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

2. 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

3. 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?

4. 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)

5. 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
Clouse K et al. J Acquir Immune Defic Syndr
Langlois V et al. Bull World Health Organisation ) 

6. How can we improve retention of MIP?

7. 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

8. 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!

9. 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

10. 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

11. *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)

12. 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

13. 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

14. 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”

15. 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

16. 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

17. 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

18. Contact details
Aurélie Nelson MCH Manager Médecins Sans Frontières Cell:

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