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Addressing the Gaps in PMTCT Care - A Dr Besser Presentation

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Addressing the Gaps in PMTCT Care - A Dr Besser Presentation

  1. 1. Mitchell J. Besser, MD Founder and Medical Director mothers 2 mothers Department of Obstetrics and Gynecology University of Cape Town 7 December 2010 mothers 2 mothers : Addressing the Gaps in PMTCT Care
  2. 2. 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
  3. 3. 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
  4. 4. Global HIV Prevalence
  5. 5. Doctors Working in the World Sub-Saharan Africa: 25% of global disease burden 3% of world ’s health workers
  6. 6. 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:
  7. 7. 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:
  8. 8. ...
  9. 9. mothers 2 mothers
  10. 10. <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 livingwith HIV ( Mentor Mothers ) educate and support HIV-positive pregnant women and new mothers in health facilities Simple, scale-able model of care
  11. 11. Goal 3. Empowerment Goal 2. Healthy mothers and infants Three m 2 m goals: Goal 1. PMTCT
  12. 12. 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>
  13. 13. <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
  14. 14. 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>
  15. 15. m 2 m services
  16. 16. 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:
  17. 17. 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
  18. 18. Community Outreach Community Outreach Community Outreach Satellite Health Centres Hospital or Major HC Site System
  19. 19. <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)
  20. 20. <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)
  21. 21. 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>
  22. 22. CD4 and HAART uptake among m 2 m antenatal clients (N=1246) Antenatal m2m clients CD4 Tests CD4 Results CD4 <350 HAART
  23. 23. CD4 and HAART uptake among m 2 m antenatal clients by number of visits (N=1246)
  24. 24. mothers & babies communities healthcare systems Demand and Supply Side:
  25. 25. South Africa Malawi Ethiopia Kenya Rwanda Zambia Swaziland Lesotho Botswana Uganda Mozambique ??? Tanzania m 2 m 2010
  26. 26. 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
  27. 27. Helping Mothers Saving Babies

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