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HIV in Pregnancy - Doing More with Less
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HIV in Pregnancy - Doing More with Less

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  • 1. Mitchell J. Besser, MD Founder and Medical Director mothers2mothersDepartment 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.
  • 4. Population HIV PrevalenceSouthern
Africa East
Africa Botswana 
 
 West
Africa
 Asia
 LAC
 South Africa Zambia Senegal Mali
  • 5. 65 60 with high HIV prevalence: Zimbabwe 55 South AfricaLife 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.
  • 6. PACTG 076 USPHS AZT Recommendations 80% decline
  • 7. Siripon Kanshana, 2007
  • 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
  • 11. Mother-to-Child Transmission (MTCT) of HIVEstimated Children Newly Infected in World UNAIDS estimates 2008
  • 12. 28%% Dept. of Health, 2008
  • 13. Challenges and Responses
  • 14. Missed PMTCT Opportunities: The Cascade Routine offer of HIV testing
  • 15. Amajuba District – KZN: PMTCT Cascade - 2007 88% 44% 37% 54% 18% 16% 21% Chopra et al MRC Report 2007
  • 16. Missed Treatment Opportunities 73%Patients 50% Mahdi, Abs. 437, HIV 25% Implementers, 2007
  • 17. Challenges and Responses
  • 18. Couples Status - Discordance Predominates Couples Status - Discordance Predominates Country Ratio Prevalence Data SourceEthiopia 6:1 1.8%/0.3% DHS-05Tanzania 3:1 7.9%/2.6% AIS 03/04Kenya ~2:1 7.4%/3.7% DHS-03Rwanda ~2:1 3.1%/1.7% DHS-05Uganda 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
  • 22. Challenges and Responses
  • 23. World Population
  • 24. Doctors Working in the World
  • 25. HIV Prevalence
  • 26. Challenges and ResponsesSub-Saharan Africa – 24% of world disease burden – 3% of healthcare workforce
  • 27. Staffing Ratios Selected categories of health care workers per 100,000 population (2007)Region/Country Physicians NursesUnited States 256 937South Africa 77 408Botswana 40 265Zambia 12 174Zimbabwe 16 72Lesotho 5 62Mozambique 3 21 http://www.hst.org.za/uploads/files/cahp9_07.pdf
  • 28. South Africa Situation South African Population (2007) – 47,849,800Public 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 SADoctors 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 RoleHIV counseling Counseling for HIV testHIV testing Perform HIV test, explain resultsCD4 counts Perform test, get and explain resultsCotrimoxazole Dispense drugInfant Feeding Choice Discuss infant feeding optionsAZT from 28 weeks Dispense drug, explain how to takeHAART - if eligible Dispense drug, explain how to takeHAART Adherence Counsel on adherence to HAARTHAART Toxicity Screen for HAART related toxicityInfant feeding adherence Reinforce exclusive infant feedingARVs for breast feeding Where available, explain how to useInfant testing at 6-weeks Perform HIV test, explain resultsReferral 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…”
  • 34. mothers2mothers
  • 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: PMTCTm2m 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-freeHIV+ 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 andwomen 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 BenefitsPromote 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 CareMothers are a community’s single greatest resourceMothers living with HIV (Mentor Mothers) educate andsupport HIV-positive pregnant women and newmothers 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. TrainingTraining 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 MMMM MMTertiary Primary Care HealthHospital Center
  • 46. Site System Community Outreach Satellite Health Centres Hospital or Major HC Community Outreach Community Outreach
  • 47. Program ImplementationBuy-in from:•  National government health services•  District health services•  Facility managers and staff•  CBOs and civil societyCommunity 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
  • 51. M2M2B – 2001 South Africa
  • 52. m2m – 2009/10 “Ethiopia” Uganda Kenya Rwanda Zambia Tanzania Malawi “Botswana” Mozambique Swaziland LesothoNamibia South Africa
  • 53. m2m – Activities 2009 Timing Sites Field Patient encounters New HIV- Staff per month positive women per monthSeptember 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 themothers… mothers…