http://informahealthcare.com/jmf ISSN: 1476-7058 (print), 1476-4954 (electronic) J Matern Fetal Neonatal Med, 2014; 27(15): 1539–1544 ! 2014 Informa UK Ltd. DOI: 10.3109/14767058.2013.865165

ORIGINAL ARTICLE

Obstetrician-initiated counseling and testing for HIV infection: a cross sectional study Babasola O. Okusanya1, Azubuike K. Onyebuchi2, Ayodeji A. Oluwole1, Maymunat A. Adegbesan-Omilabu1, and Olasurubomi K. Ogedengbe1 1

Department of Obstetrics and Gynaecology, College of Medicine, University of Lagos, Lagos, Nigeria and 2Department of Obstetrics and Gynaecology, Federal University Teaching Hospital, Abakaliki, Nigeria Abstract

Keywords

Objective: To assess the practice of provider-initiated counseling and testing (PICT) for HIV infection by Nigerian Obstetricians and estimate missed opportunities at the gynecological and family planning clinics. Methods: Online cross-sectional survey of members of the Society of Gynaecology and Obstetrics of Nigeria (SOGON) over a 4-week period using SurveyMonkeyÕ . Frequencies were used to present responses of participants. Results: There were 201 (29%) respondents. Participants’ mean age was 46  7.2 (SD) years and majority (93.3%) held consultant positions. Most respondents (92.2%) cared for HIV-infected pregnant women with dedicated HIV counselors (77.4%), and in dedicated counseling rooms (71%). Majority (75.7%) had been trained on HIV management in pregnancy and 95.3% routinely counseled and tested women attending the booking antenatal clinic. Fourteen per cent (14%) and 16% of respondents conducted routine counseling and testing for women attending the gynecological and family planning clinics, respectively, for the first time. For every 100 women tested at the antenatal clinic, 317 women were missed at each of the two clinics. Conclusions: PICT of HIV infection in Nigeria has focused on pregnancy. To eliminate new HIV infections in children, PICT should be routine at the gynecological and family planning clinics.

eMTCT, PMTCT, voluntary counseling and testing

Introduction The global epidemic of human immunodeficiency virus (HIV) infection is predominantly domiciled in sub-Saharan Africa (SSA) where almost 1 in every 20 (4.9%) adults is living with HIV. The region accounts for 71% of new infections in 2011 [1]. Nigeria has a prevalence of 4.1% [2] and has been classified to have a stable HIV infection rate among adults of reproductive age. Despite the stable infection rate, Nigeria is still an epicenter of HIV burden in the West African subregion because she had 519% reduction of HIV infection among adults of reproductive age [1]. For there to be wider coverage of care for people living with HIV and reduction in new infection in Nigeria, her physicians must initiate counseling and testing to their clients on a routine basis. While voluntary counseling and testing (VCT), is client-initiated, provider-initiated counseling and

Address for correspondence: Dr Babasola O. Okusanya, Department of Obstetrics and Gynaecology, College of Medicine, University of Lagos, Idi-Araba, Lagos, Nigeria. Tel: +2348035802349 (Mobile). E-mail: [email protected]

History Received 3 September 2013 Revised 5 November 2013 Accepted 10 November 2013 Published online 9 December 2013

testing (PICT), is the incorporation of HIV counseling and testing (HCT) into routine healthcare [3]. Nigeria adopted the policy of provider-initiated counseling and testing of HIV infection and commenced implementation in 2005. However, the policy was implemented and became routine in all antenatal clinics and clinics dedicated to the management of chronic chest infections like tuberculosis. In these settings, PICT of HIV infection for new clients has been well accepted [4–6], and led to early diagnosis of HIV infection and initiation of therapy [7]. Moreover, many students of a Nigerian University accepted PICT because they wanted to know their HIV status [8]. To the contrary, PICT of HIV infection is seldom a part of the gynecological and family planning clinics where a significant quantum of women attends. For Nigeria to improve her case-finding of HIV infection, all adults of reproductive age who utilize the health facilities should be offered PICT. This is particularly so with the target of elimination of mother-to-child transmission of HIV infection by 2015 by ensuring that all adults of reproductive age avoid HIV infection [1], and the documented safety of Efavirenzcontaining anti-retroviral (ARVs) regimen in first trimester of pregnancy [9]. The 2013 World Health Organization (WHO)

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HIV treatment guidelines, which recommends the adoption of an earlier use of ARVs for life by anyone diagnosed to be HIV positive [10], may be another reason for routine counseling and testing for HIV infection at the out-patient clinics. The objective of this research was to assess the initiation of HIV counseling and testing by Nigerian Obstetricians and Gynecologists and estimate the magnitude of missed opportunities for PICT of HIV.

Materials and methods We conducted an online survey of members of the Society of Gynaecology and Obstetrics of Nigeria (SOGON) over a period of 4 weeks (28 days) from 11 May to 7 June, 2013. SOGON was established in 1965 and has a voluntary membership policy. The membership register updated in November 2012 [11] had the names of all members, including those in the Diaspora, as at the second quarter of 2012. In spite of the voluntary membership, most Nigerian Obstetricians are members, therefore, it is a good representation of specialist obstetrician and gynecologists in Nigeria. Of the 886 members residing in Nigeria, 290 (32.7%), 176 (19.9%), 143 (16.1%), 47 (5.3%), 63 (7.1%), 80 (9.0%) and 87 (9.8%) were residents of the South-west, South-south, Southeast, North-east, North-west, North-central and the Federal Capital Territory of Abuja, respectively. We retrieved the email addresses of all members of SOGON practicing in Nigeria from the membership register and imported them to SurveyMonkeyÕ, an online survey application (www.surveymonkey.com), from which invitation to participate in the research was sent to all members. We sent weekly reminders (3 in all) to members who were yet to respond during the life span of the survey as the software allowed identification of non-responders. The survey tool comprised questions on the biosocial characteristics of respondents, information on health facility infrastructure (number of consulting rooms at the antenatal clinics, number of rooms dedicated to counseling on HIV infection), prior training on prevention of mother-to-child transmission (PMTCT) of HIV infection and the volume of clients attending out-patient clinics on a weekly basis (number of new antenatal patients/week, number of new gynecological clinic patients/week, number of new family planning clinic client/week). The practice of PICT (if all new pregnant women at the ANC, new gynecological clinic patients and new family planning clinic clients are counseled and screened for HIV infection) was also assessed. In addition, the questionnaire inquired if respondents’ clinics had trained and dedicated HIV counselors and assessed challenges to routine counseling and testing for HIV infection at the gynecological and family planning clinics. Lastly, they were asked if they would support the introduction of counseling and testing for HIV infection in all women at the gynecological and family planning clinics. The survey contained closed- and open-ended questions (45), but took less than 5 min to complete, since respondents did not have to answer all questions. To calculate the missed opportunities at the gynecological and family planning clinics in a setting where PICT of HIV is adopted and routinely practiced at the antenatal clinics,

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we used the number of new clients/week and the proportion of respondents who reported offering PICT at the antenatal clinic as reference for the calculation. Thereafter, missed opportunities at the gynecological and family planning clinics were derived from the reported number of new clients/week and the proportion of obstetricians who reported offering PICT at the gynecological and family planning clinics. Statistical Package for Social Sciences (SPSS) version 15.0 (SPSS Inc., Chicago, IL) was used to analyze responses. Descriptive statistics were used to report frequencies of responses to each question. The study was approved by the Health Research Ethics Committee of the Lagos University Teaching Hospital (LUTH), Idi-Araba, Lagos, Nigeria.

Results Of 703 potential respondents, 201 members of SOGON responded to the invitation. This gave a response rate of 29% (Figure 1). Since respondents were not required to answer every question of the survey to proceed, each question was skipped by 4–16 respondents. The changes in the denominator were noted as appropriate in the result. The mean age of respondents was 46  7.2 (SD) years. Most (182/195; 93.3%) were consultants while the rest were residents doctors (6.7%). Respondents who were consultants had worked in that position for 9.9  6.9 (SD) years while the resident doctors had been in training for 4.9  3.2 (SD) years. Respondents were predominately males (86.7%; 170/195) and married (94.9%; 187/197). Most held positions in public health facilities (86.9%; 172/198), and these were predominantly in tertiary health facilities (143/174). Other social characteristics of the respondents are as shown in Table 1. Most respondents (92.2%; 178/193) reported managing pregnant women with HIV infection. Seventy one per cent of respondents also reported the availability of dedicated HIV counseling rooms and counselors (77.4%; 151/195). They reported having an average of 3.4  1.9 (SD) dedicated counselors at each clinic. Majority of respondents (75.7%) had been trained on PMTCT and most (95.3%) reported conducting routine

Figure 1. Study participation invitation flow diagram.

Obstetrician-initiated counseling and testing for HIV infection

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similarly low proportion (16.1%; 30/186) did routine counseling and testing for new family planning clients. To the contrary, a much higher proportion of respondents (64.3%; 126/196) reported routine HIV counseling and testing for women scheduled for elective gynecological surgeries. Also, 95%, 14% and 16% of respondents routinely counseled and tested new clients at the antenatal, gynecological and family planning clinics, respectively. Using mathematical proportions and if 95% of respondents would provide PICT of HIV at all the clinics, for every two antenatal clinic patients screened, one client would be screened each, at the gynecological and family planning clinics. This implies that every week, for every new 100 ANC women, 50 women each would be screened at the gynecological and family planning clinics. Unfortunately an average of 15% of respondents reported screening at the gynecological and family planning clinics. Therefore, 50  95/15 ¼ 317 women were actually missed weekly. Table 2 shows the challenges to continued initiation of counseling and testing while Table 3 shows the reasons reported by some respondents for not initiating routine counseling and testing for HIV infection at the gynecological and family planning clinics. Out of those who reported initiating routine HIV counseling and testing at the gynecological and family planning clinics, 14.8% (8/52) and 13.7% (7/51), respectively, reported inadequate space and lack of institutional policy as very important challenges to the continuation of the service. Ten per cent (4/41) of those who provided the service reported it to be unnecessary.

counseling and testing for HIV infection for all new antenatal patients. Non-Governmental Organizations (NGOs) trained most (87.7%) respondents in the management of HIV infection in pregnancy. An average of 33.1 new antenatal clinic patients were seen weekly at each respondent’s clinic. The mean of new gynecological clinic patients and family planning clients reported per week was 14.5 and 16.8, respectively. Very few (14%; 27/194) respondents reported conducting routine HIV counseling and testing on patients attending the gynecological clinic for the first time and a Table 1. Social characteristics of respondents. Characteristics Religion Islam Catholicism Pentecostal Protestants Traditional Spiritual Geo-political zone of practice North-east North-west North-central South-west South-east South-south Marital status Married Single Divorced Widow Widower Living together

Number (%) 43 44 64 42 1 1

(22.1) (22.6) (32.8) (21.5) (0.5) (0.5)

10 19 43 58 21 46

(5.0) (9.6) (21.8) (29.4) (10.7) (23.4)

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134 (95) 3(2.0) 1(0.6) 1 (0.6) 2 (1.2) 1 (0.6)

Table 2. Reported challenges while initiating counseling and testing for HIV infection at the gynecological and family planning clinics (59 respondents). Ratings Questions Inadequate knowledge of the contents of counseling Discrimination of clients with a positive HIV infection results It is not necessary Language barrier between you and the clients Lack of adequate time Lack of Departmental policy on counseling and testing of HIV infection at the gynecological clinics Lack of Departmental policy on counseling and testing of HIV infection at the family planning clinics Lack of National Guidelines/recommendation on routine screening for HIV at the gynecological clinic Lack of National Guidelines/recommendation on routine screening for HIV at the family planning clinic Inadequate available staff at the gynecological and family planning clinics Adequate but untrained staff on HIV counseling and testing at the gynecological and family planning clinics Shortage of HIV rapid test kits Inadequate space/room for counseling on HIV infection to ensure confidentiality

Unimportant N (%)

Not so important N (%)

Important N (%)

16 (30.2) 18 (34.0)

9 (17) 12 (22.6)

19 (35.8) 17 (32.1)

21 31 7 14

(51.2) (60.8) (13.0) (27.5)

7 9 8 9

(17.1) (17.7) (14.8) (17.7)

7 9 18 18

So important N (%)

Very important N (%)

Response count N (%)

3 (5.7) 2 (3.8)

6 (11.3) 4 (7.5)

53 (100) 53 (100)

(17.1) (17.7) (33.3) (35.3)

2 (4.8) 2 (3.8) 13 (24.1) 3 (5.8)

4 (9.8) 0 8 (14.8) 7 (13.7)

41 51 54 51

(100) (100) (100) (100)

18 (39.1)

7 (15.2)

13 (28.3)

3 (6.5)

5 (10. 9)

46 (100)

16 (32.6)

9 (18.4)

15 (30.6)

4 (8.2)

5 (10.2)

49 (100)

9 (19.1)

15 (31.9)

2 (4.6)

7 (14.9)

47 (100)

9 (16.4)

9 (16.4)

16 (29.1)

10 (18.1)

12 (23.5)

17 (33.3)

13 (25.5)

8 (15.7)

1 (2.0)

51 (100)

18 (33.3) 12 (23.1)

9 (16.6) 9 (17.3)

17 (31.5) 15 (28.8)

7 (13.0) 8 (15.4)

3 (5.6) 8 (15.4)

54 (100) 52 (100)

14 (30)

11 (20)

55 (100)

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Table 3. Reported challenges for not initiating routine counseling and testing for HIV infection at the gynecological and family planning clinics (150 respondents). Ratings Questions Inadequate knowledge of the contents of counseling Discrimination of clients with a positive HIV infection results It is not necessary Language barrier between you and the clients Lack of adequate time Lack of Departmental policy on counseling and testing of HIV infection at the gynecological clinics Lack of Departmental policy on counseling and testing of HIV infection at the family planning clinics Lack of National Guidelines/recommendation on routine screening for HIV at the gynecological clinics Lack of National Guidelines/recommendation on routine screening for HIV at the family planning clinics Inadequate available staff at the gynecological and family planning clinics Adequate but untrained staff on HIV counseling and testing at the gynecological and family planning clinics Shortage of HIV rapid test kits Inadequate space/room for counseling on HIV infection to ensure confidentiality

Unimportant N (%)

Not so important N (%)

Important N (%)

72 (57.6) 69 (57.5)

33 (26.4) 23 (19.2)

11 (8.8) 13 (10.8)

30 27 16 19

(23.0) (21.8) (11.9) (15.2)

45 (34.9) 51 (41.8)

12 10 7 11

(9.0) (8.1) (5.2) (8.8)

36 (27.5) 34 (27.4) 46 (34.3) 35 (28)

14 (10.8) 28 (23)

So important N (%) 4 (3.2) 9 (7.5) 14 14 22 18

Very important N (%) 5 (4.0) 6 (5.0)

Response count N (%) 125 (100) 120 (100)

(10.5) (11.2) (16.4) (14.4)

39 (30) 39 (31.5) 43 (32.1) 42 (33.6)

131 124 134 125

(100) (100) (100) (100)

30 (23.3)

14 (20.2)

26 (10.8)

129 (100)

27 (22.0)

8 (6.6)

8 (6.6)

122 (100)

67 (55.4)

21 (17.4)

17 (14.0)

5 (4.1)

11 (9.1)

121 (100)

50 (39.7)

20 (15.9)

24 (19.0)

4 (3.2)

28 (22.2)

126 (100)

72 (57.6)

33 (26.4)

11 (8.8)

4 (3.2)

5 (4.0)

125 (100)

69 (57.5) 30 (22.8)

23 (19.2) 12 (9.2)

13 (10.8) 36 (27.5)

9 (7.5) 14 (10.7)

6 (5.0) 39 (29.8)

120 (100) 131 (100)

The very important challenges to routine initiation of counseling and testing for HIV infection reported were inadequate space (30%; 39/131), lack of institutional policy (33%; 42/125) and lack of time (32%; 43/134). While 30% (39/124) of respondents reported language barrier (39/124), another 30% (39/131) felt it was not necessary to test for HIV infection at the gynecological and family planning clinics. The introduction of routine HIV counseling and testing at the gynecological and family planning clinics would be supported by majority (84.8%; 167/197) of respondents.

Discussion The research involved members of SOGON and it had a response rate of 29% with respondents based in all geopolitical zones of the country. Responses to internet-based surveys are influenced by the study topic, characteristics of the sample population, the perceived value and general applicability of the research to the responders [12,13]. Despite the low response rate of this survey, the above results fell within a margin of error of  10% of the true practice and responses of members of SOGON if all were to participate in the survey [14]. Since members of SOGON were invited to participate in HIV-related research, the subject of the research might have influenced the response rate. This is because obstetricians who do not partake in HIV-related clinical duties were unlikely to take the survey. Knowing this, weekly reminders were sent to members of SOGON who were yet to respond during the life span of the survey. Respondents to the survey were young as seen in the average age and numbers of years

majority had held consultant positions. This agrees with the report of younger peoples’ response to internet-based surveys [13]. Other factors that might have affected the response were poor internet connectivity and access to the survey via the electronic link as well as old or unused email addresses. Counseling and testing for HIV infection is an important armament in the fight against HIV infection. The survey revealed that almost all respondents regularly counseled and tested pregnant women attending the first antenatal clinic for HIV infection and most had been trained on the subject. It also showed NGOs trained most respondents on PMTCT of HIV infection. While these trainings may have created a pool of human capital resource for the country, the governments at the Federal and state levels need to do more training of health personnel to sustain the tempo of efforts to curtail the epidemic. The scaling up of HIV treatment to primary health facilities nationwide would require the expertise of members of SOGON to supervise and mentor health personnel in these facilities to reduce new HIV infection in children as has been done in Northern Nigeria [15]. The small proportion of respondents who routinely counseled and screened women at the gynecological clinic and family planning clinic is disheartening. This is because despite the national prevalence of 4.1%, there was a consistent increase in HIV prevalence in some states and inconsistent trend in some other states of the country [2]. More so, a recent global update on the 21 priority countries in sub-Saharan Africa reported 60 000 new HIV infections among Nigerian children in 2012 [16]. This implies that current activities have not brought about the needed change in access to HIV care,

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Obstetrician-initiated counseling and testing for HIV infection

especially the number of people counseled and tested for HIV infection and those who know their HIV status. Since efforts at elimination of MTCT (eMTCT) of HIV in children must start before pregnancy, the HIV status of all adults in the reproductive age group should be determined. This only stresses one of the elements of interventions to PMTCT of HIV infection and the need for all adults to be counseled and tested for HIV infection. This would require the availability of more trained counselors at the out-patient clinics. The release of the 2013 HIV treatment guidelines by the WHO gave a strong recommendation and re-emphasized the need for provider-initiated counseling and testing for HIV infection in countries with generalized epidemics [10]. It recommended the initiation of antiretroviral therapy in adults who are HIV-infected with CD4 cell count 500 cells/ mm3, an important departure from the 2010 treatment guidelines. Additionally, there is a strong recommendation for the use of ARVs by sero-discordant couples, irrespective of the CD4 cell count of the infected partner to reduce the risk of transmission to the uninfected partner [10]. One of the implications of the recommendations is a projected increase in the number of people living with HIV who qualify for ART use. When more HIV-infected people are on therapy, they would remain healthy and the spread of HIV infection would be curtailed. The practice of PICT at the gynecological and family planning clinics will add more value for money as it would integrate counseling and testing into existing services [3]. The Nigerian Ministry of Health needs to adopt a policy of PICT at all out-patients clinics, including the gynecological and family planning clinics, in order to diagnose HIV early. This survey quantified the magnitude of missed opportunities of counseling and testing for HIV infection at the gynecological clinics and family planning clinics by obstetricians in Nigeria. The estimates show how difficult eliminating new HIV infection in children is, if the pattern of PICT continues. Most women go to a health facility only when in need of medical care and this would have been a good time to be counseled and tested for HIV infection. However, this was not the case for women attending either the gynecological or family planning clinics. Yet, women who needed gynecological elective surgeries were counseled and tested for HIV infection by six out of 10 respondents. The only reason one may ascribe to this practice is the need for the respondents to protect themselves from exposure to HIV virus including that from needle pricks during surgeries. Nigeria is having an epidemic of HIV infection and may need to update her treatment guidelines in view of the most recent WHO treatment guidelines. Therefore, if the anticipated gains of the new treatment guidelines are met with more obstetricians initiating counseling and testing for HIV infection at the gynecological and family planning clinics, Nigeria is more likely to reduce the burden of new HIV infection in children. In doing this, counselors need to give balanced information during counseling sessions so that clients know they have a right to refuse test unlike the report by Baggaley et al. [17] in which antenatal women did not know they could refuse HIV tests. Nearly all Nigerian indicators on HIV care and treatment suggest stagnation and that she is facing significant hurdles

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[16], therefore, the need arises for Nigeria to implement novel ways to reversing the trend in childhood HIV infection by evolving policies that encourage massive routine screening of all adults both within and outside health facilities on regular basis. This has the potential to reduce stigmatization of people living with the disease, an obstacle to VCT. The web-based survey gave an equal chance for all members of SOGON to participate. Though, our findings are limited by the response rate and the inability to ascertain the actual practice of PICT by respondents, it was a very good representation of the members of SOGON. While 5% of respondents reside in North-east Nigeria, SOGON’s membership from same region of the country is just 5.3%. Also, 29% of respondents practice in the South-west Nigeria, a region that accounts for 32.7% of SOGON’s membership. The introduction of PICT of HIV infection into gynecological and family planning clinics will increase case findings of HIV in adults of reproductive age and drastically reduce missed opportunities for HIV counseling and testing. We recommend development of a National policy and institutional guidelines on routine PICT at the gynecological and family planning clinics in order to eliminate new childhood HIV infection in Nigeria.

Acknowledgements The authors acknowledge the assistance of Mr. Ekpereone Esu, Lecturer in the Department of Public Health, University of Calabar, Nigeria, for his assistance.

Declaration of interest The authors declare no conflict of interest.

References 1. Global report: UNAIDS report on the global AIDS epidemic 2012. Geneva, Switzerland: Joint United Nations Programme on HIV/ AIDS (UNAIDS); 2012. 2. Nigerian Federal Ministry of Health. National HIV sero-prevalence sentinels survey. Abuja, Nigeria; 2010. 3. Obure CD, Vassall A, Michaels C, et al. Optimising the cost and delivery of HIV counseling and testing services in Kenya and Swaziland. Sex Transm Infect 2012;88:498–503. 4. Dalal S, Lee CW, Farirai T, et al. Provider-initiated HIV testing and couseling: increased uptake in two public community health centers in South Africa and implications for scale-up. PLoS One 2011;6: e27293. 5. Malaju MT, Alene GD. Assessment of utilization of providerinitiated HIV testing and counseling as an intervention for prevention of mother to child transmission of HIV and associated factors among pregnant women in Gondar town, North West Ethiopia. BMC Public Health 2012;12:226. 6. Achanta S, Kumar AM, Nagaraja SB, et al. Feasibility and effectiveness of provider initiated HIV testing and counseling of TB suspects in Vizianagaram District, South India. PLoS One 2012;7: e41378. 7. Briggs A, Partridge DG, Bates SM. HIV screening in colposcopy and termination of pregnancy services: missed opportunity? J Fam Plann Reprod Health Care 2011;37:201–3. 8. Ijadunola K, Abiona T, Balogun J, Aderounmu A. Providerinitiated (opt-out) HIV testing and counseling in a group of university students in Ile-Ife, Nigeria. Eur J Contracept Reprod Health Care 2011;16:387–96. 9. World Health Organization. Technical update on treatment optimization. Use of efavirenz during pregnancy: a public health perspective; 2012.

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10. Global update on HIV treatment 2013: results, impact and opportunities. WHO, UNICEF, UNAIDS; 2013. 11. Society of Gynaecology and Obstetrics of Nigeria (SOGON). Directory of obstetricians and gynecologists in Nigeria. Agboghoroma C, Achem FF, eds; 2012. 12. Kraner EFS, Haighton CA, McAvoy BR, Leech W. ‘So much post, so busy with practice so, no time!’: a telephone survey of general practitioners’ reasons for not participating in postal questionnaire surveys. Br J Gen Pract 1998;48:1067–9. 13. Sills SJ, Song C. Innovations in survey research: an application of web-based surveys. Social Sci Comp Rev 2002;20:22–30. 14. How many respondents do I need? SurveyMonkey Help Center. Available from: www.surveymonkey.com [last accessed 30 Jul 2013].

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15. Okusanya BO, Ashimi AO, Aigere EO, et al. Scaling up prevention of mother to child transmission of HIV infection to primary health facilities in Nigeria; findings from two primary health centres in Northwest Nigeria. Afr J Reprod Health (Special Issue on HIV/AIDS, December 2013); in press. 16. 2013 progress report on the global plan towards the elimination of new HIV infections among children by 2015 and keeping their mothers alive. Geneva, Switzerland: Joint United Nations Programme on HIV/AIDS (UNAIDS); 2013. 17. Baggaley R, Hensen B, Ajose O, et al. From caution to urgency: the evolution of HIV testing and counseling in Africa. Bull World Health Organ 2012;90:652–8B.

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Obstetrician-initiated counseling and testing for HIV infection: a cross sectional study.

To assess the practice of provider-initiated counseling and testing (PICT) for HIV infection by Nigerian Obstetricians and estimate missed opportuniti...
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