addressing the gaps in pmtct care - a dr besser presentation
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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