Acceptability and challenges of Mother-Infant Pair clinics as a model for provision of integrated HIV and Maternal, Neonatal and Child Health care: Lessons Learnt from the INSPIRE-PRIME study Victor Mwapasa, University of Malawi, College of Medicine Michael Eliya, National PMTCT Coordinator, Ministry of Health (Malawi) Frank M Chimbwandira, HIV Department, Ministry of Health (Malawi) Nurse Nyambi, Clinton Health Access Initiative Andrews Gunda, Clinton Health Access Initiative Government of Malawi

Pediatric HIV Infection in Malawi UNAIDS 2015 Goal: virtual elimination of HIV MTCT (<5%) Malawi adopted Option B+ Strategy in July 2011 ~12,000 Pediatric HIV infections annually ART Coverage in HIV+ pregnant women increased to 72% (GoM) Estimated reduction in MTCT from 2009 to 2013 : >60% (UNAIDS) Challenges with retention of mother-infant pairs in PMTCT cascade Mother retention at 12 months: 72% (MoH) Consequence of poor retention  HIV MTCT, maternal and infant morbidity and mortality

Factors associated with poor retention Demand Factors (access to health services) Poor male involvement ART side effects Out-of-pocket expenditure (transport costs) HIV-related stigma Supply Factors (sub-optimal health services delivery) Insufficient human resources for health Inadequate stocks of pharmaceutical and medical supplies, Ineffective follow up system for HIV-positive mothers Vertical delivery of health services at facility level

Mother-Infant-Pair (MIP) Clinic Concept Maternal HIV Care ART initiation, drug refills & clinical monitoring Maternal non-HIV care Family planning Infant HIV Care NVP, CXT, DNA PCR, HIV Rapid Testing & ART Infant non- HIV care Immunizations Growth & nutrition assessment Multiple health facility visits, multiple service delivery points!!

Research Questions What is the feasibility of implementing MIP clinics? How acceptable are MIP clinics to mothers and Health workers? Part of Cluster-Randomized Trial (CRT) Compare the effectiveness of three approaches on retention of mother‐infant pairs on HIV care and treatment 1.Mother‐Infant Pair (MIP) clinics (10 Primary Health Care facilities [PHCs]) 2.MIP clinic plus SMS Frontline Technology (10 PHCs) 3.Standard of Care (10 PHCs)

Methodology Study Design: Qualitative IDI, FGDs & serial field notes Study Sites: 15 PHC facilities, Mangochi & Salima districts, Southern Malawi Study period: August-September 2014 (>1 year after CRT commencement) Study population: HIV+ pregnant and post-partum women, Health Service Providers Sample size: 20 FGDs, 20 IDIs Data Analyses: Thematic content analyses (Atlas ti) Mangochi Salima

Results: Feasibility of Establishing & Sustaining MIP Clinics Establishment of fully functional MIP Clinics took 6-12 months Needed flexibility in implementation (variation in frequency of clinics & delivery approach) Human Resource challenges Availability shortages High staff turnover Technical skills Planning and management skills Attitude and commitment Infrastructure Space– could not provide all services in one place Competing Activities (workshops, field & other NGO projects) Centralized training ineffective, Needed frequent mentoring visits, exchange visits & incentives Needed District Health Management Team (DHMT) Interventions

Results: Acceptability of MIP clinics to women Positive aspects of MIP clinics reduced frequency of health facility visits. comprehensiveness of services provided per visit. supportive interactions with fellow HIV-infected women Perceived improvement of health. Negatives aspects of MIP clinics Prolonged health facility visit  few HCW vs patients, late opening of clinics Inconsistency in providing package of MNCH services Community-level stigma

Results: Acceptability of MIP clinics to Health Workers Positive: Better & positive personal interaction with women Promoted team work at health facility (clinicians, nurses, clerks, Health Surveillance Assistants) Negative Perceived increased workload—exacerbated by increase MIP attendance Views varied according to frequency of MIP clinics Suboptimal provision of non-HIV services during MIP clinic days

Conclusion MIP clinics are rated favorably by most clients but HCW had mixed views Facilitators of successful establishment MIP clinics Minimum staff compliments (Clinician/Nurse/HSA/Clerk/Counselors) Frequent and tailored HCW mentorship to (?can routine supervision work) Infrastructure (to provide “one-stop shop” model) Need for harmonized NGO activities at primary care level to avoid services disruptions DHMT need to assume leadership Need for intensification of stigma reduction campaigns to sustain demand

Limitations & Way Forward No quantitative data on workload increases Did not seek views community members Measurement bias—Evaluation done by study team Impact of MIP clinics on retention Cost-effectives of MIP Results expected in December 2016

Acknowledgements All study participants: women, infants and health workers District Health Management Teams (Salima & Mangochi) WHO-staff (Technical Support): Nigel Rollins, Nathan Shaffer, Morkor Newman, Ellen Thom, Nita Bellare Funding Agency: Canadian Department for Foreign Affairs Trade and Development PRIME Study Team

PRIME STUDY TEAM minus HCW