Mitchell J. Besser, MD Founder and Medical Director
mothers2mothers Department of Obstetrics and Gynecology
University of Cape Town
7 October 2009
Global HIV infections: 2007
33 million in world
• 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
22 million in SSA
5.7 million in SA
Grim Reality
• The prevention-treatment gap is huge – 2.7 million new infections (2007) – 2.1 million adults and children died of HIV/AIDS
(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.
UN
AID
S: 2007, 2009
Population HIV Prevalence
SouthernAfrica LACWestAfricaEastAfrica Asia
Zambia
South Africa
Botsw
ana
Senegal
Mali
with high HIV prevalence: Zimbabwe South Africa Botswana
with low HIV prevalence: Madagascar Senegal Mali
Source: UN Department of Economic and Social Affairs (2001) World Population Prospects, the 2000 Revision.
30
35
40
45
50
55
60
65
Life
exp
ecta
ncy
(yea
rs)
1950– 1955
1955- 1960
1960- 1965
1965- 1970
1970- 1975
1975- 1980
1980- 1985
1985- 1990
1990- 1995
1995- 2000
2000- 2005
PACTG 076 USPHS AZT Recommendations
80% decline
Siripon Kanshana, 2007
• 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
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
• 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
UNAIDS estimates 2008
Mother-to-Child Transmission (MTCT) of HIV Estimated Children Newly Infected in World
Dept. of Health, 2008
%
28%
Challenges and Responses
Routine offer of HIV testing
Missed PMTCT Opportunities: The Cascade
Chopra et al MRC Report 2007
88%
44% 37% 54% 18% 16% 21%
Amajuba District – KZN: PMTCT Cascade - 2007
Missed Treatment Opportunities
Patie
nts
Mahdi, Abs. 437, HIV Implementers, 2007
73%
50%
25%
Challenges and Responses
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)
Couples Status - Discordance Predominates
Couples Status - Discordance Predominates
Country % Discordant Data Source
Ethiopia 73% DHS-05
Tanzania 63% AIS 03/04
Uganda 45% AIS-04/5
Rwanda 45% DHS-05
Kenya 43% DHS-03
If Male HIV+ and in a couple…
• 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.
• 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 thus estimated to account for 470/1090 (43%) of infant infections in 2007
Impact of incident HIV infection in pregnancy
T Creek, personal communication 2008
Incident HIV is thus estimated to account for 470/1090 (43%) of all infant infections in 2007
Challenges and Responses
World Population
Doctors Working in the World
HIV Prevalence
Challenges and Responses
Sub-Saharan Africa – 24% of world disease burden
– 3% of healthcare workforce
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
South Africa Situation
http://www.hst.org.za/uploads/files/cahp9_07.pdf
Nurses 44% Doctors 10% Psychologists 4%
# of Health Professionals in Public Sector as Percentage of Total Health Professionals (2007)
South African Population (2007) – 47,849,800 Public Health Sector Dependent – Black South Africans – 93%
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%
http://www.hst.org.za/uploads/files/cahp9_07.pdf
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)
PMTCT Programs – 2001
• 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
Transmission Rates: 14-16%
PMTCT Program Interventions – 2008
• 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
Target: Transmission Rates: 2-5%
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
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…”
mothers2mothers
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
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
Goal 1: PMTCT
Goal 2: Healthy mothers and infants
Goal 3: Empowerment
mothers2mothers
m2m envisions a world where babies are not born with HIV, where
HIV+ mothers are alive and healthy to care for
their families and where HIV-positive
women are empowered to live positively
Vision To prevent babies from contracting
HIV through mother-to-child transmission and promote HIV-free
survival.
To keep HIV-positive mothers and their infants alive and healthy by increasing their access to health-
sustaining medical care
To empower mothers living with HIV/AIDS, enabling them to fight
stigma in their communities and to live positive and productive lives
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”
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
Simple, Scale-able Model of Care
• Individual and group engagement
• 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 living with HIV (Mentor Mothers) educate and support HIV-positive pregnant women and new mothers in health facilities
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
Training
• Curriculum based education • 2 weeks - Mentor Mothers • 3 weeks - Site Coordinators
– Mentor Mother training – Management training
• Periodic top-up training
Training cascade: National Trainer SC/MM Patients
Points of Service
• Antenatal clinics • Post-delivery wards
before discharge • Postnatal programs • Targeted community
outreach
m2m Does Not:
• Counsel for or perform HIV testing • Provide medication • Distribute formula
• Support medical services that do
m2m Does:
Site Management Plan
MM MM
MM
MM
SC
MM
SC
Tertiary Care
Hospital
Primary Health Center
Site Systems
Regional or District Program Manager
Community Outreach
Community Outreach Community Outreach
Satellite Health Centres
Hospital or Major HC
Site System
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
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?
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)
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
M2M2B – 2001
South Africa
m2m – 2009/10
South Africa
Malawi
“Ethiopia”
Kenya Rwanda Zambia
Swaziland Lesotho
“Botswana”
Uganda
Mozambique
Tanzania
Namibia
m2m – Activities 2009
Timing Sites Field Staff
Patient encounters per month
New HIV-positive
women per month
September 2009
581 1535 208,907 24,165
Further expansion in 2009/10: Mozambique Tanzania Uganda Namibia
Gratitudes
• James McIntyre • Monica Nolan • David Wilson • UNICEF • Zapiro • …and to all of the
mothers…
• James McIntyre • Monica Nolan • Mickey Chopra • Tanya Doherty • …and to all of the mothers…
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