention definitions will have more meaningful interpretation if they reflect engagement during, rather than at the end of a defined period.

Viral suppression was assessed as a proxy for ART adherence, which was expected to be better with structured, potentially higher-quality PS. This best explains the nearly 5-fold higher odds of viral suppression among MM-supported women. Furthermore, retention had an independent effect on viral suppression among postpartum women, indicating the importance of improving both retention and adherence toward viral suppression for PMTCT. Protease inhibitor therapy with boosted lopinavir was also associated with viral suppression, which, given the high resistance profile of protease inhibitors, is not unexpected. However, the small numbers and wide CIs warrant cautious interpretation.

The 6-month postpartum viral suppression rate of 58% falls short of UNAIDS' goal of 90%25; however, it provides a baseline for VL scale-up strategies in our study setting and similar communities.26,27 Viral suppression data from other settings are difficult to compare because of variable VL measurement time points. Seventy-one percent of women were suppressed during pregnancy in Benin28; In South Africa, 69% were suppressed at 6 weeks29 and 71% at 12-month postpartum.30

The evidence for interventions to improve postpartum retention in PMTCT care is scanty, and the impact has been largely restricted to the early (<3 months) postpartum period.31 The MoMent study provides evidence for structured PS in improving visit attendance and retention in care for PMTCT clients. The structured program included a clearly communicated, outcome-specific MM scope of work, a client visit schedule, a standardized, logbook, MM performance evaluation, and dedicated facility-based staff to provide supportive supervision for program compliance.14 Our PS intensity results suggest that the difference in outcomes between the 2 study arms was not because of the absolute number of peer counselor visits per client. The most salient aspects of the intervention with respect to successful outcomes seem to be the MM supervision and its supportive nature, plus the time-bound flagging and tracking of missed-appointment clients. Ultimately, the availability of a knowledgeable, supportive supervisor and nonarbitrary, objective-specific procedures assisted and empowered MMs in providing higher-impact PS.

MoMent was conducted in rural communities with traditionally low health service utilization and significant community-level HIV stigma. Structured PS facilitated behavioral changes that positively impacted PMTCT outcomes in this difficult setting. Scale-up can potentially narrow PMTCT gaps in our study setting and in similar communities. Formal cost-effectiveness analysis is under way; this will be important for policy making and scale-up decisions.

Study Limitations

First, the nonrandomized nature of the study was a major limitation but was unavoidable because of programmatic obligations. We aimed to minimize bias through site matching performed by an external consultant. The data used for site matching was based on historical site-documented information. Inconsistent documentation may have accounted for the significant difference in ANC monthly flow and HIV prevalence ultimately observed between matched sites during the prospective study. The postmatching imbalance in these site-level characteristics between study arms may have introduced bias. Larger, higher prevalence sites may appeal to clients in terms of less perceived stigma; clients are less likely to be recognized at large facilities. Also, perceived or actual staff skills at larger sites may be better because of experience in handling large numbers of clients. Conversely, perceived or actual quality of care may be worse at larger sites because of long wait times and less time spent per client. Nevertheless, potential confounders, including site-level characteristics, were controlled for in the multivariate analysis model. Second, viral suppression data were more available among MM-supported women, which may also have biased outcomes. However, better viral suppression would be expected with higher rates of retention and therefore, assumed adherence. This association was consistent in all mothers with better rates of retention regardless of type of PS. Finally, VL testing was performed without concurrent assessment for drug resistance mutations. It is possible that some study participants with lower rates of retention were optimally adherent but were not suppressed because of acquired drug resistance; however, the study was unable to identify such individuals.


The favorable results of this study are encouraging because they arise from a high-burden country with large PMTCT gaps. Global HIV prevention and elimination can potentially accelerate if Nigeria is able to achieve MoMent's results at scale. This study's results provide an immediate opportunity to improve the impact of current PS programs without massive resource mobilization.

Although MoMent's findings are encouraging, questions remain as to how structure and thus quality and impact can be improved for PS programs. First, these programs will warrant complete integration into formal health systems so that the injection of structure and supervision will be physically and programmatically aligned with PMTCT program implementation. In an era of lifelong ART for all people living with HIV, including Option B+ for pregnant women, the workload of health workers in resource-limited settings who are already stressed will increase further. This is an opportune time to engage, train, organize, and empower lay health workers, including people living with HIV, to assume specific tasks related to client care.


The authors thank Global Affairs Canada and the technical team from WHO in Geneva and in Nigeria for their financial support and expertise. We also acknowledge support from the Federal Ministry of Health, Nigeria, the Nasarawa State Ministry of Health, and the FCT Health and Human Services Secretariat. The authors appreciate the IHVN program implementation teams for their enabling support. Finally, the authors are grateful to the site staff and pregnant women and mothers who voluntarily participated in this project.


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PMTCT; retention; viral suppression; rural population; Nigeria; mentor mothers

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