This document summarizes the work of mothers2mothers (m2m) in preventing mother-to-child transmission of HIV. It describes how m2m uses mentor mothers to educate and support HIV-positive pregnant women and new mothers, with the goals of preventing HIV transmission to babies, keeping mothers and infants healthy, and empowering mothers. The model employs and trains local HIV-positive women to mentor others in health facilities and communities. An evaluation found that m2m significantly increases utilization of PMTCT services and improves psychosocial outcomes for participants. m2m has expanded from South Africa to 11 countries in sub-Saharan Africa.
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HIV in Pregnancy - Doing More with Less
1. Mitchell J. Besser, MD
Founder and Medical Director
mothers2mothers
Department of Obstetrics and Gynecology
University of Cape Town
7 October 2009
2. Global HIV infections: 2007
33 million in world
22 million in SSA
5.7 million in SA
• South Africa has less than 1% of world’s population but 17% of
HIV infections
• SA is one of the 12 countries which account for 3/4 of world’s
HIV positive pregnant women UNAIDS 2008
3. Grim Reality
• The prevention-treatment gap is huge
– 2.7 million new infections (2007)
– 2.1 million adults and children died of HIV/AIDS
UNAIDS: 2007, 2009
(2007)
– 4 million people on treatment (2008)
• Approximately 1 million people started on
treatment in 2008
►Twice as many people become
infected with HIV as start on
treatment each year;
► Twice as many die of AIDS
as start on treatment.
5. 65
60 with high HIV prevalence:
Zimbabwe
55 South Africa
Life expectancy (years)
Botswana
50
45
with low HIV prevalence:
40 Madagascar
Senegal
35 Mali
30
1950–1955- 1960- 1965- 1970- 1975- 1980- 1985- 1990- 1995- 2000-
1955 1960 1965 1970 1975 1980 1985 1990 1995 2000 2005
Source: UN Department of Economic and Social Affairs (2001) World Population Prospects, the 2000 Revision.
8. • 1,200 new infections in children
each day
• Approximately:
• < 1 per day in the U.S.
• 1 per day in Europe
• 100 per day in Asia and Pacific
• 1,100 per day in Africa
UNAIDS 2007
9. Annual pregnancies in HIV-positive women:
United States < 7,000
Rwanda 8,600
Soweto
9,000
Thailand 10,000
Europe
15,000
Kenya 100,000
South Africa 300,000
10. • 21% of pregnant women
received an HIV test during
pregnancy in 2008
• 45% of pregnant women with
HIV received anti-retroviral
drugs
• 15% of infants born to
mothers with HIV were tested
in the first two-months of life WHO, 2009
18. Couples Status - Discordance Predominates
Couples Status - Discordance Predominates
Country Ratio Prevalence Data Source
Ethiopia 6:1 1.8%/0.3% DHS-05
Tanzania 3:1 7.9%/2.6% AIS 03/04
Kenya ~2:1 7.4%/3.7% DHS-03
Rwanda ~2:1 3.1%/1.7% DHS-05
Uganda 1.6:1 4.6%/3.4% AIS-04/5
(Discordant/concordant)
19. Couples Status - Discordance Predominates
If Male HIV+ and in a couple…
Country % Discordant Data Source
Ethiopia 73% DHS-05
Tanzania 63% AIS 03/04
Uganda 45% AIS-04/5
DHS-05
Rwanda 45%
Kenya 43% DHS-03
20. • HIV incidence = new infections in women with a
documented negative test in that pregnancy
• MTCT rates:
• 70% among women with incident HIV during
pregnancy
• 36% during breastfeeding
• Where effective interventions have reduced
transmission in identified women, new infections
during pregnancy may be a major source of MTCT.
21. Impact of incident HIV infection in pregnancy
• A Botswana study showed:
• Among women testing negative in early pregnancy:
• 1.3% were infected in 17 weeks before delivery, and
• 1.8% were infected in the first postpartum year.
• Extrapolating this to the national Botswana figures:
• Estimate 950 women acquired HIV during pregnancy or first
postpartum year, and infected 470 infants.
• Botswana National PMTCT program transmission data show
• 13,900 women infected an estimated 620 infants (4.7%).
Incident HIV is is thus estimatedaccount for 470/1090 (43%)
Incident HIV thus estimated to to account for 470/1090
of infant infectionsof all infant infections in 2007
(43%) in 2007
T Creek, personal communication 2008
27. Staffing Ratios
Selected categories of health care workers per
100,000 population (2007)
Region/Country Physicians Nurses
United States 256 937
South Africa 77 408
Botswana 40 265
Zambia 12 174
Zimbabwe 16 72
Lesotho 5 62
Mozambique 3 21
http://www.hst.org.za/uploads/files/cahp9_07.pdf
28. South Africa Situation
South African Population (2007) – 47,849,800
Public Health Sector Dependent – Black South Africans – 93%
# of Health Professionals in Public Sector as Percentage of
Total Health Professionals (2007)
Nurses 44%
Doctors 10%
Psychologists 4%
http://www.hst.org.za/uploads/files/cahp9_07.pdf
29. South Africa Situation
Vacancies in Public Health Sector - % vacant posts
Range SA
Doctors 15 – 51% 34%
Nurses 20 – 42% 36%
All Health Professionals 19 – 43% 33%
Clinical Load at Primary Health Center Level
Doctor – 30 patients per day (one every 16 minutes)
Nurses – 40 patients per day (one every 12 minutes)
http://www.hst.org.za/uploads/files/cahp9_07.pdf
30. PMTCT Programs – 2001
Transmission Rates: 14-16%
• HIV testing – Point of care
• Single dose nevirapine to mother and baby
• Infant feeding choices
• Cotrimoxazole to infant from 6-weeks
• Infant testing at 12-18 months
31. PMTCT Program Interventions – 2008
Target: Transmission Rates: 2-5%
• HIV testing – Point of care
• CD4 counts
• Cotrimoxazole
• Combination Therapy – AZT from 28 weeks
• HAART during pregnancy if eligible
– Adherence
– Toxicity
• AZT+3TC to prevent nevirapine resistance
• Infant feeding choice/adherence – HIV-free survival
• ARVs during breast feeding
• Infant testing at 6-weeks
32. 12- Minutes per Patient – Magical thinking
Action Nurse’s Role
HIV counseling Counseling for HIV test
HIV testing Perform HIV test, explain results
CD4 counts Perform test, get and explain results
Cotrimoxazole Dispense drug
Infant Feeding Choice Discuss infant feeding options
AZT from 28 weeks Dispense drug, explain how to take
HAART - if eligible Dispense drug, explain how to take
HAART Adherence Counsel on adherence to HAART
HAART Toxicity Screen for HAART related toxicity
Infant feeding adherence Reinforce exclusive infant feeding
ARVs for breast feeding Where available, explain how to use
Infant testing at 6-weeks Perform HIV test, explain results
Referral to follow-up care Encourage and direct mother
33. Task Shifting
Task Shifting:
Global Recommendations and Guidelines
(WHO - 2008)
“…we must seek innovative ways of
harnessing and focusing both the
financial and the human resources that
already exist…”
35. PMTCT Isn’t Working…
• Poor uptake of HIV testing
• Poor uptake of AZT/NVP by mother and baby
• Uncertainties regarding infant feeding:
– Choice
– Adherence
– Weaning
• Poor follow-up for infant testing
• Poor transition of mothers to ARV programs
and Wellness Care during and after pregnancy
• Poor transition of babies to baby clinics and
HIV/AIDS care
36. Causes
• Institutional
too few nurses and midwives
poor links between PMTCT and on-going HIV
care
poor links between health care facility and
community
• Societal
disempowered women
Stigma
• Same issues across Africa
37. mothers2mothers
Vision Goal 1: PMTCT
m2m envisions a world To prevent babies from contracting
where babies are not HIV through mother-to-child
born with HIV, where transmission and promote HIV-free
HIV+ mothers are alive survival.
and healthy to care for Goal 2: Healthy mothers
their families and
and infants
where HIV-positive
To keep HIV-positive mothers and
women are empowered
their infants alive and healthy by
to live positively
increasing their access to health-
sustaining medical care
Goal 3: Empowerment
To empower mothers living with
HIV/AIDS, enabling them to fight
stigma in their communities and to
live positive and productive lives
38. Primary Objectives
• Increase HIV and CD4 testing during pregnancy
• Enhance uptake of antiretroviral medications:
PMTCT during pregnancy
ARVs during and after pregnancy
• Choice of and adherence to method of exclusive infant
feeding;
• Appropriate weaning and introduction of complementary
foods
• Infant testing
• Referral of mother and infant
to follow-up care
• Disclosure
• Reducing stigma
• Partner involvement
• Empowerment – “living positively”
39. Secondary Benefits
Promote health systems and 4-prong approach to
PMTCT:
• Attendance at antenatal and postnatal clinics
• Safe motherhood initiatives - deliveries in
health care facilities
• Family planning – reduce the number of
unwanted pregnancies
• Couples testing for primary prevention of HIV
infection in discordant couples
40. Simple, Scale-able Model of Care
Mothers are a community’s single greatest resource
Mothers living with HIV (Mentor Mothers) educate and
support HIV-positive pregnant women and new
mothers in health facilities
• Individual and group
engagement
• Daily presence for
education and support
• Mentor Mothers:
professional members of
health care team—paid
for service
41. Site Coordinators and Mentor Mothers
• Recruited locally
• Selection criteria
Mothers
HIV-positive
Attended PMTCT
Disclosed
• Basic numeracy & literacy skills
• Mentors engaged for up to two years
• Site Coordinators manage services and relieve facility
staff of management concerns
42. Training
Training cascade:
National Trainer SC/MM Patients
• Curriculum based education
• 2 weeks - Mentor Mothers
• 3 weeks - Site Coordinators
– Mentor Mother training
– Management training
• Periodic top-up training
43. Points of Service
• Antenatal clinics
• Post-delivery wards
before discharge
• Postnatal programs
• Targeted community
outreach
44. m2m Does Not:
• Counsel for or perform HIV testing
• Provide medication
• Distribute formula
m2m Does:
• Support medical
services that do
45. Site Management Plan
Regional or District Program Manager
SC SC
Site Systems
MM
MM MM
MM
MM
Tertiary Primary
Care Health
Hospital Center
46. Site System
Community Outreach
Satellite Health Centres
Hospital or
Major HC
Community
Outreach
Community Outreach
47. Program Implementation
Buy-in from:
• National government health services
• District health services
• Facility managers and staff
• CBOs and civil society
Community involvement
• Facility staff and CBOs assist with staff
recruitment
promotes integration of m2m into
healthcare facilities and communities
links PMTCT care with other community
services
48. Population Council - Horizons Study:
Research Questions
Does mothers2mothers:
– Increase HIV-positive women’s
utilization of key PMTCT
services?
– Improve PMTCT outcomes and
psychosocial well-being?
49. Population Council - Horizons Study (2007)
• PMTCT
– 95% of mothers received nevirapine
– 88% of babies received nevirapine
• Care
– 79% had CD4 counts
– 88% knew CD4 count results
• Infant Feeding
– 89% chose exclusive infant feeding method
• Family Planning
– 70% using contraception
• Disclosure
– 97% disclosed (4.4x non-participants)
50. Program Participants Report Better
Psychosocial Well-being
• Pregnant participants were significantly more
likely to feel they could:
– Do things to help themselves
– Cope with taking care of baby
– Live positively
• Postpartum participants were significantly more
likely to feel less:
– Alone in the world
– Overwhelmed by problems
– Hopeless about future
52. m2m – 2009/10
“Ethiopia”
Uganda
Kenya
Rwanda
Zambia
Tanzania
Malawi
“Botswana”
Mozambique
Swaziland
Lesotho
Namibia South Africa
53. m2m – Activities 2009
Timing Sites Field Patient encounters New HIV-
Staff per month positive
women per
month
September 581 1535 208,907 24,165
2009
Further expansion in 2009/10:
Mozambique
Tanzania
Uganda
Namibia
54. Gratitudes
• James McIntyre
• James McIntyre
• Monica Nolan
• Monica Nolan
• Mickey Chopra
• David Wilson
• Tanya Doherty
• UNICEF
• …and to all of the
Zapiro
• …and to all of the
mothers…
mothers…