Conditional cash transfers to prevent mother-to-child transmission in low facility-delivery settings: evidence from a randomised controlled trial in Nigeria

Jenny X Liu,Nancy Padian,Nicholas Wilson,Svetha Janumpalli,Patrick Stadler,Jennifer Shen

doi:10.1186/s12884-019-2172-3

Abstract

BackgroundNigeria suffers from the highest burden of mother-to-child transmission worldwide. To increase retention in care and prevention programmes, we piloted and evaluated a conditional cash transfer (CCT) programme for preventing mother-to-child transmission (PMTCT) in Akwa Ibom, Nigeria.MethodsIn a randomised controlled trial, pregnant women testing positive for HIV during antenatal care registration at three public hospitals were randomised to one of two study arms: (1) offered enrolment into the CCT programme or (2) continue in standard care for (PMTCT). In the CCT programme, women could receive a compensation package totaling 33,300 Naira (~US$114) for enroling, delivering at the facility, and obtaining a newborn early infant diagnosis (EID) test. The intent-to-treat (ITT) and per protocol (PP) effects of the programme on the primary outcomes of facility delivery and EID testing and on the secondary outcome of nevirapine administration were estimated with logistic regressions.ResultsFrom August 1, 2015 to April 19, 2017, 554 pregnant women tested positive for HIV; 273 were randomised to standard care and 281 were offered enrolment into the CCT intervention. Women offered the CCT programme were more likely to give birth at the facility (n = 109/263; 41.4%) compared to women in standard care (n = 80/254; 31.5%), an absolute difference of 9.9% (OR = 1.54, 95% CI: 1.07–2.21, p = 0.019). For EID testing there was an absolute difference of 12.8% between those offered the CCT intervention (n = 69/263; 26.2%) and those in standard care (n = 34/254; 13.4%; OR = 2.30, 95% CI 1.46–3.62, p = 0.000). PP results show larger differences for both facility deliveries (16.7% absolute difference; OR = 2.02, 95% CI 1.38–2.98, p = 0.000) and EID testing (18.9% absolute difference; OR = 3.09, 95% CI 1.93–4.94, p = 0.000) among intervention enrolees. Over 86% of the facility-delivered newborns received nevirapine, and ITT and PP estimates were similar to those for facility deliveries.ConclusionsResults show that CCTs improved the likelihood of HIV-positive women giving birth at a facility, of nevirapine being administered to their newborn, and of undergoing EID testing in Akwa Ibom, Nigeria. Effects are especially large among those who agreed to participate in the CCT intervention.Trial registrationClinicalTrials.gov NCT02447159, May 18, 2015.

Highlights

Nigeria suffers from the highest burden of mother-to-child transmission worldwide
This paper reports on the effects of the conditional cash transfer (CCT) intervention on the primary outcomes of facility delivery and early infant diagnosis (EID) testing and on the secondary outcome of nevirapine administration
Part 2 of Transfer 1 was available for retrieval at a bank 1 day after enrolment after antenatal care (ANC) registration plus 300 Naira (~US$1) of mobile phone credits (“Transfer 1”); 20,000 Naira (~US$70) when the participant gave birth at the same health facility where she registered for ANC (“Transfer 2”); and 6000 Naira (~US$20) when she returned to the facility to obtain an early infant diagnosis (EID) test for Human immunodeficiency virus (HIV) (“Transfer 3”)

Summary

Introduction

Nigeria suffers from the highest burden of mother-to-child transmission worldwide. HIV transmission from mother to child is preventable, but requires adherence to the many steps involved in the PMTCT cascade, including initiating antenatal care, HIV testing and result retrieval, adhering to antiretroviral (ARV) treatment, adhering to infant treatment including nevirapine administration at birth, and newborn follow-up testing and care [4]. With timely access to antiretrovirals, HIV-positive pregnant women can improve their own health while providing prophylaxis to prevent HIV transmission during pregnancy and reduce rates of transmission from mother to child to less than 5% [2, 5]. Nigeria continues to struggle with high unmet need for PMTCT; of the over 192,000 infected pregnant women in 2013, fewer than 58,000 received some PMTCT services, resulting in a coverage rate of only 30% [6]. Woman may fear involuntary HIV disclosure and associated negative community reactions due to prevailing social norms, including challenges engaging men in prevention and lack of knowledge about appropriate care and treatment [11,12,13,14,15]

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