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POST NATAL CLUBS

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. PMTCT: how are we doing?. Option B+ rolled out in 2013

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POST NATAL CLUBS

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  1. 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

  3. 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. 2014. Clouse K et al. J Acquir Immune Defic Syndr. 2014. Langlois V et al. Bull World Health Organisation. 2015. )

  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?

  10. PNC: Methodology • Eligibility 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 18 mths 12 mths 15 mths 9 mths 14 wks 18 wks 22 wks 6 mths 10 wks 6 wks CC Recruitement PNC PNC PNC PNC PNC PNC PNC PNC PNC

  11. 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) *High risk mother-infant pairs

  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

  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: 0798678516 MSFOCB-Khayelitsha-EID@brussels.msf.org

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

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