Int Health 2019; 11: 240–249 doi:10.1093/inthealth/ihz018 Advance Access publication 27 April 2019 Towards the elimination of mother-to-child transmission of HIV in Nigeria: a health system perspective of the achievements and challenges Babayemi O. Olakunde a,b, *, Daniel A. Adeyinka c,d , John O. Olawepo a , Jennifer R. Pharr a , Chamberline E. Ozigbu d,e , Sabastine Wakdok b , Tolu Oladele b and Echezona E. Ezeanolue f,g a Department of Occupational and Environmental Health, School of Public Health, University of Nevada, Las Vegas, 4505 S Maryland Pkwy, Las Vegas, NV 89154, USA; b National Agency for the Control of AIDS, Plot 823, Ralph Shodeinde Street, Central Business District, Abuja, Nigeria; c Department of Community Health and Epidemiology, University of Saskatchewan, 104 Clinic Place, Saskatoon, SK, Canada; d National AIDS & STIs Control Programme, Federal Ministry of Health, Plot 75, Ralph Sodeinde Street, Central Area, Abuja, Nigeria; e Department of Health Services Policy and Management, Arnold School of Public Health, University of South Carolina, 915 Greene Street, Columbia, SC 29208, USA; f Department of Pediatrics and Child Health, College of Medicine, University of Nigeria, 1, Old UNTH Road, Nsukka, Enugu, Nigeria; g HealthySunrise Foundation, 308 South Jones Blvd, Las Vegas, NV 89107, USA *Corresponding author: Tel: +1 240 883 1582; E-mail: olakunde@unlv.nevada.edu; boolakunde@yahoo.com Received 4 October 2018; revised 28 February 2019; editorial decision 8 March 2019; accepted 9 March 2019 Despite its scaled-up response for prevention of mother-to-child transmission of HIV (PMTCT), Nigeria still contri- butes the greatest number of infants infected with HIV worldwide. Drawing on our knowledge, and review of policy documents and research papers, we explored the achievements and challenges in the elimination of mother-to- child transmission of HIV in Nigeria using the WHO’s health systems framework. We found that Nigeria has increased the number of PMTCT sites, decentralized and integrated PMTCT care for expanded service delivery, adopted task-shifting to address the shortage of skilled healthcare providers, explored alternative sources of domestic funding to bridge the funding gap and harmonized the health management information system to improve data quality. Some of the challenges we identified included: difficulty in identifying HIV-infected pregnant women because of low uptake of antenatal care; interrupted supplies of medical commodities; knowledge gaps among healthcare workers; and lack of a national unique identifying system to enhance data quality. While there have been some achievements in the PMTCT program, gaps still exist in the different blocks of the health system. Elimination of mother-to-child transmission of HIV in Nigeria will require the implementation of feasible, culturally acceptable and sustainable interventions to address the health system-related challenges. Keywords: challenges, health system, HIV, Nigeria, prevention of mother-to-child transmission, achievements Background In the absence of a vaccine for primary prevention, the availabil- ity of highly active antiretroviral therapy (ART) has been pivotal in the global response to the HIV epidemic. Over the years, the use of antiretroviral (ARV) drugs has advanced from simply treating HIV-infected persons to preventing transmission of the infection. 1 One of such important preventive uses of ARV is in averting perinatal transmission of HIV, which accounts for the majority of HIV infection in children aged <15 y. 2 Multiple studies since the 1990s have shown that ARV drugs are efficacious in reducing the risk of mother-to-child transmission of HIV. 3,4 Despite the proven effectiveness of ART, a number of chil- dren in sub-Saharan African countries like Nigeria still acquire HIV through vertical transmission. In 2017, according to the joint United Nations program on HIV/AIDS (UNAIDS) estimates, 159 000 of the 180 000 new infections among children globally occurred in sub-Saharan Africa, and Nigeria alone accounted for 23% of these new infections in the subregion. 5 Annually, Nigeria is estimated to have 160 000 HIV-infected pregnant women requiring ARV, making it the second largest globally after South Africa. 5 The national prevention of mother-to-child transmission of HIV (PMTCT) program in Nigeria started in 2002, 6 following the return of a democratic government in 1999, which launched an expanded HIV response. 7 However, limited coverage of PMTCT services has continued to affect the country’s performance in reducing new infections among children. Among the 22 priority countries that were targeted by the UNAIDS global plan of elim- inating new HIV infections among children by 2015, Nigeria’s performance was the poorest, a 21% reduction in new infec- tions among children from 2009–2015. 8 Over this period, ARV coverage for PMTCT increased from 14% in 2009 to 30% in REVIEW © The Author(s) 2019. Published by Oxford University Press on behalf of Royal Society of Tropical Medicine and Hygiene. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com. 240 Downloaded from https://academic.oup.com/inthealth/article/11/4/240/5480911 by guest on 12 June 2022