Evaluation of Conditional Cash Transfers to Increase Retention in PMTCT Services in Akwa Ibom State, Nigeria
Evaluation of Conditional Cash Transfers to Increase Retention in PMTCT Services in Akwa Ibom State, Nigeria
A randomized controlled trial will be conducted to assess the effectiveness of conditional
 cash transfers (CCTs) at increasing retention in prevention of mother-to-child transmission
 (PMTCT) services specifically, in relation to pickup of ARV drugs for infected mothers,
 delivery in the hospital setting, and receipt of drugs for exposed infants. Administrative
 data will be extracted from the All Babies are Equal program and hospital records. At 8-10
 weeks after delivery, an endline survey will also be conducted with each participant to
 provide a deeper understanding of the impact of the CCTs and to assess the reasons for
 retention in PMTCT services.
Background:

 Nigeria, home to only 2% of the world's population, accounts for 30% of the world's
 mother-to-child transmissions of HIV. Over the past three years, and in collaboration with
 bilateral aid agencies, the Nigerian government has strengthened hundreds of free rural
 clinics, trained thousands of birth attendants, and begun free distribution of antiretroviral
 (ARV) drugs. Despite this, only 1.8% of low-income women deliver a baby with a skilled birth
 attendant, only 16% of HIV-positive pregnant women receive ARVs to prevent mother-to-child
 transmission (PMTCT) of HIV, and only 2.3% of infants born to HIV-infected women received ARV
 prophylaxis to reduce the risk of virus transmission. Pregnant women are lost at each step
 along the PMTCT cascade, from attending a prenatal visit to giving life-saving antiretroviral
 therapy to their newborns.

 Operated by New Incentives, a non-profit organization focused on maternal and child health,
 the All Babies are Equal (ABAE) program was established in June 2014 in Akwa Ibom to improve
 utilization of health services for PMTCT. The ABAE program provides conditional cash
 transfers (CCTs) to pregnant, HIV-positive women conditional on obtaining specific ante-,
 peri-, and postnatal services at public facilities to prevent mother-to-child transmission of
 HIV. The CCT is primarily a demand-side intervention that aims to reduce the barriers that
 women may face when seeking care, as well as encourage uptake of and retention in PMTCT
 services.

 Preliminary studies:

 A large body of evidence indicates that providing ARV drugs to HIV-positive pregnant women
 during pregnancy and at the time of birth to both mother and baby can drastically reduce the
 transmission of the virus to the newborn. However, in Nigeria, even though drugs for PMTCT
 are free and available, many women do not use them. Additionally, knowledge of
 mother-to-child transmission of HIV and PMTCT is high among the investigators' target
 population. Recent research shows that 91% of women of reproductive age have high awareness
 of PMTCT in southern Nigeria, yet 71% have poor attitudes towards PMTCT treatment and
 services, resulting in low uptake of services.

 To encourage uptake of PMTCT services, the ABAE's CCT program was designed based on research
 that has shown that CCT interventions have increased utilization of health services and
 improve child health. CCTs initially used in Latin America provided predictable sums of money
 to eligible mothers when certain actions were taken, particularly for health services and
 school enrollment. The cash payouts have been shown to alleviate short- and long-term poverty
 while building human capital among traditionally underserved populations (i.e. women and
 children in impoverished households). CCTs have also been effective for HIV prevention. For
 example, in Malawi, schoolgirls (aged 13 to 22) awarded between one and five dollars for
 attending school had significantly reduced prevalence of HIV and HSV-2 infection after 18
 months. Additionally, several studies have shown that CCTs are an effective way to improve
 both access and adherence to antiretroviral therapy and to reduce barriers to maternal and
 newborn health service utilization. A CCT program targeted at increasing births in health
 facilities in India found a significant increase in uptake of antenatal and intrapartum care
 services and an increase in facility-based deliveries. As studies continue to evaluate the
 efficacy of CCTs, ongoing efforts aim to determine the impact of these interventions on
 transmission of HIV.

 This study aims to formally evaluate the ABAE program for increasing retention of
 HIV-positive pregnant women in PMTCT through a randomized control trial. Through a
 combination of data extracted from the New Incentives program, facility records, and survey
 data, the researchers will also investigate the sources of poor attitudes towards PMTCT
 services, the influence of non-financial barriers on PMTCT retention, religious and cultural
 norms surrounding delivery outside of clinic settings, and how the CCT intervention should be
 structured to address the full cascade of PMTCT behaviors without compromising operational
 feasibility.

 Main hypothesis to be tested:

 Conditional cash transfers (CCTs) provided by the All Babies Are Equal (ABAE) program carried
 out by New Incentives, a non-governmental organization (NGO), will improve retention of
 HIV-positive, pregnant women in prevention of mother-to-child transmission (PMTCT) services
 in Akwa Ibom, Nigeria.

 Intervention procedures:

 Participant Screening:

 An ABAE program officer will be stationed at each study site on its respective antenatal
 registration (i.e. "Booking day") day from 8am to 6pm. On Booking Day, all women who test
 positive for HIV will be recorded on a separate list by the HIV counselor or lab tester on
 duty in the privacy of his/her office. For each 1-3 women listed, the names will be
 transferred to the ABAE officer who will then transcribe the list in the order that they
 appear into a spreadsheet with pre-generated random assignment of women to treatment (i.e.
 offered to enroll ABAE program) and control (i.e. not offered the program) groups.
 Individuals randomized to the treatment arm will then be approached by the ABAE officer to
 screen and verify eligibility in person and against the subject's patient record card.

 In-person visit to obtain informed consent:

 -  Potential subjects that have been randomized to the treatment arm will be directed to a
 room where the ABAE program officer will conduct the enrollment process. The ABAE
 officer will then describe the program to the woman, discuss confidentiality and
 privacy, and see if the woman is interested in participating. ABAE program officers will
 follow a standardized enrollment script per the ABAE's standard operating procedures for
 enrollment (see supplementary materials). The ABAE officers will explain both the ABAE
 program and the accompanying research study, following informed consent procedures, and
 obtain written consent for program and study participation. If the subject agrees to
 participate in the program, the ABAE program officer will follow a standardized intake
 protocol, including survey on background information, to enroll the woman into the
 program. She will also be given an informational brochure describing the program,
 including requirements to earn the cash rewards. This brochure is written in a simple
 language and includes visual graphics to facilitate easy understanding.

 -  Women receive a small cash payment and mobile phone credits when she completes
 enrollment to facilitate retrieval of cash from the bank and return phone call
 verification.

 Conditional Cash Transfer 1:

 - The participant enrolled in the ABAE program will call the New Incentives hotline the
 morning after her ANC clinic visit to receive her payment code. If successful, she will
 receive the first lump sum cash payment.

 Conditional Cash Transfer 2:

 -  A New Incentives staff member will check the data sources containing information about
 medication pickups in the antenatal care ward in the morning of each participating
 clinic's Booking Day to check which participants have met the conditions for the second
 conditional cash transfer.

 -  During enrollment, participants are informed to call the New Incentives hotline the
 Friday after retrieving their medications for the second time to receive the payment
 code for the second lump sum payment.

 Conditional Cash Transfer 3:

 -  A New Incentives staff member will call the participant four to six weeks before her
 expected due date to remind her of the third cash transfer. The participant will also be
 reminded about facility delivery by an automated robot call and several text messages.

 -  A New Incentives staff member will check the Labor Ward Registers in the morning of each
 participating clinic's Booking Day to check if study participants have met the delivery
 condition of the third conditional cash transfer.

 -  During enrollment, participants are informed to call the New Incentives hotline the
 Friday after birth to receive the payment code for the third lump sum payment.

 Conditional Cash Transfer 4:

 -  A New Incentives staff member will call the participant four to five weeks after she
 delivers to remind her of the fourth cash transfer. Furthermore, the participant
 receives a text message regarding the early infant diagnosis test that needs to be taken
 six weeks after delivery.

 -  A New Incentives staff member will check the relevant clinic register in the morning of
 each participating clinic's Booking Day to check which participants have met the
 conditions of the third transfer.

 -  During a hotline call, participants are informed to call the New Incentives hotline the
 Friday after receiving the newborn's early infant diagnosis test to receive the payment
 code for the fourth lump sum payment.

 Evaluation design:

 The effect of the conditional cash transfer program on the primary and secondary outcomes
 will be assessed using a randomized control trial. A total of 550 pregnant women testing
 positive for HIV will be screened for eligibility and randomized to the 2 arms.

 Data collection:

 Prior to obtaining consent, the HIV status of all individuals will be collected (this is
 standard procedure at participating clinics for ANC enrollment). For women in the control
 arm, additional administrative clinic data, including first name, last name, patient number,
 pregnant mother number, date of birth, estimated delivery date, month of pregnancy, and phone
 number will be collected prior to obtaining informed consent to facilitate record tracking
 and later endline phone survey. Personal identifiers, however, will be deleted once data
 collection is complete.

 There are 3 main sources of data collection:

 1. Patient records will be extracted from hospital registers on a weekly basis. Extracted
 records will reflect information collated from different facility registers, including
 Patient Card, Laboratory Investigation Report Form, Adult Pharmacy Worksheet, ARV
 Counselor's worksheet, Daily HIV Test worksheet, Nurses' notebooks, lab testers'
 notebook, Delivery Register, Labor Ward Daily Report Book, Admissions Register, Child
 Follow-up Register, Dried Blood Spot Specimen Transport Form, and the Pediatric Pharmacy
 worksheet.

 2. ABAE program data for women in the treatment arm participating in the conditional cash
 transfer program. These data include the information on program participants obtained
 through the program enrollment survey, interim telephone calls and questionnaires, and
 records of cash transfers.

 3. An endline phone survey will be administered to all women enrolled in the study for
 which a valid phone number has been obtained (8-10 weeks after delivery).

 -  At this point, the New Incentives employee will verify the subject's identification
 (i.e. recently was pregnant and registered for antenatal services at the specific
 participating clinic) and obtain verbal informed consent to participate in the
 endline survey.

 -  This is the only contact that control subjects will have with the study personnel.

 -  All individuals completing the phone survey will receive a small amount mobile
 phone credits as compensation for their time.

 -  The endline survey will ask participants about women's birth history,
 decision-making over place of delivery, perceptions on program participation (if
 enrolled in the ABAE program), a discrete choice experiment to elicit state
 preferences over place of delivery (only for women randomized to the control arm),
 and sociodemographic background.

 Data analysis:

 1. Overall program effect:

 Our basic analysis will be to calculate point estimates (e.g., achievement of each cash
 transfer condition) with reasonable precision (i.e., the margin of error) for program
 participants and non-participants overall and for key sub-categories (e.g., at each
 facility) based on data abstracted from hospital records. We will first calculate
 univariate statistics, such as mean retention for each PMTCT condition and standard
 deviations, for program participants and non-participants, and means and standard
 deviations for key sub-categories. We will then test whether retention percentages are
 different between participants and non-participants with 2-tailed chi-squared tests of
 proportions with significance at α=0.05. We can test for independent effects,
 confounding, and interactions in multivariate analysis. Logistic regression analyses
 will be used to test for autocorrelation between subjects enrolled at the same facility,
 and hausman tests will be used to assess the relative fit of facility random and fixed
 effects. Possible sources of confounding include differences in HIV testing procedures
 and collection of patient records across facilities and over time (e.g. due to holidays,
 agricultural seasons). For example, logistic regression predicting the likelihood of
 delivering at the facility where ANC was sought can be used to simultaneously assess the
 independent effect of program participation while controlling for facility site, stage
 of pregnancy when enrolled, and time. Sensitivity analyses will be conducted to account
 for known sources of attrition (e.g. participant requesting to be dis-enrolled) and/or
 potential sources of spillover across study arms (e.g. women in the control group
 reporting that they had heard about the ABAE program).

 2. Assess the differences in program attrition and self-reported attitudes and behaviors
 between control and treatment arms.

 With responses from the phone follow-up survey, which will be affected by unknown
 sources of attrition, the study of self-reported behaviors and perceptions is not
 designed to test one central hypothesis, but will involve exploratory statistical
 testing of differences in self-reported behaviors and perceptions among program
 participants vs. non-participants overall, and by key sub-categories (e.g.
 sociodemographic characteristics, location of residence). Standard multiple linear
 regression analysis will be used to assess individual determinants of outcomes and
 changes in outcomes for continuous outcomes. Logistic regression analysis will be used
 for dichotomous outcomes. For ordered categorical outcomes, count data, or potentially
 censored outcomes, we will first assess whether a binomial, poisson, or negative
 binomial distribution is appropriate by examining each outcome's dispersion. Depending
 on the specification tests in #1 above, additional adjustments of autocorrelation will
 be included. Wealth indices will be constructed using standardized methods following
 Filmer and Pritchett (2005).

 3. Assess the existence of heterogeneous treatment effects. Multivariate regression also
 allows for testing interactions, such as whether program participation retention rates
 are different for different groups of patients (e.g., by stage of pregnancy, facility, a
 newly diagnosed HIV case, age).

 4. Determine women's stated preferences for facility-based deliveries. We will complement
 our primary analysis with a discrete choice experiment (DCE). The DCE is designed to
 solicit respondents' preferences over several key childbirth or delivery
 characteristics. Each DCE question asks respondents to state a preference for
 hypothetical options A or B. First, for each question, we will use comparison of means
 (and Chi-squared tests) and regression analysis (and t-tests) to compare the proportion
 of respondents indicating A to the proportion indicating B. Second, using the same
 statistical tools, we will pool questions with overlapping characteristics and measure
 the change in stated choice associated with a particularly delivery characteristic.

 Enrollment projection:

 Sample sizes were calculated assuming a baseline delivery and drug pickup rate of 50%, which
 produced the largest possible variance. A conservative estimate of the effect of the
 intervention would be from a 50% baseline of delivery rates and drug collection to 70% after
 the intervention. Such results would have 99.9% power if each group consists of 250 people.
 Contrary to these conservative calculations assuming a 50% baseline, the baseline rate of
 delivery is approximately 30% at clinic sites and drug pickup rates are even lower, according
 to the clinic data. We therefore expect the study results to have 100% power. Power
 calculations were carried out using the DS Research online power calculator. An additional
 10% upward adjustment is made to account for possible refusals to participate.

 Study sites:

 General Hospital, Ikot Ekpene, Akwa Ibom State, Nigeria General Hospital, Iquita Oron, Akwa
 Ibom State, Nigeria Immanuel General Hospital, Eket, Akwa Ibom State, Nigeria
Inclusion Criteria:

 -  HIV positive

 -  Pregnant

 -  Attended an antenatal care visit at one of three participating clinics.

 Exclusion Criteria:

 -  Not HIV positive

 -  Not pregnant

 -  Not registered for antenatal care at a participating clinic.