PMTCT Outcomes Enhanced by Psychosocial Support and Education

for Mothers

June 19, 2012Johannesburg, South Africa

m2m Goals

• Reduction in early and late transmission of HIV

• Reduction in maternal mortality associated with HIV

• Improved RMNCH

• Empowerment of women

• Reduction in stigma associated with HIV

m2m Overview

• Operating for over 10 years• Trains and employs women living with HIV

from local communities to provide PMTCT peer education and support

• Serves pregnant women, new mothers & their male partners

• Employed more than 4,000 Mentor Mothers since m2m’s founding

• Employs 1519 staff, in 609 health facilities in 7 countries

Key findings from m2m 2010 and 2011 client cohorts

Gestational age at 1st visit by country: most women present late for care

Kenya Lesotho Malawi South Africa

Swaziland Uganda Zambia Overall0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

7% 8% 7% 5% 5% 6% 5% 6%

49%52% 56%

45% 49% 44% 48% 47%

44% 40% 37%

50% 46% 49% 48% 47%

3rd trimester2nd trimester1st trimester

n=3474 n=751 n=983 n=10435 n=1624 n=308 n=669 N=18244

Uptake of any ARV during pregnancy, by country, 2010 and 2011 Cohorts

Lesotho Zambia Kenya South Africa Swaziland0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

82%77% 75%

53%

65%

83%

77% 75%71%

67%

2010 Cohorts

2011 Cohorts

* UNICEF. (2011). Children and AIDS: Fifth stocktaking Report, 2010. Geneva: UNICEF, UNAIDS, WHO & UNFPA.

*53% Uptake in Low to Middle income

countries

2011: n=771 n=724 n=3568 n=11123 n=1765

2010: n= 1313 n=991 n= 2059 n=4217 n=898

m2m clients receiving more psychosocial support report higher uptake of ARV during pregnancy

m2m Kenya* m2m Lesotho**

2 m2m visits 3 m2m visits 4+ m2m visits Kenya National Comparison

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

76%

85%

94%

73%

2 m2m visits 3 m2m visits 4+ m2m visits Lesotho National Comparison0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

82%

89%

96%

64%

*X2 =399.09, p<.001 **X2 =71.33, p<.001

n-=781 n=499 n=871 n-=164 n=127 n=242

Coefficients and odds ratio from logistic regression of uptake of any antenatal ARV amongst m2m clients in 2011

B S.E. 95% C.I. for EXP(B)

Lower Odds ratios Upper

Disclosure Not yet disclosed* 1 Disclose to anyone 1.14** .04 2.89 3.14 3.40

Done CD4 testNo* 1Yes .66** .04 1.77 1.93 2.10Came as a CoupleNo* 1Yes .09 .10 0.90 1.10 1.33Knowledge of Male partner status

No* 1Yes .39** .05 1.34 1.47 1.62Gestational at 1st visit 1st Trimester* 1 2nd Trimester .38** .08 1.25 1.46 1.713rd Trimester 1.32** .08 3.19 3.75 4.40Number of m2m antenatal visits

1 m2m visit* 1 2+ m2m visits .27** .05 1.19 1.31 1.443+ m2m visits .83** .07 2.02 2.30 2.624 + m2m visits 1.39** .07 3.52 4.03 4.60*Reference categoryR Square=.17 (Cox & Snell), .25 (Nagelkerke)**P<.001

High Disclosure rates amongst clients receiving psychosocial support in 2010 and 2011 Cohorts

Lesotho Kenya South Africa Swaziland m2m overall 0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

78%

69%

61%

41%

70%

81%

72% 70%

61%

73%

2010 Cohorts2011 Cohorts

2011: n=1579 n=1250 n=5763 n=17200 n=4225 n=32120

2010: n= 1133 n= 2366 n= 4069 n= 4947 n=2573 n=15088

*Uptake of PCR testing amongst m2m clients higher amongst those enrolled earlier in psychosocial

support…

m2m client type overall pattern… m2m Country differentials…

Kenya

Lesotho

Swazila

nd0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

57%50%

32%

73% 70%

58%

seen only after deliveryseen during pregnancy and after delivery

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

37%52%

*Fishers exact test for differences within countries, p<.001

n=12842 n=7200

*Infant PCR test positivity is lower amongst m2m clients enrolled earlier in psychosocial

support…Country Program

Enrolled to m2m after delivery N (%)

Total Enrolled during pregnancy & post deliveryN (%)

Total

Kenya 124 (12) 1038 52 (4) 1306

Lesotho 20 (12) 164 7 (3) 247

Malawi 14 (23) 60 1 (7) 40

South Africa 163 (11) 1456 32 (3) 1031

Swaziland 57 (10) 574 12 (4) 278

Uganda 28 (9) 323 4 (3) 157

Zambia 27 (10) 261 9(9) 98

*m2m overall 433 (11%) 3876 117 (4%) 3157

*Fishers exact test for differences between clients enrolled during pregnancy vs. enrolled post delivery p<.001

Discussion• m2m evidence shows that retention in psychosocial care

improves outcomes• “Dose response” importance of psychosocial visits=health

facility dose• Disclosure key to uptake and adherence of services• Earlier enrolment and follow through in psychosocial

services improve outcomes• Challenges

• Late presentation of women for antenatal care• Implications for retention and initiation in care

• Retention is challenging given inter-health facility movements in health systems

m2m services:• integrated in facilities, promote referrals• generate demand for PMTCT services,

treatment, and care to keep mothers alive

• stigma reduction diminishes demand-side barriers to ARV uptake

Demand Creation and Retention

Retention Initiatives

• Let’s SOAR (Strengthening Outcomes by Analyzing Results): enables site staff to understand data/improve program

• Active Client Follow Up (ACFU): active client follow-up improves client retention in PMTCT cascade through phone calls, SMSes, and/or home visits

1) Daily site-level data collection

2) Quarterly data review and action planning

3) Improve client health!

HOW we ‘SOAR’

m2m Program Department

16

Thank you!