This document summarizes research on maternal mortality, HIV/AIDS, and loss to follow up in prenatal care programs in Central Mozambique. It finds that HIV has played a major role in increasing maternal mortality rates in sub-Saharan Africa. Despite prevention of mother-to-child transmission programs, high rates of loss to follow up occur at each step, with many women and infants dropping out of treatment programs. Possible reasons for this include stigma, domestic violence, food insecurity, and confusion regarding HIV status. The researchers argue for strengthening health systems and integrating HIV care with primary care to improve outcomes.

1. Maternal Mortality, HIV/AIDS and the
New Counter-Geography of Surviving
Pregnancy in Central Mozambique
Rachel Chapman, Ph.D.
Javelina Aguilar, CD
Beatriz Thome, M.D., MPHc
Wendy Johnson, M.D.
James Pfeiffer, Ph.D., M.P.H.

2. Despite overall MMR decreases:
HIV Played a Major Role in
Increasing MMR mostly Sub-
Saharan Africa
NO SURPRISE…
UNAIDS 2010 Report on the global AIDS epidemic

3. Overlapping Shadows?
 Global Maternal  Global HIV Infection
Mortality (WHO)  (UNAIDS)

4. Overlapping Shadows?
 Global Maternal  Global HIV Infection
Mortality (WHO)  (UNAIDS)

5. HIV and Maternal Mortality
(UNICEF. 2010. Interagency Estimates of Maternal Mortality Levels
and Trends: 1990-2008)
 Direct: associated
increase in pregnancy
complications such as
anaemia, post-partum
haemorrhage and  Maternal HIV in
puerperal sepsis Sub-Saharan Africa
 in resource-constrained
settings, HIV accounts for an
 Indirect: increased estimated 10X increased risk
susceptibility to of maternal death
opportunistic infections  symptomatic women with
such as Pneumocystis HIV infection are at greater
carinii pneumonia, risk of dying from infectious
tuberculosis and diseases.

6. Response: Prevention of
Mother to Child Transmission
(PMTCT)
 pregnant women living with HIV in sub-
Saharan Africa who received antiretroviral
drugs to prevent transmission of HIV to their
children:
 2005: 15%
 2009: 54%

7.  Around the world to Mozambique!

8. HAI/MOH HIV
Treatment
Tambara
Guro
Chemba Expansion Plan
through public
Macossa
Maringue
sector
collaboration
Cheringoma 2003
HF Providing HAART (new)
Muanza 1 (1)
PLWHA Registered (%)
Sussundenga
2,000 (1)
Chibabava
Eligible in HAART (%)
2003
94 (0)
Machanga
Machaze

9. Guro Tambara
Chemba HIV Treatment
Expansion Plan
Maringue
Macossa
2004
Cheringoma
HF Providing HAART (new)
Muanza 2 (1)
Sussundenga
PLWHA Registered (%)
7,300 (2)
Chibabava
2003 Eligible in HAART (%)
2004 600 (1)
Machanga
Machaze

10. Guro Tambara
Chemba HIV Treatment
Expansion Plan
Maringue
Macossa
2005
Cheringoma
HF Providing HAART (new)
Muanza 5 (3)
Sussundenga
PLWHA Registered (%)
18,600 (5)
Chibabava
2003 2004 Eligible in HAART (%)
2005 2,500 (4)
Machanga
Machaze

11. Guro Tambara HIV Treatment
Chemba
Expansion Plan
Macossa
Maringue 2006
HF Providing HAART (new)
Cheringoma
17 (13)
Muanza PLWHA Registered (%)
36,270 (9)
Sussundenga
Eligible in HAART (%)
Chibabava
5,250 (9)
2003 2004 Children <15 y in HAART
2005 2006 (% of those in HAART)
Machanga
420 (8)
Machaze

12. Guro Tambara HIV Treatment
Chemba
Expansion Plan
Macossa
Maringue 2007
HF Providing HAART (new)
Cheringoma
47 (30)
Muanza PLWHA Registered (%)
63,390 (16)
Sussundenga
Eligible in HAART (%)
Chibabava
13,225 (22)
2003 2004 Children <15 y in HAART
2005 2006 (% of those in HAART)
Machanga
2007 1,323 (10)
Machaze

13. Guro Tambara HIV Treatment
Chemba
Expansion Plan
Macossa
Maringue 2008
HF Providing HAART (new)
Cheringoma
53 (7)
Muanza PLWHA Registered (%)
100,490 (25)
Sussundenga
Eligible in HAART (%)
Chibabava
23,903 (40)
2003 2004
Children <15 y in HAART
2005 2006
(% of those in HAART)
Machanga 2007 2008
3,585 (15)
Machaze

14. 2009 Treatment Plan
Guro Tambara Manica and Sofala scale-
Chemba
up through existing PHCs
Maringue • 87 facilities offering HAART
Macossa
(55 March 2008)
• 180,000 PLWHA registered for
Cheringoma HIV care (49% of the infected)
(92,600 March 2008)
Muanza
• 45,000 in HAART (64% of eligible)
(22,000 Mar. 2008, 31% of eligible)
Sussundenga
• All HUs with TB treatment in
Sofala and Manica testing for HIV
Chibabava HCB HPC
and strengthening of TB screening
HG HR in PLWHA
CS Proj.
Machanga • 202 CPN with PMTCT (156 March
2008)
Machaze

15. THE PROBLEM: Major loss to follow-up
(LTFU) occurs at each stage of the
“treatment cascade
Maternal and PMTCT LOSS TO FOLLOW-UP:
women and exposed infants drop from
programs to treat maternal HIV and prevent
maternal to child transmission at any step
along the “treatment cascade”

16. pMTCT strategy in Mozambique
Figure 1. PMTCT patient flow
Pre-natal consult
Pregnant woman counseled
and tested for HIV Children followed
in pediatric clinic
and tested for
HIV at 18 months
Treatment center (if
exists): HIV clinical and
laboratory staging
Mothers
Woman starts Woman does not
breastfeed
ART need ART
through 6 months,
followed by
“rapid transition”
Maternity
to regular food
Woman / newborn
given dose of NVP

17. The Emerging Data from Sub-Saharan
Africa
 less than ten percent of pregnant women in Africa infected with HIV receive interventions to
reduce MTCT,
 one in twenty mother-infant pairs are successfully initiating ART
 Malawi (Manzi et al. 2005):
 55% lost to follow up at 36th week of pregnancy,
 68% at delivery,
 70% at 1st post natal visit
 81% at the baby’s 6 month post natal visit
 Kenya (2005): 53.6% ♀ not enrolling at HIV clinic (Moth 2005)
 South Africa : Joburg -85% by baby’s 12th month visit , Gauteng - 90% of babies have no
final HIV diagnosis (Jones 2005; Sherman 2004)
 Mozambique: PMTCT coverage 45% (Pfeiffer 2009)
8% HIV+ pregnant ♀ started on HAART
11% infants tested at 18 months

18. Dueling Hypotheses:
Possible reasons for high loss to follow up
rates
Health Systems Structural/Social / Cultural
contributing factors contributing factors
 Inadequate counseling  Stigma, and
 Authorized and discrimination,
unauthorized fees  Gender conflict, violence
 Poor quality, rude staff  Lack of basic resources,
 Slow or lost tests food, social support
 Too many appointments  Distance and transport
fees
 Poor linkages within
programs at the health  Religious, cultural healing
facility beliefs and practices
 Cost of transport and
inaccessibility of clinics

19. Depoliticize, Individualize, Medicalize
the High Cost of Austerity Economics
Ignore failed structural Overlook free market
adjustment programs (SAPS) fundamentalist cost-shifting
 Cutting public sector  Remove price
 Privatization subsidies
 Cutting services  Fees for services
 Lay-offs, salary cuts  Erodes social safety
and freezes nets
 Selective and  Abolish social
vertical interventions security

20. Costs of Austerity to Women’s
Health
 Macro: Erosion of health system budget, facilities,
staff, salaries, basic resources, services, moral
 Meso: Institution of vertical,
selective health programs
silo-ing focus and resources from
Integrated primary care
 Micro: destroys social fabric
as people eek out survival from overburdened
household resources, especially social-

21. HIV care and treatment scale up
exposes costs of Austerity
Economics
 AIDS-related maternal
mortality
 Health systems failures
 AIDS-related stigma
= tangible consequences
of trickle-down politics
which have
immiserated African
households and public

22. Ethnography: Effects of
inequality
Identities of Control and Resistance
1. Spirit Intervention
2. The Power of Words
3. Female Envy
4. Strangers and Stress
5. Uterine Battles
6. Spirit Wives
7. Inheriting Infertility
8. Witches

23. Current costs of inequality to
Maternal Health?
 Women hide pregnancy
 Avoid prenatal care
 Heightened household tension and domestic
violence
 Men circulate informally among several
households to assure survival (and welcome)
 Women cannot afford to not get pregnant to
assure male support
 Increased sex-work in time of increasing
prevalence rates of HIV infection

24. counter-geography of survival
(Davis 2004, Planet of Slums)
 Home birth outside of biomedical
surveillance,
 defining health from their own experience,
 balancing beliefs about social threats and
spiritual protections with biomedical
explanations,
 participating in lively church communities that

25. Women are not “lost” to follow-
up

26. New Research Question:
 What accounts for
loss to follow-up?

27. Findings
1. Stigma and fear
2. Domestic violence and
negotiation of disclosure
3. food and drug insecurity in
spurring new hungers, new
resistances
4. Confusion regarding pregnancy
and seropositive status

28. Where are all the pregnant HIV+
women going after they test positive?
 HIV testing and
treatment
complicates
women’s interface
with clinical care.

29. ♀
♀
♀ ♀g+
♀
♀ ♀
♀g+
♀
♀

30. New collaboration:
Option B (2012 WHO
Guidelines)
1. Starting triple therapy ART directly after
testing rather than waiting (test and treat)

31. Option A vs. Option B
Pregnant woman
comes to ANC visit
Counseling
Woman tested for HIV CD4 visits, clinician Start ART
<350 visits
HIV chart Draw
Woman
opened in HIV CD4 Counseling Start
HIV+
clinic CD4 visits, clinician AZT+sdN
>350 visits VP
CD4 <350 Continue ART
Start ART Draw CD4 lifelong
Stop ART 1 week
CD4 >350
after breastfeeding

32. Benefits
1. simplification of
regimen and service
delivery and
harmonization with ART
programs,
2. protection against
mother-to-child
transmission in future
pregnancies,
3. continuing prevention
benefit against sexual
transmission to
serodiscordant

33. Not enough:
Trojan Horse of ART Scale-Up
 Quality HIV care
and services are
only possible within
context of building
strong, sustainable,
public sector health
systems

34. action agenda
 “The is clear. To get Millennium Development
Goal 5 on track by reducing the contribution of
AIDS to maternal mortality, we must prevent
HIV infection in women and girls, prevent
unwanted pregnancies, expand HIV testing
and counselling, accelerate initiation of
antiretroviral treatment in pregnant women
who are HIV-positive, and strengthen service
delivery and integration of HIV care and
obstetric services, along with data collection to
track progress.” (Moodley, et al. 2011, editor’s

35. Answer to Wendy’s question:
How do we balance science and
advocacy?
 DO BOTH!
 They are inseparable.
 They are not mutually exclusive.
 To do one without the other challenges the
legitimacy and efficacy of either.

36. Scientists MUST
Challenge Austerity Politics and
Policies
means?
1. Challenge NGO-centric model of global
health, resources go NGO rather than public
sector and return to donor through phantom
aid channels.
2. Challenge representations of African peoples,
cultures and institutions as pathological,
inferior needing management and programs
that make this vision inevitable.
3. Remove hiring freezes and hire, train and
adequately remunerate health care providers.

37. Public Health Spending – enough
said
Worldmapper

38. BASTA!

39. Thank You!
University of Washington
James Pfeiffer
Wendy Johnson
Beatrice Thome
Mozambican Ministry of Health
Health Alliance International
Javelina Aguiar
Lucia Lazaro