Preventing MTCT in Africa: Using New Paradigms - A Dr Besser Presentation

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  • FIX ANIMATION
  • Nigeria is the most populous country in Africa
  • Re-animate
  • Mitch - Fix this slide
  • Mitch - Fix this slide
  • NEW SLIDE
  • Discuss high viral load during incident infection
  • BOTTOM ARROW IS PRESENT AT THE BEGINNING – REVIEW ANIMATION
  • NEW SLIDE - CAN WE MAKE THIS SLIDE MORE ATTRACTIVE
  • NEW SLIDE
  • NEW SLIDE - CAN WE MAKE THIS SLIDE MORE ATTRACTIVE
  • Emphasize all babies breast fed and transmission related to breast feeding alone.
  • Africa also has a disproportionate share of the world ’s doctors All you have to do is go to a hospital in London to see why.
  • … we must seek innovative ways of harnessing and focusing both the financial and the human resources that already exist…
  • Goal 1. PMTCT Prevent babies from contracting HIV through mother-to-child transmission Goal 2. Healthy mothers and infants Keep mothers and babies living with HIV/AIDS alive and healthy by increasing their access to health-sustaining medical care Goal 3. Empowerment Empower mothers living with HIV/AIDS, enabling them to fight stigma in their communities and to live positive and productive lives
  • Training both for providing client services, but also for educating and developing the capacity of our staff and providing them the foundations in professional skills.
  • INSERT BOX WITH SITE COORDINATOR = SC; MENTOR MOTHER = MM
  • Background Two Cross-Sectional surveys of women attending antenatal and post delivery care at three facilities in Pietermaritzburg, South Africa – before m2m introduced and one year later, after m2m introduced. Program analysis: 345 HIV+ pregnant women and 350 HIV+ post-partum women – and these were divided into program participants and non-participants. Interviews ascertained self reported behaviors and knowledge about PMTCT among women who had received m2m services more than 2 times (participants) or had no contact. >50% of HIV+ women attending services, during antenatal care or after delivery, had received services from m2m . Results Post-partum women on average received m2m services 6 times over the course of ante and post-natal period. Findings among postpartum program participants significantly better than among non-participants (bivariate analysis).
  • One graph only
  • THREE LEVELS OF IMPACT: Mothers & babies Communities Healthcare system
  • Preventing MTCT in Africa: Using New Paradigms - A Dr Besser Presentation

    1. 1. Mitchell J. Besser, MD Founder and Medical Director mothers 2 mothers 14 December 2010 mothers 2 mothers: Preventing Mother-to-Child HIV Transmission in Africa Using New Paradigms in Health Care Delivery
    2. 2. Population HIV Prevalence Zimbabwe South Africa Botswana Senegal Mali
    3. 3. Life Expectancy: 1950-2005 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 . 1950– 1955 1955- 1960 1960- 1965 1965- 1970 1970- 1975 1975- 1980 1980- 1985 1985- 1990 1990- 1995 1995- 2000 2000- 2005 30 35 40 45 50 55 60 65 Life expectancy (years)
    4. 4. Grim Reality UNAIDS: 2010 FACTS: <ul><li>2.6 million new HIV infections (2010) </li></ul><ul><li>1.8 million adults and children died of HIV/AIDS (2010) </li></ul><ul><li>1.2 million people started on treatment in 2010 </li></ul>Each year: ► Twice as many people become infected with HIV as start on treatment; ► Twice as many people die of AIDS as start on treatment.
    5. 5. Global HIV Prevalence 33.3 million living with HIV in 2010 Sub-Saharan Africa 22.4 million
    6. 6. 90% of HIV-positive pregnant women are in Sub-Saharan Africa 1.4 million pregnant women in low- and middle-income countries are infected with HIV
    7. 7. Towards Universal Access, WHO, 2009 Grim Inequities Prevalence in Pregnancy Nigeria 2.4 - 4% South Africa 29% US and UK 0.6% Adult Prevalence Nigeria 3% South Africa 18% US and UK 0.3 - 0.6% PMTCT Coverage Nigeria 10% South Africa 73% US and UK > 95% ARV Coverage (children) Nigeria 12% South Africa 61% US and UK > 95%
    8. 8. Pediatric HIV infections in U.S. 80% decline CDC PACTG 076 – AZT treatment starts
    9. 9. Siripon Kanshana, 2007 Pediatric HIV infections in Thailand 80% decline HIV testing PMTCT ARVs National PMTCT program
    10. 10. UNAIDS estimates 2008 Pediatric HIV infections in World
    11. 11. 1100 children infected per day in 2008
    12. 12. ≈ 1000 in Africa <1 in the US 1 in Europe 100 in Asia & the Pacific
    13. 13. Annual pregnancies in HIV-positive women United States (7000) Rwanda (8000) South Africa (300,000) Baragwanath Hospital (8000) (Soweto)
    14. 14. PMTCT Cascade Gap = Missed Opportunities
    15. 15. Reducing the Risk: Treatment PMTCT Treatment Transmission Rate at 6 Weeks No Treatment 25% Single-dose Nevirapine (sdNVP) 12% AZT (28 weeks) + sdNVP 3% HAART 1%
    16. 16. Myth of the 80s <ul><li>Transmission rates: </li></ul><ul><li>NVP (12% MTCT): 61 infected </li></ul><ul><li>AZT+NVP (3% MTCT): 15 infected </li></ul><ul><li>HAART (1% MTCT): 5 infected </li></ul>Adapted from P. Barker, IHI, WHO PMTCT Mtg Nov 2008, L Mofenson, 2009 <ul><li>Number of HIV+ babies: </li></ul><ul><li>NVP: 183 </li></ul><ul><li>AZT+NVP: 137 </li></ul><ul><li>HAART: 127 </li></ul>640 512 Enter into program 800 488 No Rx (25% MTCT): 122 infected 200 160 128 Missed - no PMTCT Attend ANC: 80% Counseled and tested for HIV: 80 % Get ARVs: 80% 1000 positive mothers
    17. 17. Reality of the 80s <ul><li>Transmission rates: </li></ul><ul><li>NVP (12% MTCT): 96 infected </li></ul><ul><li>AZT+NVP (3% MTCT): 24 infected </li></ul><ul><li>HAART (1% MTCT): 8 infected </li></ul>Adapted from P. Barker, IHI, WHO PMTCT Mtg Nov 2008, L Mofenson, 2009 <ul><li>Number of HIV+ babies: </li></ul><ul><li>NVP: 145 </li></ul><ul><li>AZT+NVP: 73 </li></ul><ul><li>HAART: 57 </li></ul>865 804 Enter into program 930 196 No Rx (25% MTCT): 49 infected 70 65 61 Missed - no PMTCT Attend ANC: 93% Counseled and tested for HIV: 93 % Get ARVs: 93% 1000 positive mothers
    18. 18. HIV Infected Babies Myth of the 80s Reality of the 80s NVP: 12% 183 146 AZT+NVP: 3% 137 73 HAART: 1% 127 57
    19. 19. HIV Infected Babies Myth of the 80s Reality of the 80s NVP: 12% 183 146 AZT+NVP: 3% 137 73 HAART: 1% 127 57
    20. 20. 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
    21. 21. Incident HIV Challenges and Responses
    22. 22. Discordant /concordant Couple Status – Discordance Predominates Country Ratio Data Source Ethiopia 6 :1 DHS-05 Tanzania 3 :1 AIS 03/04 Kenya 2 :1 DHS-03 Uganda 2 :1 AIS-04/5
    23. 23. If man is HIV+ and in a couple… Couple Status – Discordance Predominates Country … % Woman HIV + Data Source Ethiopia 27% DHS-05 Tanzania 37% AIS 03/04 Uganda 55% AIS-04/5 Kenya 57% DHS-03
    24. 24. Incident HIV in pregnancy = new infections in women with a documented negative test in that pregnancy Where effective interventions have reduced transmission in women identified as HIV-positive, new infections during pregnancy may be a major source of MTCT. <ul><li>MTCT rates associated with new infection to mother: </li></ul><ul><ul><li>70% during pregnancy and childbirth </li></ul></ul><ul><ul><li>36% during breastfeeding </li></ul></ul>HIV Incidence in Pregnancy
    25. 25. T Creek, personal communication 2008 Impact of Incident HIV Infection in Pregnancy A study in Botswana showed: Among women testing negative in early pregnancy: Botswana National PMTCT program transmission data show: Extrapolating incident HIV to the national Botswana figures : Incident HIV is thus estimated to account for 470/1090 (43%) of all infant infections in 2007 1.3% were infected in 17 weeks before delivery 1.8% were infected in the first year after delivery 13,900 HIV+ women infected estimated 620 infants (4.7%) Estimate 950 women acquired HIV during pregnancy or first postpartum year, and infected 470 infants
    26. 26. Feeding the Baby
    27. 27. <ul><li>Infant feeding is one of the most difficult and most emotive issues in HIV management in low-resource settings </li></ul><ul><li>An estimated 300,000 children acquire infection through breast feeding each year </li></ul><ul><li>HIV transmission in early childhood remains a challenge in places where infant formula cannot be safely provided </li></ul>Infant feeding and HIV
    28. 28. Am J Epidem 1995 Timing of HIV Transmission (non Breastfeeding cohort)
    29. 29. Months 0 5 10 15 20 25 30 35 1 12 18 % HIV infected Transmission Cumulative 4% Transmission of HIV for every 6 months of breast-feeding 6 -3 Delivery Timing of HIV Transmission Delivery
    30. 30. Infant Feeding and HIV Transmission Infant Age Coutsoudis,13th AIDS Conf, 2000 8% 7% 7% 19% 19% 26% 0 10 20 30 % Transmission 1 Day 6 Mos Never Breastfed (N=157) Exclusive Breastfed (N=118) Mixed Feeding (N=276)
    31. 31. Exclusive Breastfeeding in HIV+ Women in Clinical Trials in Resource-Poor Countries
    32. 32. Requirements for safe replacement feeding <ul><li>Assessment should also include: </li></ul><ul><li>Health service accessibility </li></ul><ul><li>Counselling and support available </li></ul><ul><li>Is replacement feeding… </li></ul><ul><li>… for the mother and baby </li></ul>Henderson, WHO, 2006 <ul><ul><li>A cceptable </li></ul></ul><ul><ul><li>F easible </li></ul></ul><ul><ul><li>A ffordable </li></ul></ul><ul><ul><li>S ustainable </li></ul></ul><ul><ul><li>S afe </li></ul></ul>
    33. 33. Feeding Method - Issues <ul><li>Clean water – “tap” </li></ul><ul><li>Clean bottles – “flame” or “electric” </li></ul><ul><li>Source of formula </li></ul><ul><ul><li>Free </li></ul></ul><ul><ul><li>Accessible </li></ul></ul><ul><li>Disclosure </li></ul>
    34. 34. HIV Infection through Age 7 Months is Higher in Breast Fed than Formula Fed Infants p=0.04 Thior I et al. JAMA 2006;296:794-805 7 Months
    35. 35. Mortality through Age 7 Months is Higher in Formula Fed than Breast Fed Infants p=0.004 Predominant causes infant death: Diarrheal disease and pneumonia 7 Months
    36. 36. No Difference in 18-Month HIV-Free Survival Between Formula Fed and Breast Fed Infants p=0.41 Thior I et al. JAMA 2006;296:794-805 18 Months
    37. 37. No Difference in 18-Month HIV-Free Survival Between Formula Fed and Breast Fed Infants p=0.41 Thior I et al. JAMA 2006;296:794-805 18 Months FF: 33 infected, 46 deaths BF: 54 infected, 34 deaths
    38. 38. BAN: Probability HIV positive or death by week 28 visit in infants uninfected at birth BAN Study: Probability of HIV+ or Death by 28 week visit in infants uninfected at birth Age (weeks) Probability HIV positive or death 1 4 8 12 16 20 24 28 0.00 0.02 0.04 0.06 0.08 Control vs Maternal HAART: p= 0.03 7.6% 4.7% 2.9% Control – No ARVs Maternal HAART Infant NVP
    39. 39. BAN: Probability HIV positive or death by week 28 visit in infants uninfected at birth BAN Study: Probability of HIV+ or Death by 28 week visit in infants uninfected at birth 7.6% 4.7% Age (weeks) Probability HIV positive or death 1 4 8 12 16 20 24 28 0.00 0.02 0.04 0.06 0.08 Control vs Maternal HAART: p= 0.03 7.6% 4.7% 2.9% Control – No ARVs Maternal HAART Infant NVP
    40. 40. BAN: Probability HIV positive or death by week 28 visit in infants uninfected at birth BAN Study: Probability of HIV+ or Death by 28 week visit in infants uninfected at birth 7.6% 2.9% Age (weeks) Probability HIV positive or death 1 4 8 12 16 20 24 28 0.00 0.02 0.04 0.06 0.08 Control vs Infant NVP: p <0.0001 7.6% 4.7% 2.9% Control – No ARVs Maternal HAART Infant NVP
    41. 41. BAN: Probability HIV positive or death by week 28 visit in infants uninfected at birth BAN Study: Probability of HIV+ or Death by 28 week visit in infants uninfected at birth 4.7% 2.9% Age (weeks) Probability HIV positive or death 1 4 8 12 16 20 24 28 0.00 0.02 0.04 0.06 0.08 Maternal HAART vs Infant NVP: p= 0.07 7.6% 4.7% 2.9% Control – No ARVs Maternal HAART Infant NVP
    42. 42. 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 HIV / AIDS
    43. 43. Magical Thinking Health Systems
    44. 44. Global HIV Prevalence
    45. 45. Doctors Working in the World Sub-Saharan Africa: 25% of global disease burden 3% of world ’s health workers
    46. 46. http://www.hst.org.za/uploads/files/cahp9_07.pdf Staffing Ratios 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
    47. 47. http://www.hst.org.za/uploads/files/cahp9_07.pdf Staffing Ratios 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
    48. 48. SA Population (2009): 49 million population dependent on public health sector health professionals in public sector 85% 44 % 10% vacant posts in public health sector Doctors Nurses 36% 34% 30%
    49. 49. Has only minutes per patient 1) Counsel for HIV test 2) Perform HIV test, explain results 3) Dispense single dose nevirapine, 4) Explain how to take 5) Discuss infant feeding options 6) Reinforce exclusive infant feeding 7) Perform infant HIV test at 12-months, 8) Explain results PMTCT Program Interventions: In 2001… Transmission Rates: 14-16% Nurse:
    50. 50. Still has only minutes per patient 1) Counsel for HIV test 2) Perform HIV test, explain results 3) Perform CD4 test, get and explain results. Refer for HAART if CD4<350 4) Dispense cotrimoxazole 5) Discuss infant feeding options 6) Dispense AZT (from 14 weeks), explain how to take 7) Dispense HAART (if eligible), explain how to take 8) 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:
    51. 51. ...
    52. 52. mothers 2 mothers
    53. 53. <ul><ul><li>Individual and group meetings </li></ul></ul><ul><ul><li>Daily presence for education and support </li></ul></ul><ul><ul><li>Mentor Mothers: professional members of health care team - paid for service </li></ul></ul>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 Simple, scale-able model of care
    54. 54. Goal 3. Empowerment Goal 2. Healthy mothers and infants Three m 2 m goals: Goal 1. PMTCT
    55. 55. Site Coordinators and Mentor Mothers <ul><li>Recruited locally </li></ul><ul><li>Selection Criteria: </li></ul><ul><ul><li>Mothers </li></ul></ul><ul><ul><li>HIV-positive </li></ul></ul><ul><ul><li>Attended PMTCT </li></ul></ul><ul><ul><li>Disclosed </li></ul></ul><ul><li>Basic numeracy and literacy skills </li></ul><ul><li>Site Coordinators manage services </li></ul><ul><li>Mentor Mothers engaged for up to two years </li></ul>
    56. 56. <ul><ul><ul><li>Curriculum based education </li></ul></ul></ul><ul><ul><ul><li>2 weeks - Mentor Mothers </li></ul></ul></ul><ul><ul><ul><li>3 weeks - Site Coordinators </li></ul></ul></ul><ul><ul><ul><li>Periodic top-up training </li></ul></ul></ul>Training Training Cascade: National Trainer Site Coordinator / Mentor Mother Patients
    57. 57. Points of Service <ul><li>Prenatal clinics </li></ul><ul><li>Labor and delivery </li></ul><ul><li>Postnatal programs </li></ul><ul><li>Targeted community outreach </li></ul>
    58. 58. m 2 m services
    59. 59. task-shifting
    60. 60. m 2 m Services <ul><li>Counsel for, or perform HIV testing </li></ul><ul><li>Provide medication </li></ul><ul><li>Distribute formula </li></ul><ul><li>Support medical services that do </li></ul>m 2 m Does: m 2 m Does Not:
    61. 61. 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 Coordinator MM = Mentor Mother
    62. 62. Community Outreach Community Outreach Community Outreach Satellite Health Centres Hospital or Major HC Site System
    63. 63. <ul><li>Research Questions </li></ul><ul><li>Does mothers 2 mothers : </li></ul><ul><li>Increase HIV-positive women ’s utilization of PMTCT services? </li></ul><ul><li>Improve PMTCT outcomes and psychosocial well-being? </li></ul>Population Council: Horizons Study (2007)
    64. 64. <ul><li>PMTCT </li></ul><ul><ul><li>95% of mothers received nevirapine </li></ul></ul><ul><ul><li>88% of babies received nevirapine </li></ul></ul><ul><li>Care </li></ul><ul><ul><li>79% had CD4 counts </li></ul></ul><ul><ul><li>88% knew CD4 count results </li></ul></ul><ul><li>Infant Feeding </li></ul><ul><ul><li>89% chose exclusive infant feeding method </li></ul></ul><ul><li>Family Planning </li></ul><ul><ul><li>70% using contraception </li></ul></ul><ul><li>Disclosure </li></ul><ul><ul><li>97% disclosed (4.4x non-participants) </li></ul></ul>Population Council: Horizons Study (2007)
    65. 65. <ul><li>Pregnant women felt they could: </li></ul><ul><ul><li>Do things to help themselves </li></ul></ul><ul><ul><li>Cope with taking care of baby </li></ul></ul><ul><ul><li>Live positively </li></ul></ul><ul><li>Postpartum women felt less: </li></ul><ul><ul><li>Alone in the world </li></ul></ul><ul><ul><li>Overwhelmed by problems </li></ul></ul><ul><ul><li>Hopeless about future </li></ul></ul>Program Participants Report Better Psychosocial Well-Being Population Council: Horizons Study (2007)
    66. 66. m 2 m Outcomes – Lesotho (2010) <ul><li>Program started 2007 </li></ul><ul><ul><li>58 program sites </li></ul></ul><ul><li>64% m 2 m country coverage </li></ul><ul><li>77% disclosure rates among clients attending > 3 times </li></ul><ul><li>79% early infant diagnosis </li></ul>
    67. 67. CD4 and HAART uptake among m 2 m antenatal clients (N=1246) Antenatal m2m clients CD4 Tests CD4 Results CD4 <350 HAART
    68. 68. CD4 and HAART uptake among m 2 m antenatal clients by number of visits (N=1246)
    69. 69. <ul><li>“ Standard ” intervention </li></ul><ul><li>Clinic based care only </li></ul><ul><li>Improved education on importance of early infant HIV testing </li></ul><ul><li>Use of m 2 m wheel to estimate date of return visit </li></ul><ul><li>Client information sheet – date and location of baby HIV test </li></ul><ul><li>“ Enhanced ” intervention </li></ul><ul><li>Clinic based care + active client follow-up </li></ul><ul><li>8 week telephone call </li></ul><ul><li>10 week call + home visit if needed </li></ul>Early Baby Testing Study
    70. 70. Baby HIV Testing Tool Baby HIV Test Card Resources Developed for Study
    71. 71. <ul><li>“ Standard ” intervention </li></ul><ul><li>Clinic based care only </li></ul><ul><li>Improved education on importance of early infant HIV testing </li></ul><ul><li>Use of m 2 m wheel to estimate date of return visit </li></ul><ul><li>Client information sheet – date and location of baby HIV test </li></ul><ul><li>“ Enhanced ” intervention </li></ul><ul><li>Clinic based care + active client follow-up </li></ul><ul><li>8 week telephone call </li></ul><ul><li>10 week call + home visit if needed </li></ul>Early Baby Testing Study
    72. 72. Cellphone Subscribers - 2009 North America: 276m Africa: 358m
    73. 73. Non-ACFU Sites n = 204 ACFU Sites n=214 Eligible 8 week call Yes =179 (84%), No =35 (16%) Eligible 10 week call & home visit Yes =53 (32%), No =114 (68%) * Of 167 consenting for home visit 10 week home visit Reached =24 (45%) Not Reached = 22 (42%) Excluded/too far = 7 (13%) Early Infant Diagnosis Study
    74. 74. Non-ACFU Sites n = 204 ACFU Sites n=214 Eligible 8 week call Yes =179 (84%), No =35 (16%) Eligible 10 week call & home visit Yes =53 (32%), No =114 (68%) * Of 167 consenting for home visit 10 week home visit Reached =24 (45%) Not Reached = 22 (42%) Excluded/too far = 7 (13%) 60% reached by phone (108) Early Infant Diagnosis Study
    75. 75. Non-ACFU Sites n = 204 ACFU Sites n=214 Eligible 8 week call Yes =179 (84%), No =35 (16%) Eligible 10 week call & home visit Yes =53 (32%), No =114 (68%) * Of 167 consenting for home visit 10 week home visit Reached =24 (45%) Not Reached = 22 (42%) Excluded/too far = 7 (13%) Early Infant Diagnosis Study
    76. 76. Non-ACFU Sites n = 204 ACFU Sites n=214 Eligible 8 week call Yes =179 (84%), No =35 (16%) Eligible 10 week call & home visit Yes =53 (32%), No =114 (68%) * Of 167 consenting for home visit 10 week home visit Reached =24 (45%) Not Reached = 22 (42%) Excluded/too far = 7 (13%) Early Infant Diagnosis Study
    77. 77. Non-ACFU Sites n = 204 ACFU Sites n=214 Eligible 8 week call Yes =179 (84%), No =35 (16%) Eligible 10 week call & home visit Yes =53 (32%), No =114 (68%) * Of 167 consenting for home visit 10 week home visit Reached =24 (45%) Not Reached = 22 (42%) Excluded/too far = 7 (13%) 11% of total (214) reached by home visit Early Infant Diagnosis Study
    78. 78. Early Infant Diagnosis Study (N = 55,13) (N = 115,167) p < 0.01
    79. 79. Early Infant Diagnosis Study (N = 55,13) (N = 115,167) p < 0.01
    80. 80. Early Infant Diagnosis Study (N = 55,13) (N = 115,167) * Of those with known test results
    81. 81. mothers & babies communities healthcare systems Demand and Supply Side:
    82. 82. South Africa M2M2B - 2001
    83. 83. South Africa Malawi Ethiopia Kenya Rwanda Zambia Swaziland Lesotho Botswana Uganda Mozambique ??? Tanzania m 2 m 2010
    84. 84. m 2 m Today
    85. 85. Total HIV-positive pregnant women enrolled: 20% of the global disease burden m 2 m Activities 2010 Current Date Nov-10 Sites 703 Field Staff 1766 Patient Encounters Per Month 267,103 New HIV-positive Women Per Month 22,111
    86. 86. Helping Mothers Saving Babies

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