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…