Improving uptake of prevention of mother-to-child HIV transmission services in Benue State, Nigeria through a faith-based congregational strategy.

BACKGROUND: Nigeria has low antiretroviral therapy (ART) coverage among HIV-positive pregnant women. In a previous cluster-randomized trial in Nigeria, Baby Shower events resulted in higher HIV testing coverage and linkage of pregnant women to ART; here, we assess outcomes of Baby Shower events in a non-research setting.
METHODS: Baby Shower events, including a prayer ceremony, group education, music, gifting of a "mama pack" with safe delivery supplies, and HIV testing with ART linkage support for HIV-positive pregnant women, were conducted in eighty sites in Benue State, Nigeria. Client questionnaires (including demographics, ANC attendance, and HIV testing history), HIV test results, and reported linkage to ART were analyzed. Descriptive data on HIV testing and ART linkage data for facility-based care at ANC clinics in Benue State were also analyzed for comparison.
RESULTS: Between July 2016 and October 2017, 10,056 pregnant women and 6,187 male partners participated in Baby Shower events; 61.5% of women attended with a male partner. Nearly half of female participants (n = 4515, 44.9%) were not enrolled in ANC for the current pregnancy, and 22.3% (n = 2,241) of female and 24.8% (n = 1,532) of male participants reported they had never been tested for HIV. Over 99% (n = 16,240) of participants had their HIV status ascertained, with 7.2% of females (n = 724) and 4.0% of males (n = 249) testing HIV-positive, and 2.9% of females (n = 274) and 2.3% of males (n = 138) receiving new HIV-positive diagnoses. The majority of HIV-positive pregnant women (93.0%, 673/724) were linked to ART. By comparison, at health facilities in Benue State during a similar time period, 99.7% of pregnant women had HIV status ascertained, 8.4% had a HIV-positive status, 2.1% were newly diagnosed HIV-positive, and 100% were linked to ART.
CONCLUSION: Community-based programs such as the faith-based Baby Shower intervention complement facility-based approaches and can reach individuals who would not otherwise access facility-based care. Future Baby Showers implementation should incorporate enhanced support for ART linkage and retention to maximize the impact of this intervention on vertical HIV transmission.

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

Implementation setting and site selection

Benue State is located in north-central Nigeria, is predominantly Christian, and is one of the states with the highest HIV prevalence in Nigeria (4.8% HIV prevalence among age 15–64 year-olds in Benue State vs. 1.4% nationally) [3]. Within Benue State, health facilities with HIV and PMTCT programs receive support through the US President’s Emergency Plan for AIDS Relief (PEPFAR), and data on HIV testing among pregnant women, ART uptake, and other HIV indicators are reported by health facilities to PEPFAR on a quarterly basis. In ANC settings, all pregnant women with unknown HIV status should be tested for HIV at the first ANC visit per national guidelines [12].

Across 12 local government areas (LGAs) in Benue State, 101 churches were assessed and, of these, eighty churches were selected and enrolled into the Baby Showers program. Sites were selected based on the capacity and willingness of the church, congregational size, and accessibility, including proximity to a health facility.

Description of Baby Showers implementation

A detailed description of the Baby Showers approach has been published previously [9]. The preparatory phase involved adaptation of standard procedures and tools from research for a programmatic context, site selection, community mobilization, church sensitization, enrollment and training. Once enrolled and trained, sites were activated to begin conducting Baby Shower events. During church service prior to each Baby Shower event, the priest or pastor invited pregnant women and their male partners in the congregation to approach the altar for a prayer session and then to attend the Baby Shower. At the Baby Shower event, potential participants were assessed for eligibility. Inclusion criteria for female participants included a visible pregnancy; women who had previously attended a Baby Shower event in the current pregnancy were excluded. Inclusion criteria for male participants included being a male partner of an eligible pregnant woman. Eligible participants were given information about the Baby Shower event, and verbal consent to participate was ascertained.

The Baby Shower event, typically held after the church service, included group health education, celebratory singing and dancing, gifting of a “mama pack” with safe delivery supplies, and health screening, including weight and blood pressure measurement, as well as HIV and other integrated testing. Baby Receptions were later held as celebrations of birth for new parents and their infants. Trained volunteers called Church Health Assistants, or CHAs, tracked consenting HIV-positive pregnant women and their HIV-exposed infants to support and ensure linkage to PMTCT services including ART at a health facility of their choice.

At Baby Shower events, HIV testing for pregnant women and their male partners was conducted by trained CHAs according to the national HIV testing algorithm using Determine (Abbott Laboratories, IL, US), Uni-Gold (Trinity BioTech, ROI), and Stat-Pak (Inverness Medical-Biostar Inc., DE, US) rapid HIV antibody tests as appropriate [12]. Written consent was obtained for HIV testing. In alignment with Nigerian national guidelines for HIV testing services, young people under the 18 who were married, pregnant or sexually active were considered “mature minors” and were able to give their own consent for HIV testing services.

Pregnant women who tested HIV-positive were asked if they were already on ART. CHAs tracked consenting HIV-positive women not yet on ART to ensure linkage to ART. Where possible, CHAs escorted the women to the health facility, serving as a support system and to observe linkage to ART. Where not possible to escort women (based on distance, timing, or client preference), CHAs tracked women through phone calls and home visits to ask about linkage to ART. Health facility records were not reviewed in this evaluation.

Data collection and data management

At Baby Shower events, each participant completed a pre-tested semi-structured questionnaire, including socio-demographic information (sex, age, marital status, highest educational attainment, occupation), HIV testing history, and pregnancy history (for women only) (S1 Questionnaires). Questionnaire results and health screening results, including HIV testing, were entered into a de-identified Microsoft Access database with linked participant ID numbers for pregnant women and their male partners. The code linking the de-identified data and participants ID were kept separately in locked storage by study leads to prevent unintended disclosure of protected health information.

Linkage of HIV-positive pregnant women to ART was recorded by CHAs and entered in an Excel database. Women were documented as linked to ART if they were already on ART at the time of testing, were observed to start ART when escorted to the health facility, or verbally reported starting ART during the pregnancy period but after time of testing. For women not linked to ART, the CHA was able to document a reason for lack of ART linkage.

Data analysis

We reviewed the program data from a cohort of self-identified pregnant women and their male partners who participated in Baby Shower events during the study period and compared these results to program data from PEPFAR-supported PMTCT facilities in the same geographic area for a similar time period.

The Baby Shower and linkage databases were merged in STATA14, and descriptive analyses were conducted with frequencies and proportions for demographic, HIV testing, and pregnancy-related variables. HIV testing coverage, positivity, yield and linkage to ART in community-based Baby Showers events were compared to ANC/PMTCT data from PEPFAR-supported health facilities for approximately the same time period (PEPFAR annual program results for October 2016-September 2017) in the 12 LGAs participating in Baby Showers in Benue State. PEPFAR data were obtained from PEPFAR publicly available datasets and programmatic reporting [13].

For both congregation-based and facility-based analyses, four key variables are evaluated for pregnant women: HIV testing coverage, HIV positivity, HIV testing yield, and linkage to ART. HIV testing coverage refers to the proportion of pregnant women who have a known HIV status (either newly tested for HIV or previously known to be HIV-positive). HIV positivity among pregnant women refers to the proportion of pregnant women who are HIV-positive, both those who are previously known to be HIV-positive and those who are newly diagnosed. HIV testing yield refers to the proportion of women tested who newly test HIV-positive. Linkage to ART refers to the proportion of HIV-positive pregnant women who are on ART. For this analysis, both women previously on ART and those who newly start ART were considered linked to ART.

Ethical considerations

Participation in Baby Showers was voluntary. Verbal consent was provided for participation in Baby Shower events, and written consent was obtained prior to HIV testing of participants. HIV testing and subsequent tracing for linkage to care were conducted in alignment with the national HIV testing program guidelines [12]. Ethical approvals from the Nigeria National Health Research Ethics Committee and the Health Research Ethics Committee of the University of Nigeria Teaching Hospital, Enugu, Nigeria were obtained to conduct an analysis of the de-identified program data and publish the findings. The protocol was also reviewed in accordance with the Centers for Disease Control and Prevention (CDC) human research protection procedures and was determined to be research, but CDC investigators did not interact with human subjects or have access to identifiable data or specimens for research purposes.

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.

Table 1

Characteristics of female and male participants in Baby Shower events.

	Females (n = 10,056)		Males (n = 6,187)		Total (n = 16,243)
	n	%	n	%	n	%
Age categories, years
<20	1442	14.3%	103	1.7%	1545	9.5%
20–24	3978	39.6%	912	14.7%	4890	30.1%
25–29	2726	27.1%	1541	24.9%	4267	26.3%
30–34	1341	13.3%	1406	22.7%	2747	16.9%
35–39	414	4.1%	978	15.8%	1392	8.6%
≥40	155	1.5%	1247	20.2%	1402	8.6%
Education level
No formal education	1803	17.9%	351	5.7%	2154	13.3%
Completed primary school	2963	29.5%	1126	18.2%	4089	25.2%
Completed secondary school	4650	46.2%	3579	57.9%	8229	50.6%
Attended/completed post-secondary education	640	6.4%	1131	18.3%	1771	10.9%
Occupation
Farmer	8482	84.4%	4415	71.4%	12897	79.4%
Trader	623	6.2%	444	7.2%	1067	6.6%
Unemployed	229	2.3%	336	5.4%	565	3.5%
Civil Servant	169	1.7%	344	5.6%	513	3.2%
Other occupation	260	2.6%	325	5.3%	585	3.6%
More than one occupation	293	2.9%	323	5.2%	616	3.8%
Marital status
Married	9946	98.9%	6181	99.9%	16127	99.2%
Single	23	0.2%	4	<0.1%	27	0.2%
Separated/Divorced	20	0.2%	0	0.0%	20	0.1%
Widowed	67	0.7%	2	<0.1%	69	0.4%

ANC attendance and HIV testing history

Among pregnant women, 55.1% (n = 5,541) reported that they were enrolled in ANC for the current pregnancy. Of 10,055 pregnant women with self-reported gestational age and ANC enrollment status, the proportion of women enrolled in ANC increased based on the trimester of current pregnancy, with 38.1% ANC enrollment among women in the first trimester of pregnancy, 50.4% among women in the second trimester, and 63.7% of women in the third trimester. Nearly one quarter of participants reported that they had never had a HIV test before (22.3%, n = 2,241 female participants and 24.8%, n = 1,532 male participants, respectively).

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).

Table 2

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

	Females (n = 10,056)	Males (n = 6,187)
Individuals tested, n (%)	10,055 (>99.9%)	6,185 (>99.9%)
HIV positive, n (%)	724 (7.2%)	249 (4.0%)
Newly diagnosed, n (%)	274 (2.9%)	138 (2.3%)
Previously known, n (%)	450 (4.5%)	111 (1.8%)

Linkage of HIV-positive pregnant women to ART

Over 90% of HIV-positive pregnant women (n = 673) were linked to ART, including both women who were previously on ART and those started ART after the Baby Shower. Of 51 HIV-positive pregnant women recorded as not linked to ART, 26 (51.0%) had unknown reasons for failed linkage. Among the remaining women, reasons provided for not being linked to ART were unable to reach client (52%, n = 13), not ready because of issues with their male partner (20%, n = 5), client moved (8%, n = 2), and refused ART (8%, n = 2).

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).

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.

Indicator	Pregnant women at designated health facilities, N (%)
Pregnant women enrolled in ANC	75676
Pregnant women with HIV status ascertained at first ANC visit	75469 (99.7%)
HIV-positive pregnant women	6367 (8.4%)
Newly diagnosed HIV-positive	1577 (2.1%)
Previously known HIV-positive	4790 (6.3%)
HIV-positive pregnant women on ART*	6375 (100.1%)

*The number of HIV-positive pregnant women on ART may be greater than number of HIV-positive pregnant women, as in this case, due to either programmatic data quality issues or because women may be diagnosed and started on ART in different reporting periods for these cross-sectional indicators.

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.

This is the Excel data file for Baby Showers participants and linkage of HIV-positive pregnant women to ART.

(XLSX)

Click here for additional data file.

This file contains the questionnaires used in the Baby Shower events, including the registration/biodata form (used for both female and male participants), the male health questionnaire, the female health questionnaire, and the clinical TB and HIV screening form (used for both female and male participants).

(PDF)

Click here for additional data file.

14 Jun 2021

PONE-D-20-35814

Improving uptake of prevention of mother-to-child HIV transmission services in Benue State, Nigeria through a faith-based congregational strategy

PLOS ONE

Dear Dr. Montandon,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Both reviewers have identified a number of points that should be addressed thoroughly in a revision of your manuscript. Please ensure you carefully work through all of the issues they have highlighted.

Please submit your revised manuscript by Jul 28 2021 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.

A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.

An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols.

We look forward to receiving your revised manuscript.

Kind regards,

Jamie Males

Staff Editor

PLOS ONE

Journal Requirements:

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

When submitting your revision, we need you to address these additional requirements.

1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at

and

https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf

2. Please include additional information regarding the survey or questionnaire used in the study and ensure that you have provided sufficient details that others could replicate the analyses. For instance, if you developed a questionnaire as part of this study and it is not under a copyright more restrictive than CC-BY, please include a copy, in both the original language and English, as Supporting Information.

3. In your Methods section, please provide additional information about the participant recruitment method and the demographic details of your participants. Please ensure you have provided sufficient details to replicate the analyses such as:

- a description of any inclusion/exclusion criteria that were applied to participant recruitment

- a statement as to whether your sample can be considered representative of a larger population.

4. In the Methods, please clarify that participants provided oral consent. Please also state in the Methods:

- Why written consent could not be obtained

- Whether the Institutional Review Board (IRB) approved use of oral consent

- How oral consent was documented

For more information, please see our guidelines for human subjects research: https://journals.plos.org/plosone/s/submission-guidelines#loc-human-subjects-research

5. You indicated that you had ethical approval for your study. In your Methods section, please ensure you have also stated whether you obtained consent from parents or guardians of the minors included in the study or whether the research ethics committee or IRB specifically waived the need for their consent.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Partly

Reviewer #2: Yes

**********

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: N/A

Reviewer #2: Yes

**********

3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

**********

4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

**********

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: This is a well-written manuscript, describing an effective initiative that was evaluated through a methodologically sound process. It should be published. However, there are some elements that require clarification.

1) P. 5, line 71: Can the authors note whether the baby shower event reflects an existing cultural practice in Nigeria, whether it is an adaptation of such a practice, or whether this is a new event introduced into the community.

2) P 6, line 93ff: Please say a bit more about your selection process of these congregations. How many churches were considered initially? What exclusion criteria were utilized to the this number down to the 80 eventually chosen? How large were these congregations? Were they all Roman Catholic parishes (and if so, it would be helpful to note whether plans are underway to expand this to non-Catholic Christian communities when noting that such plans are underway to expand to Muslim communities).

3) P.7, lines 109-112: Did you assess whether finding out HIV status in a public setting such as this might elicit worry or trigger negative feelings (e.g., shame) in women or men who test positive? Some discussion on considerations regarding this possibility would be helpful if you did indeed consider it.

4) P. 9, lines 150-159: The "Ethical Considerations" sub-section seems misplaced to me as a reader. Shouldn't it be placed ahead of "Data collection and management?"

5) P. 11, lines 188-193: It would interesting to include a specific breakdown of the percentage of women who were newly diagnosed who did not follow up with referral to care. As is, your discussion of the 51 who did not follow up doesn't distinguish between those newly diagnosed and those already aware of their HIV status.

6) P. 13, lines 230-231. The participation rate among men was far lower in your program in Benue State than that of men in the trial. Do you have any data as to why this is so or do you have any assumptions (even if not verified with data) that you could include in a discussion as to possible reasons for this discrepancy?

7) P 14, lines, lines 244-246: You note that the documentation of linkage to care and reasons for unsuccessful linkages was not robust or clear. Can you discuss how you intend to address this in subsequent baby shower programs?

8) THIS IS THE MOST IMPORTANT ELEMENT I WOULD ASK YOU TO ADDRESS: In reading the manuscript, I noted from as early as page 3 (lines 41-43) that comparing results from the baby showers to results from ANC clinics was a bit of an "apple/orange" comparison. I was glad to see the authors acknowledge this themselves and note that the results from the baby shower programs was significantly higher than those from other community based programs (p. 13, lines 226-228). I believe you need to highlight this more clearly and earlier in your manuscript. Clearly lay out that you comparison is indeed looking at cohorts from two very different settings (one clinical and one community-based). Explain why you are making this comparison (I assume you don't have access to the data from similar community initiatives-- if you can access these data, I would include you to include a discussion comparing your program to those in other community settings), and highlight the outcomes from your program (which are impressive as reported) as yielding comparable results as those from a clinical setting. In short, please describe the issue of the differences in setting and how your program yielded outcomes that were nonetheless comparable to those from a clinical program.

Reviewer #2: I find this a very interesting research project which is written up clearly in this article. I think there could be a bit more literature cited and discussed in relation to the unique role of churches and church organizations in responding to HIV&AIDS. I recommend the authors look at my work on this in South Africa and browse the references for other material. It can be cited as follows: Deborah Simpson (2018) “Bringing back hope”: how faith-based responses to HIV and AIDS differ from secular responses, African Journal of AIDS Research, 17:2, 175-182,

DOI: 10.2989/16085906.2018.1478313 and the link to this article is available here: https://doi.org/10.2989/16085906.2018.1478313. Though this is a qualitative study, I believe it will be useful in framing why religious leaders carry so much sway in HIV education, testing, and advocacy. Other than that, it is a convincing and clear article which nicely captures an interesting PEPFAR-funded research project.

**********

6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: Yes: John B. Blevins

Reviewer #2: Yes: Dr. Deborah Simpson

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

23 Jul 2021

Dear Editors/Reviewers,

Thank you for your careful review of our manuscript entitled “Improving uptake of prevention of mother-to-child HIV transmission services in Benue State, Nigeria through a faith-based congregational strategy” (PONE-D-20-35814).

We greatly appreciate your comments. We have revised the manuscript and provided responses to each of the points below.

Journal requirements

1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming.

We reviewed the PLOS ONE style requirements and have ensured that the manuscript fulfills all criteria. To the best of our knowledge, the reference list is complete and current. We added an additional reference as suggested by Reviewer 2, noted below.

2. Please include additional information regarding the survey or questionnaire used in the study and ensure that you have provided sufficient details that others could replicate the analyses. For instance, if you developed a questionnaire as part of this study and it is not under a copyright more restrictive than CC-BY, please include a copy, in both the original language and English, as Supporting Information.

The Baby Shower questionnaires have been added as Supporting Information 2 and referenced in the Methods. This includes the Registration/biodata form (used for both female and male participants), the male health questionnaire, the female health questionnaire, and the clinical TB and HIV screening form (used for both female and male participants).

3. In your Methods section, please provide additional information about the participant recruitment method and the demographic details of your participants. Please ensure you have provided sufficient details to replicate the analyses such as:

- a description of any inclusion/exclusion criteria that were applied to participant recruitment

- a statement as to whether your sample can be considered representative of a larger population.

Thank you for noting the need for additional information on recruitment and eligibility. This was added to the Methods section. The subheading was changed to “Description of Baby Showers implementation” to include recruitment, eligibility, and enrollment.

The demographic details of participants are found in Table 1.

A statement noting that participants in congregational sites are not necessarily representative of a larger population was noted as a limitation in the Discussion section (line 268).

4. In the Methods, please clarify that participants provided oral consent. Please also state in the Methods:

- Why written consent could not be obtained

- Whether the Institutional Review Board (IRB) approved use of oral consent

- How oral consent was documented

For more information, please see our guidelines for human subjects research: https://journals.plos.org/plosone/s/submission-guidelines#loc-human-subjects-research

We have clarified the consent process in the Methods section “Description of Baby Showers implementation.” Oral consent to participate in the Baby Showers event was obtained from all participants, and written consent was obtained prior to HIV testing. Following oral consent, participants were entered in a participant log and assigned a Member ID # that was used on all subsequent documentation (see Supplemental Information 2). Written consent forms were kept in a locked cabinet in a study office in Enugu, Nigeria. This consent process was approved by the Nigeria National Health Research Ethics Committee, the Health Research Ethics Committee of the University of Nigeria Teaching Hospital, and the US Centers for Disease Control.

5. You indicated that you had ethical approval for your study. In your Methods section, please ensure you have also stated whether you obtained consent from parents or guardians of the minors included in the study or whether the research ethics committee or IRB specifically waived the need for their consent.

We added this sentence in the Methods section to answer this question: “In alignment with Nigerian national guidelines for HIV testing services, young people under the 18 who were married, pregnant or sexually active were considered “mature minors” and were able to give their own consent for HIV testing services.” This process for consent of minor was approved by research ethics committees.

Reviewer 1

1) P. 5, line 71: Can the authors note whether the baby shower event reflects an existing cultural practice in Nigeria, whether it is an adaptation of such a practice, or whether this is a new event introduced into the community.

While baby showers (receptions held in honour of a pregnant woman where she plays pregnancy-related games and receives gifts from friends, usually, items she would need during delivery or immediately after birth) occur commonly in Nigeria, church-organized group baby showers are not typical. Adapting the personal baby shower to a church-based group event that incorporates health screenings and HIV testing is part of the innovation of this approach.

To clarify this point, we altered the description of the Baby Shower intervention in the introduction section (line 72) to state:

“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.”

2) P 6, line 93ff: Please say a bit more about your selection process of these congregations. How many churches were considered initially? What exclusion criteria were utilized to the this number down to the 80 eventually chosen? How large were these congregations? Were they all Roman Catholic parishes (and if so, it would be helpful to note whether plans are underway to expand this to non-Catholic Christian communities when noting that such plans are underway to expand to Muslim communities).

Thanks for these questions. We added to the Methods section that 101 churches were evaluated, and of these, 80 churches were selected as well-suited for Baby Showers implementation. As noted in the methods, the churches were selected based on the capacity/willingness of church (includes adequate space and volunteers), congregational size, and accessibility, including proximity to a health facility. The 21 churches that were evaluated but not selected did not meet one or more of these criteria. The churches were both NKST (translates to “Universal Reformed Christian Church," a Christian Reformed church based in Nigeria) and Catholic, the two main churches in Benue State. The initial RCT in Enugu state also involved both Catholic and non-Catholic churches.

3) P.7, lines 109-112: Did you assess whether finding out HIV status in a public setting such as this might elicit worry or trigger negative feelings (e.g., shame) in women or men who test positive? Some discussion on considerations regarding this possibility would be helpful if you did indeed consider it.

There were challenges around providing HIV results in a private, confidential way during a celebratory, group event. The positive results were typically given toward the end of the event, and the church health assistants (CHAs) followed up with positive clients as noted in the paper to provide additional support and ensure linkage to treatment, since it is often hard to process the results on the first day. We are also planning to publish a manuscript/brief on implementation lessons learned (i.e. taking the Baby Showers from research to practice) that will delve into these issues further. We agree that it is an important point to mention, however, and we edited an existing paragraph in the discussion to include this point (line 241-244):

“Providing HIV results confidentially as part of a group, celebratory event is challenging, and participants who are newly diagnosed HIV-positive in any circumstance and setting 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.”

4) P. 9, lines 150-159: The "Ethical Considerations" sub-section seems misplaced to me as a reader. Shouldn't it be placed ahead of "Data collection and management?"

This is not specified in author instructions, and it appears that published manuscripts from PLOS ONE include the ethics section in different parts of methods. Because the ethical review involved all aspects of methods (including data management and analysis), we included it at the end of the methods section, but are open to changing the order as preferred by the editor.

5) P. 11, lines 188-193: It would interesting to include a specific breakdown of the percentage of women who were newly diagnosed who did not follow up with referral to care. As is, your discussion of the 51 who did not follow up doesn't distinguish between those newly diagnosed and those already aware of their HIV status.

Thank you for this excellent point. We would have liked to do this breakdown, but the distinction between newly diagnosed and those already aware of their HIV status was complicated. For the new vs. known data presented in the paper, we use the information from the Baby Shower questionnaire. However, when participants were followed up to ensure linkage to ART, we often received different information about whether they previously knew their HIV status. It was then difficult to decide which self report to use for ART linkage analysis. We alluded to this in the limitations section, but further detailed this issue with the text (line 260):

“…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.”

6) P. 13, lines 230-231. The participation rate among men was far lower in your program in Benue State than that of men in the trial. Do you have any data as to why this is so or do you have any assumptions (even if not verified with data) that you could include in a discussion as to possible reasons for this discrepancy?

One possibility is that in a more routine implementation setting, without the intensive support of a RCT, there was less active recruitment of male participants.

In a related publication from this study that focuses specifically on male testing (Gbadamosi et al, PLOS ONE, January 2019), the discussion notes:

“It is unclear why our findings are inconsistent with those of the HBI trial. The different cultural contexts in which HBI was conducted may offer a plausible explanation. Gender norms that have a strong influence on male partners’ involvement in pregnancy-related events[33,34] may be more pronounced in this setting compared to the southeastern region of Nigeria. Future studies to understand the socio-cultural contexts that enhance male participation in HTS may be beneficial in designing culturally acceptable and scalable partner testing interventions.”

The suggestion for further investigation into context of male participation and how to enhance male engagement has been incorporated into the discussion section (line 254).

7) P 14, lines, lines 244-246: You note that the documentation of linkage to care and reasons for unsuccessful linkages was not robust or clear. Can you discuss how you intend to address this in subsequent baby shower programs?

As noted in line 243, strengthening the role of CHAs in supporting linkage and ongoing retention is a priority for the approach moving forward. While the data from the Baby Shower events was closely reviewed, the subsequent linkage tracking was less standardized and tools were not regularly reviewed for quality. In future programs, the linkage tracking would be reviewed with the same rigor as tools from the events.

8) THIS IS THE MOST IMPORTANT ELEMENT I WOULD ASK YOU TO ADDRESS: In reading the manuscript, I noted from as early as page 3 (lines 41-43) that comparing results from the baby showers to results from ANC clinics was a bit of an "apple/orange" comparison. I was glad to see the authors acknowledge this themselves and note that the results from the baby shower programs was significantly higher than those from other community based programs (p. 13, lines 226-228). I believe you need to highlight this more clearly and earlier in your manuscript. Clearly lay out that you comparison is indeed looking at cohorts from two very different settings (one clinical and one community-based). Explain why you are making this comparison (I assume you don't have access to the data from similar community initiatives-- if you can access these data, I would include you to include a discussion comparing your program to those in other community settings), and highlight the outcomes from your program (which are impressive as reported) as yielding comparable results as those from a clinical setting. In short, please describe the issue of the differences in setting and how your program yielded outcomes that were nonetheless comparable to those from a clinical program.

Thank you for this comment – we have tried to clarify this in the text. The reason for comparison is that facility-based services are the existing standard of care for HIV testing in pregnant women (we added to the Introduction, line 87, that the comparison was reviewed “in order to determine how Baby Showers results in the community setting compare to the standard of care.”) Since there are limited resources for PMTCT programs, we need to explore how to prioritize and/or blend facility and community approaches (this is the subject of last three paragraphs of discussion). By comparing this intervention to the standard facility-based approach, we aimed to show that we can achieve comparable HIV testing yield to facility settings and, importantly, reach women who may be missed by health facilities.

Reviewer 2

I think there could be a bit more literature cited and discussed in relation to the unique role of churches and church organizations in responding to HIV&AIDS. I recommend the authors look at my work on this in South Africa and browse the references for other material. It can be cited as follows: Deborah Simpson (2018) “Bringing back hope”: how faith-based responses to HIV and AIDS differ from secular responses, African Journal of AIDS Research, 17:2, 175-182,

DOI: 10.2989/16085906.2018.1478313 and the link to this article is available here: https://doi.org/10.2989/16085906.2018.1478313. Though this is a qualitative study, I believe it will be useful in framing why religious leaders carry so much sway in HIV education, testing, and advocacy. Other than that, it is a convincing and clear article which nicely captures an interesting PEPFAR-funded research project.

Thank you for this suggestion. We have reviewed the articles you mentioned and referenced the article on “Bringing back hope” in the introduction. We acknowledge that the discussion of the role of faith-based organizations and churches is limited in this paper since it focuses on intervention results; however, we do plan for a more general paper on implementation lessons that will incorporate additional context about working with faith-based and church organizations.

Submitted filename: Response to reviewers.docx

Click here for additional data file.

16 Nov 2021

Improving uptake of prevention of mother-to-child HIV transmission services in Benue State, Nigeria through a faith-based congregational strategy

PONE-D-20-35814R1

Dear Dr.  Montandon,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org.

If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Professor Kwasi Torpey, MD PhD MPH

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Comments have been adequately addressed

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #2: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #2: (No Response)

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #2: (No Response)

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #2: (No Response)

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #2: (No Response)

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #2: (No Response)

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #2: Yes: Deborah Simpson

23 Nov 2021

PONE-D-20-35814R1

Improving uptake of prevention of mother-to-child HIV transmission services in Benue State, Nigeria through a faith-based congregational strategy

Dear Dr. Montandon:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

If we can help with anything else, please email us at plosone@plos.org.

Thank you for submitting your work to PLOS ONE and supporting open access.

Kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Professor Kwasi Torpey

Academic Editor

PLOS ONE