Health Outcomes Indaba 2016 POST NATAL CLUBS Health Outcomes Indaba 2016 Presented by: Dr Aurelie Nelson

Setting Khayelitsha, Cape Town Population ~ 500,000 HIV antenatal prevalence: 34% (2012) Town 2 clinic CoCT: 10 clinics providing HIV care, including ARV enrolment. Town 2: all services under one roof, 203 PMTCT babies (2015) M2M: An Africa based global organisation established in 2001Focus on MNCWH, Adolescent and early childhood development Provides peer education and psychosocial support through employment and training of Mentor Mothers(HIV positive women) in health facilities & communities MSF: HIV/TB innovative care in Khayelitsha since 1999

So what happens post-natally? PMTCT: how are we doing? Option B+ rolled out in 2013 Birth PCR and 10 weeks PCR implemented since April 1st, 2016 Nationally, MTCT at 3 months weeks is 2,7% (Goga et al., IAS, 2016) Khayelitsha:, MTCT (2015) at 10 weeks is 0.8% DOING WELL! BUT Many recent changes in PMTCT guidelines MTCT at 18 months: Nationally : 4.3% (Goga et al., IAS, 2016) Khayelitsha: Unknown but only 39% come for testing So what happens post-natally?

PMTCT postnatally: One of the main issues: Poor RIC of mother infant pair (MIP) post natally 29% of mothers LTFU by 6 months post natally in Gugulethu (Phillips et al., JIAS, 2014) Even if participants were paid R100 per visit, only 71% of infants returned at 18 months (Goga et al, 2016) Khayelitsha: only 39% return at 18 months (2015)

Why is post natal retention of MIP poor? Long clinic waiting times High patient volumes at the ART clinic Non-disclosure of HIV status Lack of partner involvement Travel costs Poor access to postnatal services (Phillips T et al. J Int AIDS Soc. 2014. Clouse K et al. J Acquir Immune Defic Syndr. 2014. Langlois V et al. Bull World Health Organisation. 2015. ) 

How can we improve retention of MIP?

What we know works: Adult ART club Benefits to patient Easier access Group dynamic and peer support Empowers through self management Community network for tracing Ensures access to clinical care -Improves retention in care and virological outcomes Benefits for health system Reduces patient load Optimizes clinician’s time Optimizes capacity to initiate and manage unstable

What we know works: Integration of care for PMTCT Benefit of integrated services is known and recommended: USAID. Integrating prevention of mother-to-child transmission of HIV interventions with maternal, newborn, and child health services. Technical brief. The National Integrated Prevention of Mother-To-Child Transmission (PMTCT) of HIV Accelerated Plan at a Glance. South African Department of Health. 2011 BUT IMPLEMENTATION IS POOR!

How can we combine these solutions together? Mother: HIV, FP, Pap smear, MH, other Child: PMTCT, weight, EPI, vit A, Deworm, NDV, IMCI One stop shop Clinical visit at every session Postnatal nurse, NIMART Mental health Early childhood development Support BF 45 min session Peer support Facilitated by m2m mentors HIV and non HIV topics Adult ART club 1000 days Integration of HIV and non HIV care Integration of maternal and child health Explain exactly what happens at every visit. For example explain the first session: tummy time, making mobiles. Then what the nurse does. Explain MH: Edinburgh post natal depression screen

PNC: Methodology Eligibility criteria: Exclusion criteria: All HIV positive mothers and their HIV exposed infants High risk* MIP get extra interventions Exclusion criteria: HIV positive infants and their mothers Active TB Maternal ART care at another clinic M2m follows up patients that are excluded from the clubs 12 mths 15 mths 18 mths 10 wks 14 wks 18 wks 22 wks 6 mths 9 mths 6 wks CC Recruitement PNC PNC PNC PNC PNC PNC PNC PNC PNC

*High risk mother-infant pairs Maternal risk factors: VL >1000 after 28 weeks Mother on ART and no VL in last 3/12 On ART < 12 weeks prior to delivery Mother diagnosed with HIV after 28 weeks or in labour or immediately postpartum Chorioamnionitis Prolonged rupture of membranes >18 hours Infant risk factors: Born <37 weeks ie premature Abandoned newborn, orphans who are HIV exposed (positive rapid test)

PNC: objectives VL suppression for the mother (measured at 12m and 18m) Prevention of sero-conversion of the HIV exposed infant (measured at 9m and 18m) Retention of the mother in the ARV cohort at 18 months Maternal access to timely family planning over 18 months Completion of all scheduled infant HIV testing by 18 months of life Completion of full infant vaccination coverage at 12 months

Outcomes Number % PMTCT babies Feb-June 2016 74 PNC started 11   Number % PMTCT babies Feb-June 2016 74 PNC started 11 Mother infant pair (MIP) recruited 56 76% Mothers recruited 54 High risk mothers 3 5% Mothers with VL at baseline (done within 3 months) 49 90% Mothers virally suppressed at baseline 100% PCR done on baby at 10 weeks 32 PCR positive at 10 weeks 0% MIP retained in care at 2 months post enrollment 15 Breastfeeding 30 54% Formula feeding 26 46% Referral to doctor 5 5 referral to doctors: 2 for high MH screen, one for HTN, one for headache, one for Bell s palsy 3 high risk mothers:1 had preterm tiwns and defaulted treatment, 1 has preterm baby, one defaulted treatment 2 IUD insrted, more than 10 pap smears done

Outcomes Mothers enjoy: “meeting other HIV positive mothers” , “activities for the babies” “the one stop shop” “better to come one time for everything” “babies lying down on the mat : doesn’t feel like a clinic” “a space to talk freely”

Benefits Very early days but so far: Good uptake of services Signs of early RIC Good VL suppression Open communication with the mothers and peer support Qualitatively mothers seem to be enjoying it Workload shifted from PMTCT sister to PNC IUCD and pap smear encouraged and done at the one stop shop

Challenges Long clinical visits Need NIMART trained sister for PNC Small groups Scheduling of PNC difficult Meeting space (infrastructure) M+E too long Many social issues uncovered

Way forward Continue recruiting at Town 2 Plan to scale up to other clinics Ultimately plan for HIV negative mothers to be part of similar intervention

Contact details Aurélie Nelson MCH Manager Médecins Sans Frontières Cell: 0798678516 MSFOCB-Khayelitsha-EID@brussels.msf.org

Thank You! Big thank you to: MIP patients at Town 2 Town 2 facility team m2m team MSF team