Peer- and community-based interventions can significantly increase retention in care of mothers with HIV and early antenatal clinic visits, according to results from two large multi-country studies presented last month at the Eighth International AIDS Society Conference on HIV Pathogenesis, Treatment and Prevention (IAS 2015) in Vancouver, Canada.
For mother-to-child HIV transmission to be eliminated, supporting mothers living with HIV and their infants to stay in care is crucial. Encouraging women to visit an antenatal clinic early in their pregnancy can ensure that HIV is diagnosed far enough in advance of labour and delivery that antiretroviral therapy can be started, and HIV fully suppressed, before giving birth
Two large studies, one evaluating the mothers2mothers (m2m) mentor mother model, the other a randomised comparison of a community-based intervention with a standard-of-care group, showed that retention in care, infant HIV testing and antenatal clinic presentation can be improved.
The m2m mentor model comprises mentor mothers living with HIV who have recently experienced services aimed at preventing mother-to-child transmission (PMTCT) being trained and employed to support other mothers and their families through the same process.
Evaluation of the m2m mentor model (part of the Strengthening TB and HIV & AIDS Response in East-Central Uganda [STAR-EC]) was undertaken to determine whether maternal and infant PMTCT outcomes and maternal psychosocial wellbeing outcomes were linked to contact with m2m mothers.
PMTCT outcomes were measured retrospectively in this quasi-experimental matched-comparison design studying 2282 mother-infant pairs accessing PMTCT services between January 2011 and March 2014 in 31 intervention sites and 31 matched control facilities. m2m mentor mothers provided peer education and psychosocial support in the intervention sites whereas no peer education or psychosocial support was available in the control sites.
Between June 2012 and March 2014, 794 pregnant women and new mothers accessing PMTCT services from both study arms took part in facility-based psychosocial wellbeing surveys.
Operating in six Option B+ (lifelong antiretrovirals for pregnant and breastfeeding women living with HIV) countries in sub-Saharan Africa, the m2m model showed a remarkable increased retention in care among women with HIV 12 months after starting antiretroviral therapy (ART) compared to the control group (90.9% vs 63.6%, p<0.001). The difference between HIV-exposed infants given a PCR test at six weeks after birth compared to the control group was also significant (71.5% vs 45.8%, p<0.001).
In the m2m mentor model, 60.9% of HIV-positive infants were linked to paediatric ART compared to just 27.8%, (p < 0.001) in the control group.
Additionally, there was increased coping self-efficacy as well as HIV disclosure and safer sex self-efficacy compared to the control group, (86% vs 64.5%, p < 0.001, and 71.7% vs 50.7%, p < 0.001, respectively).
Dr Kathrin Schmitz, presenting the results, recommended the integration of peer education and psychosocial support into clinical PMTCT standards of care.
Additional improved PMTCT outcomes among women and infants exposed to the m2m model compared to the control group included the percentage of HIV-exposed children given an HIV test 18 months after delivery, 60.9% vs 27.8%, (p < 0.001); and of mothers not experiencing depression 83.3% vs 78.1% (p < 0.028).
The m2m model showed evidence of greatly improved uptake of PMTCT services, and also showed that psychosocial peer support helps HIV-positive pregnant women, new mothers and their families better cope with HIV as well as improving their psychosocial wellbeing.
Improving early antenatal clinic visits
Another presentation at the same session raised the important issue of the timing of the first antenatal clinic (ANC) visit for pregnant women living with HIV, a critical step for maternal and child health (MCH) and for PMTCT. In sub-Saharan Africa, this averages 24 to 25 weeks into the pregnancy (gestational age). The earlier in pregnancy diagnosis is made or confirmed and treatment initiated, the better for the health of the mother and in reducing the risk of HIV transmission to the infant.
According to Mary Pat Kieffer presenting on behalf of the study group known as ACCLAIM (Advancing Community Level Action for Improving MCH/PMTCT) community-based interventions resulted in a significant (p < 0.0001) 13% increase in the proportion of first antenatal clinic visits at 20 weeks or less gestation for the first 12 months of its implementation in Swaziland, Uganda and Zimbabwe.
Community-level barriers limiting demand for and uptake of PMTCT services have not been adequately addressed. Interventions addressing community norms that include harmful gender norms, barriers to positive health behaviours and health-seeking behaviours for all women, may improve PMTCT performance, Dr Kieffer noted. For the successful implementation of Option B+ and the approaching reality of ‘Test and Treat’ there is an urgent need for new approaches to community engagement, she added.
The aim of ACCLAIM, a three-arm randomised trial in 45 clusters in Swaziland, Uganda and Zimbabwe, is to improve access, uptake and retention in MCH/PMTCT services.
Three interventions were evaluated:
Community Leader Engagement comprising Community Leaders Institute participation and mentoring to engage community action.
Community Days and structured dialogues; use of MCH and PMTCT data to develop Community Action Plans with community stakeholders to address barriers to antenatal care and PMTCT; use of dialogues to conduct community advocacy to encourage families to protect the life of the child and mother, and to emphasise early antenatal clinic visits for facility delivery, and;
Male and female MCH classes: a set of four peer-led structured sessions.
While a baseline survey showed awareness among the community of the need for early antenatal care this was not reflected in practice.
In this sub-study, baseline gestational age data at the first ANC visit were collected from July to September 2013 (January to March 2014 in Uganda) from health facilities before implementation of the interventions and every three months thereafter. Dr Kieffer and colleagues then compared the proportions of women attending antenatal clinics at 20 weeks gestation or less at baseline and 6 to 12 months after the interventions.
Of 5030 women, at baseline 45% attended their first antenatal clinic visit at 20 weeks or less gestation. At 12 months after implementation this increased significantly to 51%, p<0.0001.
The proportion of those attending their first antenatal clinic during the first trimester (at or under 12 weeks) also increased from 11.7% to 14.1%, p = 0.163 and from 12% to 14.1%, (p < 0.0001) in Swaziland and Zimbabwe, respectively. In Uganda this increased from 16% to 19%.
Data analysis is ongoing. Dr Kieffer concluded preliminary results suggest community leader training and engagement is associated with a positive trend of an earlier first antenatal clinic visit.
Schmitz K et al. Retaining mother-baby pairs in care and treatment: the mothers2mothers Mentor Mother Model. The Eighth International AIDS Society Conference on HIV Pathogenesis, Treatment and Prevention, Vancouver, abstract TUAD0201, 2015.
Kieffer MP et al. Improving early ANC attendance through community engagement and dialogue: project ACCLAIM in three African countries. The Eighth International AIDS Society Conference on HIV Pathogenesis, Treatment and Prevention, Vancouver, abstract TUAD0206LB, 2015.
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