|Year : 2013 | Volume
| Issue : 2 | Page : 70-76
Appraisal of repeat intrapartum human immunodeficiency virus screening in a prevention of mother-to-child transmission program in Nigeria
Joseph U. E. Onakewhor1, Abieyuwa Osemwenkha1, Ochuko Ovbagbedia1, Austine I Omoigberale2, Wilson E Sadoh2, Alash'le Abimiku3, Man Charurat3
1 Department of Obstetrics and Gynecology, University of Benin Teaching Hospital, Benin, Edo, Nigeria
2 Department of Child Health, University of Benin Teaching Hospital, Benin, Edo, Nigeria
3 Department of Child Health, Institute of Human Virology, University of Maryland School of Medicine, Baltimore, Maryland, United States of America
|Date of Acceptance||06-Feb-2014|
|Date of Web Publication||6-Feb-2014|
Joseph U. E. Onakewhor
Department of Obstetrics and Gynecology, University of Benin and University of Benin Teaching Hospital, Benin City - 300 001, Edo, Nigeria.
Source of Support: None, Conflict of Interest: None
DOI: 10.4103/2321-9157 .126634
Objective: The objective of the study is to determine whether retesting for human immunodeficiency virus (HIV) in labor is important in Nigeria. Subjects and Methods: A prospective cohort study involving 400 antenatal women who tested HIV-negative at booking in an obstetric unit of a university college hospital in Nigeria were retested in labor at least 12 weeks from initial tests. Seropositive mothers and exposed infants had antiretroviral prophylaxis and were followed-up. Main outcome measures were rate of acceptance to rescreen, incidences of seroconversion, mother-to-child transmission and associated factors. Results: Majority 96.4% (400/415) accepted whereas 3.6% (15/400 N) declined retesting on the grounds of a previous negative result. The seroconversion rate was 0.25%. Maternal age ≥25 years (OR = 5.0), secondary and post-secondary education (OR = 622.4) and parity ≥1 (OR = 17.2) were significant factors for acceptance to rescreen whereas occupation (P = 0.25) and marital status (P = 0.23) were not. The only HIV-exposed infant from the seroconverted mother was not breastfed and tested negative at 6 and 12 weeks using deoxyribonucleic acid polymerase chain reaction. Conclusion: The rate of seroconversion was low, but perinatal HIV infection was averted. Supposedly low-risk women could seroconvert and cause vertical transmission (VT). Retesting may still be important in resource-constrained settings to identify women with recent infection, institute appropriate interventions to avert VT thereby achieving the international goal of "no new HIV infection by 2015". Although a large multicenter study to evaluate our findings is ongoing, studies to determine the cost-benefits of such interventions are justified.
Keywords: Averting perinatal human immunodeficiency virus, intrapartum screening, seroconversion
|How to cite this article:|
Onakewhor JU, Osemwenkha A, Ovbagbedia O, Omoigberale AI, Sadoh WE, Abimiku A, Charurat M. Appraisal of repeat intrapartum human immunodeficiency virus screening in a prevention of mother-to-child transmission program in Nigeria. J HIV Hum Reprod 2013;1:70-6
|How to cite this URL:|
Onakewhor JU, Osemwenkha A, Ovbagbedia O, Omoigberale AI, Sadoh WE, Abimiku A, Charurat M. Appraisal of repeat intrapartum human immunodeficiency virus screening in a prevention of mother-to-child transmission program in Nigeria. J HIV Hum Reprod [serial online] 2013 [cited 2017 Feb 19];1:70-6. Available from: http://www.j-hhr.org/text.asp?2013/1/2/70/126634
| Introduction|| |
Nigeria is the most populous country in Africa and ranks second after South Africa in the number of people living with human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS).  Her high HIV burden has continued to be a source of concern to the global community and is among the United Nations few HIV-priority countries (including Chad, Democratic Republic of the Congo) where <20% of pregnant women living with HIV were identified in 2010.  In these countries, antiretroviral (ARV) coverage for pregnant women living with HIV was only 9%, which is markedly below the 80% target set for the Millennium Development Goals by the United Nations General Assembly Special Session. 
To achieve universal access (80%) by 2015  and mitigate the impact of vertical transmission (VT), the Nigerian government with support from international partners, is rapidly scaling up prevention of mother-to-child transmission (PMTCT) services to secondary and primary health care centers. , Antenatal HIV testing and counseling (AHTC) is the entry point for PMTCT of HIV services. ,,
The recent antenatal seroprevalence survey of HIV in Nigeria showed persistent wide geographical variations. The South-south and North-central zones had the highest prevalence of 8.2% each. This was twice the national average of 4.1%.  and this high prevalence could impact negatively on the rate of VT of HIV.  In 2009, early infant diagnosis (EID) using polymerase chain reaction (PCR) for HIV deoxyribonucleic acid (DNA) test in Nigeria showed that 13.1% of infants born to HIV-infected mothers were themselves infected,  which is unacceptably high. Without preventive interventions, HIV VT rates range from 15% to 45% especially when breastfeeding is continued for more than 18 months. , More than 95% of MTCT of HIV occurs during the intrapartum period.  The VT rate can be reduced to <2% when women receive triple ARV preventive therapy and do not breastfeed.  Culturally, however, most Nigerian women breastfeed their infants.
Accessing HIV counseling and testing (HCT) at an opportune time during pregnancy is often limited by socio-cultural and economic factors.  When AHTC is combined with intrapartum HIV testing and counseling (IHTC), the yield is expected to improve. ,, In pregnancy, HIV poses additional physical, immunological and psychological stress and increases maternal and perinatal morbidity and mortality.  High maternal viral load (VL) and low CD4 count are risk factors for VT. Maternal acute HIV infection during pregnancy is associated with higher VL. 
In the last 2 decades, the availability of facilities for diagnosis and antiretroviral therapy (ART) has revolutionized HIV management including PMTCT. ,,,,,, In pregnancy, the principle of management of HIV infection is aimed at reducing VT by reducing VL and improving maternal immunity through appropriate use of ARVS , nutritional supplementation, infant ARV prophylaxis and optimum infant feeding practices. ,, EID and initiation of ART or prophylaxis is the mainstay of management. ,, Effective utilization of triple ARVs (highly active ART or HAART) in pregnant women who qualify for it is beneficial for the women's own health and best prophylaxis against MTCT. ,, This standard of care in developed countries has dramatically reduced MTCT rates to <2% in those settings. ,,
To benefit from these interventions, HIV diagnosis through HCT must first be done to enable initiation of ART or prophylaxis. In resource-constrained settings such as in Nigeria, HIV diagnosis is often based on rapid test; a method that cannot diagnose the infection in the "window period. , The use of PCR test to pick up the viral particles in patients" blood or serum is confirmatory but not feasible as routine in antenatal settings.  Consequently, when initial opportunity is missed, another window of opportunity is provided at 34-36 weeks gestation or in labor for repeat testing for HIV to detect women who may be acutely infected or seroconvert during the pregnancy.  This provides benefit for ARV prophylaxis, modified obstetric interventions and infant feeding practices.  This intervention targets women without access to AHTC; unbooked women or women with unknown HIV status. Others are women whose testing is more than 3 months previously. These women could benefit from early IHTC, peripartum ARV prophylaxis and other PMTCT interventions. 
Repeat HIV testing in labor and delivery has been recommended as a standard of care as it increases ARV provision for women who seroconvert during pregnancy.  Though recommended, this intervention is yet to be made routine in most hospitals in Nigeria. Reports from Uganda , and South Africa , where the HIV epidemics are considered to be generalized have shown that retesting for HIV is important. Nigeria's status was recently changed from generalized to "mixed epidemic" by the United Nations Program on HIV/AIDS. , The goal of this study, therefore, is to determine whether retesting is also important in Nigeria.
| Subjects and Methods|| |
This prospective study was a pilot study to determine the feasibility and value of introducing routine repeat screening for women in labor. The study involved booked consecutive pregnant women confidentially enrolled at delivery at the University of Benin Teaching Hospital, Nigeria from July 1 through September 30, 2009. To qualify for enrolment into the study, each volunteer had to give informed consent after counseling and should have had a previous negative HIV test result not <12 weeks previously. Women with previous unknown HIV status, though are routinely screened for HIV and managed accordingly in this unit, were excluded from the study. Confidentiality was maintained for all patients by coding of results known only to the care givers.
The hospital's Ethics and Research Committee gave approval for the study.
HIV screening and management protocol
Each volunteer had a volume of 5 ml of blood taken from the ante-cubital vein and sent to the laboratory in a potassium ethylene diamine tetra acetic acid-anticoagulant containing specimen bottle for serological test. The specimens were centrifuged and the plasma separated and analyzed for HIV 1 and 2 antibodies using Capillus HIV-1/HIV-2 (Trinity Biotech PLC, Jamestown, New York, USA) and then Genie1I HIV-1/HIV-2(Bio-Rad, Marnes La Coquette-France) rapid test kits. Determine HIV-1/2 (Abbott Laboratories, Illinois, USA) was used as a "tie-breaker" when there is serodiscordance in accordance with the WHO double/triple Algorithm.  Mothers had post-test counseling by regular hospital counselors of the PMTCT program as soon as it was convenient. Women newly diagnosed as HIV positive in labor received a single dose Nevirapine (sdNVP) tablet 200 mg orally followed by lamivudine (3TC) 150 mg 12 hourly and zidovudine (ZDV) 300 mg 12 hourly for 1 week (to prevent Nevirapine (NVP) resistance pending the outcome of the CD4 count result), in accordance with the Nigerian National Guideline on PMTCT of HIV.  The women also received psychological and social support from trained counselors throughout the duration of labor. When the diagnosis of HIV is made in early labor with intact fetal membrane, the women in addition to ARV prophylaxis were counseled for cesarean section (c/s) and those who accepted were so delivered.  Women that declined having c/s were offered appropriate labor management,  including delay in artificial rupture of the fetal membrane and vaginal cleansing with chlorhexidine hydrochloride if the membranes were ruptured. All HIV positive women were given infant feeding counseling. 
At the time of study, during the postpartum period, if the CD4 was ≤250 cells/ml, the woman was placed on HAART under the management of a trained physician in the adult ARV clinic. If the CD4 count >250 cells/ml she was followed-up at the adult clinic while ARVs were delayed until the CD4 count was ≤250 as recommended by the National Guideline on PMTCT of HIV/AIDS  (The current National Guideline has changed recommending HAART for pregnant women with CD4 count ≥350 cells/ml for prophylaxis irrespective of clinical stage of the HIV disease  ).
The cost of ART/prophylaxis, hospitalization, delivery including cesarean sections and postnatal care were free to the patient under the Government of Nigerian (GON) free obstetric care program for HIV-positive women. This program was funded by the GON in collaboration with the United States Government through the President's Emergency Plan for AIDS Relief (PEPFAR). ,
The study was designed to have a sample size 400 at 95% level of confidence, α of 0.05, error margin of 2.5% and allowing for 25% rate of decline to test with a national antenatal HIV seroprevalence 4.6% (approximately 5%) in the 2008 serosentinel survey.  All analysis were intention-to-treat. The data were analyzed using the GraphPad Instat tm Software statistical package version 3.06 (GraphPad Software Inc., El Cammino Real, San Diego, USA). Subgroups were compared using Fisher's Exact Test and descriptive statistics for proportions where appropriate. The two-sided P < 0.05 was considered to be significant.
| Results|| |
Of the 415 women qualified for enrolment during the period of the study, 400 (96.4%) accepted while 15 (3.6%) declined. Those that declined cited their previous negative HIV test results. Furthermore, that there had been no changes in their social behavior and that of their spouses since the last test. The demographic characteristics of the study population are shown in the [Table 1].
The mean age was 29.4 ± 3.6 (range 18-43) years, parity 2.0 ± 1.4 and gestational age 37.3 ± 8.6 weeks. Four out of 30 (13.3%) women who were ≤24 years declined the test compared with 11 out of 370 (3.0%) who were 25 years or older (P < 0.02); OR: 5.02.
Women with no-formal and primary education 17.6% (13/17) compared with those that had secondary and tertiary education 0.5% (2/383) were more likely to decline the test (P < 0.0001; OR: 622.38). Nulliparous women 8.2% (12/146) compared with primiparous and multiparous 1.2% (3/254) were more likely to decline the test (P < 0.0001; OR: 17.15). There was no statistical difference between those who accepted or declined the test in terms of occupation and marital status.
The HIV incidence was 0.25% (1/400) while 99.75% were seronegative. One seroconverter was a 27-year-old woman who booked and tested HIV-seronegative at gestational age of 15 weeks, had an uneventful antenatal care and presented in labor at 38 weeks. She received sdNVP 200 mg + 3TC 150 mg + ZDV 300 mg orally as soon as diagnosis was made in labor. Postpartum she had ZDV + 3TC for 7 days. Her CD4+ T-lymphocyte count was 386 cells/ml. For logistic reasons, we could not assess the woman's VL levels. She was counseled for and accepted cesarean delivery. She was delivered of a 3.1 kg male neonate.
The baby received sdNVP 6 mg (2 mg/kg) immediately after birth plus ZDV 12 mg 12 hourly (4 mg/kg/dose 12 hourly) for 6 weeks (This was the practice as at the time of study using the 2007 National PMTCT Guideline of the Federal Ministry of Health). The mother opted for breast milk substitute for her infant's nutrition. She was referred to the adult and the baby to the pediatric ARV clinics respectively for follow-up management. Using PCR DNA for EID, the baby tested HIV negative at 6 and 12 weeks of age. The child's growth parameters were normal. She later notified the spouse who accepted screening and he tested negative at 4 and 12 weeks from the time of diagnosis of HIV in the spouse.
| Discussion|| |
Infants infected with HIV suffer ill-health and mortality especially in the absence of diagnosis and ART. Therefore, preventing maternal transmission through effective PMTCT interventions is an acceptable way of ensuring HIV-free infant survival. This study has provided one of such opportunity through repeat intrapartum screening.
In this study, the rate of acceptance to retest in labor of 96.4% is high and encouraging. Data for intrapartum testing of cohort of women antenatally seronegative for HIV is scarce in this environment making comparison difficult. However, the acceptance rate is comparable with the 86% for Ugandan women  and 95.3% for HIV negative Kenyan women who retested 6 weeks postpartum at immunization clinic.  The few studies from Northern  and South-west Nigeria,  and Cameroon  included women with unknown status. Thus, to the best of our knowledge, this is the only study from Nigeria that has a cohort of women who were all HIV-seronegative during the antenatal period and retested in labor.
The high rate of acceptance to rescreen may be attributable to knowledge acquired by the women from initial antenatal health education and counseling by the public health nurses/midwives and counselors of the PMTCT program respectively. Furthermore, the patients' initial negative test results may have acted as further "stimulus" to rescreen. Maternal age more than 25 years, secondary and post-secondary education and parity ≥1 were all statistical significant factors associated with acceptance to rescreen. However, occupation and marital status were non-significant factors. Similar findings had been reported for Cameroonian women.  The low mean parity of women in this study was due to the high preponderance of nulliparous women (31.0%).
The incidence of HIV in this study, 0.25%, is much lower than the 2.3-12% reported for Ugandan women, , the 2.6%, 2.9%, 3.0% and 4.4% for women in Kenya,  Botswana,  South Africa  and Swaziland  respectively. A recent study from South Africa showed an estimated point HIV incidence of 11.2% per year.  In a disaggregated data from a northern Nigerian study,  2.1% seroconversion rate was reported. This is over eight-fold the incidence of HIV found in this study. In these other studies, the time interval from early pregnancy to repeat peripartum HIV testing ranged from 12 to 60 weeks. In this study, the minimum time interval was 12 weeks.
Early commencement of HAART and continuing during labor, delivery and immediate postpartum period plus neonatal ARV prophylaxis is the mainstay of reducing VT especially when the infant is not breastfed. , Such intervention is associated with VT ≤2% ,,,,,, even though WHO recently recommended breastfeeding with ARV prophylaxis. 
Without retesting, one woman in this study would not have received appropriate intrapartum and postpartum HIV interventions. This study highlights the benefit of this strategy especially when the risk of seroconversion or new infection cannot be convincingly excluded. In Botswana, it has been estimated that maternal transmission secondary to HIV seroconversion during pregnancy could account for more than 40%. , The outcome for the one HIV-exposed infant was good (HIV negative), which was the main objective of PMTCT interventions. The physical and psychological benefit to the couple, family members and friends, care-givers and the society of preventing perinatal HIV/AIDS compared with the high infant mortality and expensive cost of lifetime medical care of an infected child , cannot be quantified in monetary terms.
One limitation of this study is the relatively small sample size. In spite of this, one case of seroconversion (acute or new infection) was detected and a new infant infection averted. Thus, any measures that will avert perinatal HIV and reduce heterosexual HIV infections through HCT for spouse and safer sex practices are, obviously, well-directed interventions and intrapartum rescreening is one of them.
| Conclusion|| |
The study has attempts to highlight the benefit of repeat intrapartum screening of supposedly low-risk women whose status of HIV seroconversion (acute or new infection) was uncertain. Though the rate of seroconversion was low, a perinatal HIV infection was averted thus contributing to the realization of the international goal of "no new HIV infection by 2015". Although a large multicenter study to evaluate our findings are ongoing, studies to determine the cost-benefits of such interventions are necessary.
| Acknowledgements|| |
We are grateful to the study participants, the PMTCT Program counselors, the antenatal and labor ward staff for their assistance. We acknowledge the technical assistance of the Institute of Human Virology Nigeria and the University of Maryland School of Medicine. We also appreciate the Government of Nigeria and the US Government (PEPFAR and the US National Institutes of Health Fogarty AIDS International Training Research Program-D43 TW001041) for their support for the program and capacity building from which our clients and staff are beneficiaries. Finally, we are indebted to Professor Lorraine Sherr for the useful perspective.
| References|| |
|1.||National Agency for the Control of AIDS (NACA), Nigeria. Mode of Transmission of HIV in the Nigerian: Analysis of the Distribution of New HIV Infections in Nigeria and Recommendations for Prevention. Abuja, Nigeria: NACA; 2010. p. 1-48. |
|2.||Joint United Nations Programme on HIV/AIDS (UNAIDS). UNAIDS Data Tables / 2011. UNAIDS/JC2225E. Geneva, Switzerland: UNAIDS; 2011. |
|3.||WHO, UNAIDS and UNICEF. Towards Universal Access: Scaling up Priority HIV/AIDS Interventions in the Health Sector - Progress Report. Geneva: WHO; 2010. |
|4.||Federal Ministry of Health (FMOH) Nigeria. Scale up Planning Guide for the Prevention of Mother to Child Transmission of HIV and Paediatric HIV Care, Treatment and Support of HIV. Abuja, Nigeria: FMOH; 2009. p. 1-98. |
|5.||Federal Ministry of Health (FMOH) Nigeria. National PMTCT Scale up Plan 2010-2015. Abuja Nigeria: FMOH; 2010. p. 1-49. |
|6.||Paltiel AD, Weinstein MC, Kimmel AD, Seage GR 3 rd , Losina E, Zhang H, et al. Expanded screening for HIV in the United States - An analysis of cost-effectiveness. N Engl J Med 2005;352:586-95. |
|7.||Sanders GD, Bayoumi AM, Sundaram V, Bilir SP, Neukermans CP, Rydzak CE, et al. Cost-effectiveness of screening for HIV in the era of highly active antiretroviral therapy. N Engl J Med 2005;352:570-85. |
|8.||Federal Ministry of Health (FMOH), Nigeria. Nigerian National Guidelines on Prevention of Mother-To-Child Transmission (PMTCT) of HIV. Abuja, Nigeria: FMOH; 2007. p. 1-88. |
|9.||Federal Ministry of Health (FMOH), Nigeria. National AIDS/STI Control Programme. 2010 National HIV Sero-prevalence Sentinel Survey. Abuja, Nigeria: FMOH; 2010. p. 1-97. |
|10.||National Agency for the Control of AIDS (NACA), Nigeria. UNGASS Country Progress Report Nigeria. The United Nations General Assembly Special Session (UNGASS). Abuja, Nigeria: NACA; 2010. p. 1-109. |
|11.||World Health Organization. HIV/AIDS: Mother-to-child transmission of HIV. WHO. Geneva. Available from: http://www.who.int/hiv/topics/mtct/en/. [Last accessed on 2013 May 1]. |
|12.||Minkoff H. Prevention of mother-to-child transmission of HIV. Clin Obstet Gynecol 2001;44:210-25. |
|13.||Pai NP, Klein MB. Rapid testing at labor and delivery to prevent mother-to-child HIV transmission in developing settings: Issues and challenges. Womens Health (Lond Engl) 2009;5:55-62. |
|14.||Gay CL, Mwapasa V, Murdoch DM, Kwiek JJ, Fiscus SA, Meshnick SR, et al. Acute HIV infection among pregnant women in Malawi. Diagn Microbiol Infect Dis 2010;66:356-60. |
|15.||Gray RH, Li X, Kigozi G, Serwadda D, Brahmbhatt H, Wabwire-Mangen F, et al. Increased risk of incident HIV during pregnancy in Rakai, Uganda: A prospective study. Lancet 2005;366:1182-8. |
|16.||Moodley D, Esterhuizen TM, Pather T, Chetty V, Ngaleka L. High HIV incidence during pregnancy: Compelling reason for repeat HIV testing. AIDS 2009;23:1255-9. |
|17.||Onakewhor JU, Olagbuji BN, Ande AB, Ezeanochie MC, Olokor OE, Okonofua FE. HIV-AIDS related maternal mortality in Benin City, Nigeria. Ghana Med J 2011;45:54-9. |
|18.||World Health Organization. Antiretroviral drugs for treating pregnant women and preventing HIV infections in infants: Recommendations for a public health approach 2010 version. Geneva: WHO; 2010. |
|19.||Taha TE, Kumwenda NI, Gibbons A, Broadhead RL, Fiscus S, Lema V, et al. Short postexposure prophylaxis in newborn babies to reduce mother-to-child transmission of HIV-1: NVAZ randomised clinical trial. Lancet 2003;362:1171-7. |
|20.||Gray GE, Urban M, Chersich MF, Bolton C, van Niekerk R, Violari A, et al. A randomized trial of two postexposure prophylaxis regimens to reduce mother-to-child HIV-1 transmission in infants of untreated mothers. AIDS 2005;19:1289-97. |
|21.||Lallemant M, Jourdain G, Le Coeur S, Mary JY, Ngo-Giang-Huong N, Koetsawang S, et al. Single-dose perinatal nevirapine plus standard zidovudine to prevent mother-to-child transmission of HIV-1 in Thailand. N Engl J Med 2004;351:217-28. |
|22.||Volmink J, Siegfried NL, van der Merwe L, Brocklehurst P. Antiretrovirals for reducing the risk of mother-to-child transmission of HIV infection. Cochrane Database Syst Rev 2007: CD003510. |
|23.||Petra Study Team. Efficacy of three short-course regimens of zidovudine and lamivudine in preventing early and late transmission of HIV-1 from mother to child in Tanzania, South Africa, and Uganda (Petra study): A randomised, double-blind, placebo-controlled trial. Lancet 2002;359:1178-86. |
|24.||Bhoopat L, Khunamornpong S, Lerdsrimongkol P, Sirivatanapa P, Sethavanich S, Limtrakul A, et al. Effectiveness of short-term and long-term zidovudine prophylaxis on detection of HIV-1 subtype E in human placenta and vertical transmission. J Acquir Immune Defic Syndr 2005;40:545-50. |
|25.||World Health Organization. WHO Global Programme on AIDS 1991: Operational characteristics on commercially available assays to detect antibodies to HIV-1 and/or HIV-2 in human sera. Report 4. Geneva, WHO; 1991. p. 5. |
|26.||Kieffer MP, Hoffman H, Nlabhatsi B, Mahdi M, Kudiabor K, Wilfert C, et al. Repeat HIV testing in labor and delivery as a standard of care increases ARV provision for women who seroconvert during pregnancy. Program and abstracts of the 17 th Conference on Retroviruses and Opportunistic Infections (CROI); San Francisco, California; 2010. Abstract 156. |
|27.||Homsy J, Kalamya JN, Obonyo J, Ojwang J, Mugumya R, Opio C, et al. Routine intrapartum HIV counseling and testing for prevention of mother-to-child transmission of HIV in a rural Ugandan hospital. J Acquir Immune Defic Syndr 2006;42:149-54. |
|28.||Kharsany AB, Hancock N, Frohlich JA, Humphries HR, Abdool Karim SS, Abdool Karim Q. Screening for 'window-period' acute HIV infection among pregnant women in rural South Africa. HIV Med 2010;11:661-5. |
|29.||Joint United Nations Programme on HIV/AIDS and World Health Organization. AIDS epidemic update: December 2007. "UNAIDS/07.27EJC1322E". Available from: http://data.unaids.org/pub/EPISlides/2007/2007_epiupdate_en.pdf.[Last assessed on 2012 April 29].. |
|30.||Spina A. Nigeria's Mixed Epidemic: Balancing Prevention Priorities between Populations. Case Study Series. Arlington, VA: USAID's AIDS Support and Technical Assistance Resources, AIDSTAR-One, Task Order 1. AIDSTAR-One; 2011. Available from: http://www.aidstar-one.com. [Last assessed on 2012 April 29]. |
|31.||Federal Ministry of Health (FMOH), Nigeria. National Guidelines on the Prevention of Mother-to-Child Transmission (PMTCT) of HIV. Federal Ministry of Health, National AIDS and STI Control Programme. Nigeria: NASCP; 2010. p. 1-97. |
|32.||Kinuthia J, Kiarie J, Farquhar C, Richardson B, Nduati R, Mbori-Ngacha D, John-Stewart G. Co-factors for HIV incidence during pregnancy and the postpartum period. Program and abstracts of the 17 th Conference on Retroviruses and Opportunistic Infections (CROI) February 16-19, 2010. San Francisco; California: 2010. Abstract 155. |
|33.||Sagay AS, Musa J, Adewole AS, Imade GE, Ekwempu CC, Kapiga S, et al. Rapid HIV testing and counselling in labour in a northern Nigerian setting. Afr J Reprod Health 2006;10:76-80. |
|34.||Olatunji AO, Sule-Odu AO, Oladapo OT. Intrapartum HIV at a university hospital in Nigeria. Niger Med Pract 2008;53:113-6. |
|35.||Kongnyuy EJ, Mbu ER, Mbopi-Keou FX, Fomulu N, Nana PN, Tebeu PM, et al. Acceptability of intrapartum HIV counselling and testing in Cameroon. BMC Pregnancy Childbirth 2009;9:9. |
|36.||Lu L, Legwaila K, Motswere C, Smit M, Jimbo W, Creek T. HIV incidence in pregnancy and the first postpartum year and implications for PMTCT programs. Program and abstracts of the 16 th Conference on Retroviruses and Opportunistic Infections (CROI) February 8-11, 2009; Montreal, Quebec, Canada. 2009. Abstract 91. |
|37.||Cooper ER, Charurat M, Mofenson L, Hanson IC, Pitt J, Diaz C, et al. Combination antiretroviral strategies for the treatment of pregnant HIV-1-infected women and prevention of perinatal HIV-1 transmission. J Acquir Immune Defic Syndr 2002;29:484-94. |
|38.||Grobman WA, Garcia PM. The cost-effectiveness of voluntary intrapartum rapid human immunodeficiency virus testing for women without adequate prenatal care. Am J Obstet Gynecol 1999;181:1062-71. |
|39.||Gorsky RD, Farnham PG, Straus WL, Caldwell B, Holtgrave DR, Simonds RJ, et al. Preventing perinatal transmission of HIV - Costs and effectiveness of a recommended intervention. Public Health Rep 1996;111:335-41. |