Mitchell J. Besser, MDFounder and Medical Director

mothers2mothers

Department of Obstetrics and Gynecology

University of Cape Town

7 December 2010

mothers2mothers: Addressing the Gaps in PMTCT Care

Four Prongs of PMTCT

Prevention of unintended pregnancies among

HIV infected women

Preventing mother to child

transmission of HIV

Primary prevention of HIV infection in women

Provision of care and support for HIV

infected mothers, their infants, partners and families

Integrating HIV into the push for MDGs 4 & 5

GOAL 4: REDUCE CHILD MORTALITY

GOAL 5: IMPROVE MATERNAL HEALTH

GOAL 6: COMBAT HIV/AIDS, MALARIA & OTHER DISEASES Target 1: Have halted by 2015 and begun to reverse the spread of HIV/AIDS

Target 2:Achieve, by 2010, universal access to treatment for HIV/AIDS for all those who need it

Target 1: Reduce by two thirds, between 1990 and 2015, the under-five mortality rate

Target 1: Reduce by three quarters the maternal mortality ratio

Target 2:Achieve universal access to reproductive health

H

IV /

AID

S

Global HIV Prevalence

Doctors Working in the World

Sub-Saharan Africa:

25% of global disease burden

3% of world’s health workers

Has only minutes per

patient

1) Counsel for HIV test 2) Perform HIV test, explain results3) Dispense single dose nevirapine,4) Explain how to take5) Discuss infant feeding options6) Reinforce exclusive infant feeding7) Perform infant HIV test at 12-months, 8) Explain results

PMTCT Program Interventions:

In 2001…

Transmission Rates: 14-16%

Nurse:

Still has only minutes per

patient

1) Counsel for HIV test 2) Perform HIV test, explain results3) Perform CD4 test, get and explain results. Refer for HAART if CD4<3504) Dispense cotrimoxazole5) Discuss infant feeding options6) Dispense AZT (from 14 weeks), explain how to take7) Dispense HAART (if eligible), explain how to take8) Counsel on adherence to HAART

9) Screen for HAART related toxicity 10) Reinforce exclusive infant feeding 11) Where ARVS for breast feeding are

available, explain how to use 12) Perform infant HIV test at 6

weeks, 13) Explain results 14) Refer mother to follow-up care,

15) Encourage her to attend 16) RH/FP

PMTCT Program Interventions:

In 2010…

Transmission Rates: 2-5%

Nurse:

...

mothers2mothers

• Individual and group meetings

• Daily presence for education and support

• Mentor Mothers: professional members of health care team - paid for service

Mothers are a community’s single greatest resource

Mothers livingwith HIV (Mentor Mothers) educate and support HIV-positive pregnant women and new mothers in health facilities

Simple, scale-able model of careSimple, scale-able model of care

Goal 3. Empowerment

Goal 2. Healthy mothers

and infants

Threem2m goals:

Goal 1. PMTCT

Site Coordinators and Mentor Mothers

• Recruited locally

• Selection Criteria: Mothers HIV-positive Attended PMTCT Disclosed

• Basic numeracy and literacy skills

• Site Coordinators manage services

• Mentor Mothers engaged for up to two years

• Curriculum based education• 2 weeks - Mentor Mothers • 3 weeks - Site Coordinators• Periodic top-up training

Training

Training Cascade:National Trainer Site Coordinator / Mentor Mother Patients

Points of ServicePoints of Service

• Prenatal clinics• Labor and delivery• Postnatal programs• Targeted community outreach

m2m services

m2m Services

• Counsel for, or perform HIV testing• Provide medication• Distribute formula

• Support medical services that do

m2m Does:

m2m Does Not:

Site Management Plan

MM MM

MM

MM

SC

MM

SC

Tertiary Care

Hospital

Primary Health Center

Site Systems

Regional or District Program Manager

SC = Site CoordinatorMM = Mentor Mother

Community Outreach

Community Outreach Community Outreach

Satellite Health Centres

Hospital or Major HC

Site System

• 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)

Population Council: Horizons Study (2007)

• Pregnant women felt they could:– Do things to help themselves – Cope with taking care of baby– Live positively

• Postpartum women felt less:– Alone in the world– Overwhelmed by problems– Hopeless about future

Program Participants Report Better Psychosocial Well-Being

Population Council: Horizons Study (2007)

m2m Outcomes – Lesotho (2010)

• Program started 2007– 58 program sites

• 64% m2m country coverage • 77% disclosure rates among clients attending

>3 times• 79% early infant diagnosis

CD4 and HAART uptake among m2m antenatal clients (N=1246)

Antenatal m2m clients

CD4 Tests

CD4 Results

CD4 <350

HAART

CD4 and HAART uptake among m2m antenatal clients by number of visits (N=1246)

mothers & babies

communities

healthcare systems

Demand and Supply Side:

South Africa

Malawi

Ethiopia

Kenya

Rwanda

Zambia

Swaziland

Lesotho

Botswana

Uganda

Mozambique ???

Tanzania

m2m 2010

Total HIV-positive pregnant women enrolled:

20% of the global disease burden

mm22mm Activities 2010 Activities 2010

Current Date Nov-10Sites 703Field Staff 1766Patient Encounters Per Month 267,103

New HIV-positive Women Per Month 22,111

Helping MothersSaving Babies