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PMTCT Package of care: women receiving care in the ANC Isabelle Yersin PMTCT Program Manager ICAP - MOZAMBIQUE

Overview of the presentation. PMTCT realities in resource poor settings (MZ example) Package of care for women and childrenWhere are we losing women?Considerations for making the best of lost opportunitiesFor women, for children and for familiesOptimal package of care for engaging healthy posit

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PMTCT Package of care: women receiving care in the ANC Isabelle Yersin PMTCT Program Manager ICAP - MOZAMBIQUE

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    2. Overview of the presentation PMTCT realities in resource poor settings (MZ example) Package of care for women and children Where are we losing women? Considerations for making the best of lost opportunities For women, for children and for families Optimal package of care for engaging healthy positive women in long term follow-up

    3. PMTCT Coverage in Mozambique Population = ~19 million (2005) Women of child bearing age = 4,750,000 (~25%) HIV prevalence in adults = 16.5% ((National survey, 2004) Trained nurses = 4282 Nurse to female patient ratio = 1:1109 As of 2006, only 29% of health facilities offer PMTCT services (222/775) *Source: Demographic Impact of HIV/AIDS in Mozambique, MoH, National Institute of Statistics, May 2004 *Source: Demographic Impact of HIV/AIDS in Mozambique, MoH, National Institute of Statistics, May 2004

    4. Package of Care - ANC One stop strategy + HIV rapid test + CD4 drawnOne stop strategy + HIV rapid test + CD4 drawn

    5. Package of Care ANC (cont.) Referral to ART clinic Counselors and support groups Pt walked over to ART clinic by peer educator ART UNI provided Clinical chart ANC continues in PMTCT pCTX if warranted Referral to Medical Consultation No counselors or support groups No HIV UNI provided No clinical chart ANC continues in PMTCT pCTX if warranted Women not eligible to ART do not have a access to comprehensive package of care: no counseling by counselors or psychologists, no clinical file, no appointment written in a HIV patient card (which they dont have). Women not eligible to ART do not have a access to comprehensive package of care: no counseling by counselors or psychologists, no clinical file, no appointment written in a HIV patient card (which they dont have).

    6. Package of Care Post Partum care Referral of mother and child to PPC 7 days after delivery (up to 60 days) HIV test result recorded in ANC card Growth monitoring pCTX Infant feeding counseling DNA-PCR Referral to pediatric ART clinic if HIV infected

    7. Care Package: Successes & Challenges Successes: Ability to introduce more efficacious PMTCT prophylactic regimens More women enrolling in ART More exposed infants initiating cotrimoxazole prophylaxis Initiating integration of services (caring for mothers at ARCC) However: Focus of most PMTCT programs has been on antenatal and labor & delivery BUT PMTCT DOES NOT END AT DELIVERY!!!! Substantial risk continues during post natal period during breastfeeding Positive women not qualifying for HAART are most often lost to follow-up after delivery Family planning services are underused

    8. So where are we losing opportunities to engage and retain women and their families in long term care and treatment?

    9. Lost Opportunities: where are we losing women? Post Natal Care (PNC) Attendance: Maputo city: 21.4% pp women do not receive any PNC 74.5% receive PNC within 2 days of delivery Nampula province: 68.7% do not receive any PNC 37% within 41 days of delivery Family Planning (FP) Attendance: Maputo city: Coverage: ~70% (1st contact, 2006) Nampula province: Coverage: 5-20%

    10. Where can we find mothers and children?

    11. Making the best of lost opportunities

    12. How can we ensure that mothers not qualifying for ART are retained in care? What about BRINGING services to where women are coming rather than waiting for them to come access the services?

    13. Bringing services to where the women are Identify HIV+ women at healthy babies and EPI services C&T, HIV rapid test, CD4, referral to care Create a mom-baby wellness day Integration of mother and infant consultations at PPC / FP / ARCC Extending psycho social component at all MCH level not only at ANC Nurses, peer educators, counselors

    14. Bringing services to where the women are. Cont. Involving all MCH staff, including EPI into C&T Coordinating mother and children visits schedule: build linkages between HIV follow up care and PPC (referral, clinical chart, appointment)

    15. Can we dream? HIV integrated and comprehensive care for both mothers and babies at MCH: The same MCH nurse offering basic HIV follow up care for mother (CTZ, repeat CD4, some OI management, ART initiation? Psycho social support integrated as essential component of care?

    16. Very 1st steps toward service integration Very early phase of implementation at Jose Macamo PMTCT Model Center: At exposed infant consultation: 6months PP repeat CD4 testing of mothers not enrolled in care & treatment program Involvement of peer educators to promote HIV T&C among all mothers Linkages with care and treatment supportive services for mothers not in care

    17. Will enhancing the package of care provided to positive women not qualifying for HAART ensure that they will return for follow-up visits? Ensuring? May be not, but improving, definitely yes. Other approaches (sustainability?): Support patient transportation reimbursement in an attempt to increase follow-up? Reward system (example: for every five appointments adhered, mother to receive an incentive such as food basket, reimbursement for child school fees, etc)?

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