Introduction

Nigeria, the most populous country in Africa with an estimated population of over 200 million, accounted for nearly fifteen percent of all newly acquired global HIV infections in children in 2019, with 22,000 estimated new child infections [1]. Despite the presence of a prevention of mother-to-child HIV transmission (PMTCT) program including HIV testing and antiretroviral therapy (ART), uptake of PMTCT services in Nigeria is low, with 43% of pregnant women living with HIV on ART and a mother-to-child transmission (MTCT) rate of 22% [1]. This low ART coverage among pregnant women can be partially attributed to low facility attendance for antenatal care (ANC) in pregnancy and low rates of health facility deliveries, since facility-based care provides an opportunity for HIV testing and enrollment in PMTCT services. In the 2018 Nigeria Demographic and Health Survey (NDHS), 67% of women who gave birth in the five years preceding the survey received ANC from a skilled provider, and 57% had at least four ANC visits. Only 39% of women delivered their last live birth in a health facility, with large variations in facility delivery by zone and state within the country [2]. In the 2018 Nigeria HIV/AIDS Indicator and Impact Survey, 77% of women who gave birth in the previous three years reported attending ANC, and 40% reported knowing their HIV status during pregnancy [3].

Various studies have demonstrated the effectiveness of engaging religious and community leaders to improve ANC attendance, HIV testing among pregnant women, and other PMTCT outcomes [4–6], and how faith-based responses to HIV differ from and may complement secular responses [7]. In the 2018 NDHS, 46.0% of Nigerians identified their religion as Catholic or other Christian, 53.5% Islam, and 0.5% Traditionalist or other [2]. Nigeria has a strong network of faith-based institutions with high religious service attendance, and faith plays a strong role in the social life of Nigerians [8].

In 2013, based on the strength of religious institutions and leaders in Nigeria and evidence supporting community engagement approaches for PMTCT, a cluster-randomized trial, the Healthy Beginning Initiative (HBI), tested the effectiveness of a faith-based congregational strategy for HIV testing among pregnant women in Enugu State, Nigeria [9]. The approach modified the baby shower that commonly occurs in the community (a reception held in honour of a pregnant woman where she plays pregnancy-related games and receives gifts from friends) into a celebratory gathering held at the church, with prayer, singing, dancing, group education, and health screening, including HIV testing for pregnant women and their male partners [10]. The HBI trial demonstrated improved uptake of HIV testing during pregnancy (OR 11.2, 95% CI 8.77–14.25), linkage to care before delivery (OR 6.2, 95% CI 2.14–18.25), and male partner testing (OR 12.0, 95% CI 9.63–14.79) in the intervention group compared to the controls [11].

Based on the favorable results of the HBI trial and persistent gaps in PMTCT service uptake, the US Centers for Disease Control (CDC)-Nigeria and the US National Institutes of Health supported Catholic Caritas Foundation of Nigeria (CCFN), APIN, University of Nigeria and the HBI research team to implement Baby Showers in Benue State, Nigeria from July 2016 to December 2018. In this paper, we report the findings from Baby Shower events conducted between July 2016 to October 2017, the time period for which linkage to ART was systematically collected for HIV-positive pregnant women and referred to as the study period. We also compare HIV testing coverage, positivity, yield, and ART linkage from Baby Shower events to the standard approach of facility-based ANC testing for pregnant women in Benue State in order to determine how Baby Shower results in the community setting compare to the standard of care.

Materials and methods

Results

Demographic characteristics

Between July 2016 and October 2017, the enrolled church congregations (n = 80) held 679 Baby Shower events, with a median event size of 30 participants (Interquartile range (IQR) 23 to 46 participants). In total, 16,243 individuals participated in Baby Shower events, including 10,056 pregnant women and 6,187 male partners. Approximately 62% (n = 6,187) of pregnant women attended the Baby Shower with a male partner.

Characteristics of female and male participants in Baby Shower events are shown in Table 1. The majority (80%, n = 8045) of female participants were between 20–34 years of age, and 14% of female participants were less than 20 years of age. No formal education was reported by 18% of female and 6% of male participants. Over 99% of women and men reported they were married. Eighty-eight percent of women and 77% of men identified their occupation as farmer.

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Table 1. Characteristics of female and male participants in Baby Shower events.

https://doi.org/10.1371/journal.pone.0260694.t001

HIV testing results

Acceptance of HIV testing at the Baby Shower events was nearly universal with 99.9% (n = 16,240) of participants tested for HIV. Overall, 7.2% of female and 4.0% of male participants tested HIV-positive (n = 724 and n = 249 respectively). Based on HIV test results and self-reported HIV testing history from the client questionnaire, 2.8% of females and 2.2% of males were classified as newly diagnosed with HIV (Table 2).

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Table 2. HIV testing and results for pregnant women and their male partners participating in Baby Shower events.

https://doi.org/10.1371/journal.pone.0260694.t002

Facility-based ANC/PMTCT data in Benue State

In the same geographic area and time period as Baby Shower events, health facilities reported greater than 99% ascertainment of HIV status among pregnant women at first ANC visit and HIV positivity among pregnant women of 8.4%, with 2.2% of women tested receiving a new HIV-positive diagnosis and all HIV-positive women linked to ART (100.1%) (Table 3).

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Table 3. PMTCT results from PEFPAR-supported health facilities in the 12 local government areas in Benue State where Baby Showers were conducted, October 2016-September 2017.

https://doi.org/10.1371/journal.pone.0260694.t003

Discussion

With training and ongoing implementation support, eighty churches in Benue State carried out Baby Showers events involving over sixteen thousand participants, nearly all of whom received HIV testing in addition to other educational and supportive interventions to improve maternal, child and family health. Nearly one thousand participants were identified as HIV-positive. CHAs provided supportive counseling for those already on ART to encourage ART adherence and supported linkage to ART for those who were newly diagnosed, with over 90% linkage to ART among HIV-positive pregnant women.

The HIV positivity of Baby Shower participants was slightly higher than HIV prevalence in Benue State established in the NAIIS survey (6.3% for females and 3.5% for males age 15–64 years) [3]. A significant proportion of female Baby Showers participants had established risk factors for HIV and/or low PMTCT uptake, including young age, low educational attainment, and not attending ANC, indicating that the Baby Showers included many women and families at risk [14–16]. Pregnant women participating in Baby Showers in Benue State reported lower ANC attendance (55.1% vs. 79.6%) and higher HIV positivity (7.2% vs. 2%) when compared to women enrolled in the Baby Showers trial in Enugu State, Nigeria in 2013–2014 [9]. Thus, Benue State and the selected sites seemed well-suited for this intervention, and these church-based events captured even more missed opportunities for PMTCT intervention than the previous cluster randomized trial that demonstrated the approach’s effectiveness.

The high acceptability of HIV testing using the congregation-based approach may be due to the influential role of religious leaders in supporting the Baby Showers as well as the engagement of the CHAs, volunteers who are active members of the church congregation and who provided counseling and support for women and their partners. Community and peer supporters have been shown to be effective in promoting uptake of PMTCT services [4, 17]. Linkage to ART for HIV-positive pregnant women in the Baby Showers implementation, while lower than in facility-based care in Benue State, was considerably higher than reported linkage from other community-based HIV testing interventions [18, 19]. Providing HIV results confidentially as part of a group, celebratory event is challenging, and participants who are newly diagnosed HIV-positive require ongoing support. Strengthening the role of CHAs in supporting participants’ psychosocial needs and linkage and retention on ART is a priority for this approach moving forward.

While male participation in Baby Showers events in Benue State was lower than in the HBI trial (62% vs. 89% male participation, respectively) [20], male participation in facility-based ANC/PMTCT services in sub-Saharan Africa are often reported around or below fifty percent, with significant variation by country and level of programming around male engagement [21–23]. Previous studies demonstrate that male participation in ANC and PMTCT services improve HIV testing uptake, PMTCT retention and infant outcomes, as well as male partner and family health [24–27]. The majority of men who tested HIV-positive in Baby Showers in Benue State were newly diagnosed (138 newly diagnosed HIV-positive male partners out of 249 HIV-positive overall), demonstrating the opportunity of this intervention for finding men and linking them to ART. In a published analysis of the Benue Baby Showers events focused on couples HIV testing results and male participation, the importance of testing male partners of HIV-positive women is noted, and future studies to understand the socio-cultural contexts that enhance male participation in Baby Shower events and HIV testing are recommended [28]. Additionally, index testing of male partners of HIV-positive women, even those who may not attend the events, could be incorporated into this intervention in future.

Extensive data were collected during the Baby Showers implementation in Benue State, with resources dedicated to data collection and management; yet, these data were limited by the biases of self-reported questionnaires, especially for HIV testing history, and contain some data quality gaps. For example, participants may report that they were newly diagnosed with HIV at the Baby Shower event, then later share that they were already on ART during the follow up visits to ensure ART linkage. For this analysis, the information on HIV testing history reported on the Baby Shower questionnaire was used, despite these known limitations. While data from Baby Showers events was of high quality, documentation of subsequent linkage to ART was less complete, and the extent of CHA tracking efforts as well as reasons for lack of linkage were often unclear.

The comparison of Baby Showers results to facility ANC/PMTCT data is imperfect since the congregational sites and health facilities may not have the exact same catchment area and represent slightly different time periods. Neither clients at health facilities or participants in congregational sites are necessarily representative of the general population in the geographic area. Despite these limitations, we report on a large number of pregnant women, and it is worth noting that the positivity and yield for HIV testing are comparable between the facility and community-based HIV testing. The Baby Showers identified many HIV-positive individuals not receiving facility-based services; in this and similar settings with low ANC attendance, community-based approaches to MCH and PMTCT care are particularly important to complement facility services, with opportunities for communities to link individuals to health facilities and also for communities to provide ongoing support for retention in clinical care.

Despite significant financial investments in HIV programs, we were far from reaching the UNAIDS and PEPFAR Start Free-Stay Free-AIDS Free target of less than 20,000 new child HIV infections in 2020 [1]. The health care systems in many low and middle-income countries are not equipped to manage HIV care alone. Community engagement and community-based interventions are needed to ensure high quality, client-centered care, as well as to share some of the health facility workload in terms of ART adherence support and retention tracking.

The Baby Showers approach uses multicomponent events (not focused on HIV alone) and subsequent follow-up by peer volunteers in Christian church congregations to improve PMTCT uptake, but may be adapted for other settings and health challenges. Baby Showers may incorporate other HIV-related services, such as testing other children in the family and connection with orphans and vulnerable children (OVC) programming, as well as non-HIV related services. The Baby Shower approach exemplifies innovations that leverage social networks and faith-based structures to expand testing and linkage to care for a high burden health condition. Given the large Muslim population in Nigeria, there is proposed work to adapt Baby Showers for the Muslim community and mosques, and this approach could be expanded to other religious and community institutions. Broad maternal, child and sexual health interventions, integrated chronic disease screenings, and evaluation for tuberculosis and other stigmatized conditions could be addressed through similar faith-based and community-oriented approaches.

The Baby Showers approach and similar integrated, multicomponent interventions can improve the efficiency of service provision at the community level. Health screenings, education, linkage to facility care, and client tracking can be done for communicable and non-communicable health conditions, using the same manpower and resources. Such approaches have the potential to improve the efficiency, quality, acceptability, and sustainability of care, especially in resource-limited settings.

Supporting information

Acknowledgments

The authors acknowledge the support from the clergy leadership, community leaders at participating sites, staff of the participating health facilities, the pregnant women and their partners. The authors are indebted to the many staff members of Caritas Nigeria and the Center for Translation and Implementation Research (CTAIR) of the University of Nigeria, Nsukka, Enugu who made the Baby Shower events a joyful experience for the participating pregnant women and their partners.

Disclaimer: The findings and conclusions in this paper are those of the authors and do not necessarily represent the official position of the funding agencies.