rachel chapman: new approaches to maternal mortality in africa

Rachel Chapman, Ph.D.Javelina Aguilar, CDBeatriz Thome, M.D., MPHcWendy Johnson, M.D.James Pfeiffer, Ph.D., M.P.H.

Maternal Mortality, HIV/AIDS and the New Counter-Geography of Surviving Pregnancy in Central Mozambique

UNAIDS 2010 Report on the global AIDS epidemic

Despite overall MMR decreases:HIV Played a Major Role in Increasing MMR mostly Sub-Saharan AfricaNO SURPRISE…

Overlapping Shadows?

Global Maternal Mortality (WHO)

Global HIV Infection

(UNAIDS)

HIV and Maternal Mortality(UNICEF. 2010. Interagency Estimates of Maternal Mortality Levels and Trends: 1990-2008)

Direct: associated increase in pregnancy complications such as anaemia, post-partum haemorrhage and puerperal sepsis

Indirect: increased susceptibility to opportunistic infections such as Pneumocystis carinii pneumonia, tuberculosis and malaria.(McIntyre. 2003)

Maternal HIV in Sub-Saharan Africa

in resource-constrained settings, HIV accounts for an estimated 10X increased risk of maternal death

symptomatic women with HIV infection are at greater risk of dying from infectious diseases.

(Moodley, et al. 2011, Int. J. Obs. Gyn. editor’s note)

Response: Prevention of Mother to Child Transmission (PMTCT) pregnant women living with HIV in sub-

Saharan Africa who received antiretroviral drugs to prevent transmission of HIV to their children:

2005: 15% 2009: 54%

Around the world to Mozambique!

Guro Tambara

Chemba

MaringueMacossa

Sussundenga

Machaze

Machanga

Muanza

Cheringoma

Chibabava

HF Providing HAART (new) 1 (1)

PLWHA Registered (%) 2,000 (1)

Eligible in HAART (%) 94 (0)

HAI/MOH HIV Treatment Expansion Plan through public sector collaboration2003

2003

Guro Tambara

Chemba

MaringueMacossa

Sussundenga

Machaze

Machanga

Muanza

Cheringoma

Chibabava



Eligible in HAART (%) 600 (1)

HIV Treatment Expansion Plan2004

2003

2004

Guro Tambara

Chemba

MaringueMacossa

Sussundenga

Machaze

Machanga

Muanza

Cheringoma

Chibabava



Eligible in HAART (%) 2,500 (4)


2003

2005

2004

Guro Tambara

Chemba

MaringueMacossa

Sussundenga

Machaze

Machanga

Muanza

Cheringoma

Chibabava

HF Providing HAART (new)

17 (13)



Children <15 y in HAART (% of those in HAART)

420 (8)


2003 2004

2005 2006

Guro Tambara

Chemba

MaringueMacossa

Sussundenga

Machaze

Machanga

Muanza

Cheringoma

Chibabava

HF Providing HAART (new)

47 (30)




1,323 (10)


2003 2004

2005 2006

2007

Guro Tambara

Chemba

MaringueMacossa

Sussundenga

Machaze

Machanga

Muanza

Cheringoma

Chibabava





3,585 (15)


2003 2004

2005 2006

2007 2008

• 87 facilities offering HAART (55 March 2008)

• 180,000 PLWHA registered for HIV care (49% of the infected) (92,600 March 2008)

• 45,000 in HAART (64% of eligible)

(22,000 Mar. 2008, 31% of eligible)

• All HUs with TB treatment in Sofala and Manica testing for HIV and strengthening of TB screening in PLWHA

• 202 CPN with PMTCT (156 March

2008)

2009 Treatment PlanManica and Sofala scale-up through existing PHCs

Guro Tambara

Chemba

MaringueMacossa

Sussundenga

Machaze

Machanga

Muanza

Cheringoma

Chibabava

CS

HCB

HR

HPC

HG

Proj.

THE PROBLEM: Major loss to follow-up (LTFU) occurs at each stage of the “treatment cascade

Maternal and PMTCT LOSS TO FOLLOW-UP: women and exposed infants drop from programs to treat maternal HIV and prevent maternal to child transmission at any step along the “treatment cascade”

pMTCT strategy in Mozambique

Figure 1. PMTCT patient flow

Children followed in pediatric clinic

and tested for HIV at 18 months

Mothers breastfeed

through 6 months, followed by

“rapid transition”to regular food

MaternityWoman / newborn given dose of NVP

Pre-natal consultPregnant woman counseled

and tested for HIV

Treatment center (if exists): HIV clinical and

laboratory staging

Woman does not need ART

Woman starts ART

The Emerging Data from Sub-Saharan Africa

less than ten percent of pregnant women in Africa infected with HIV receive interventions to reduce MTCT,

one in twenty mother-infant pairs are successfully initiating ART

Malawi (Manzi et al. 2005): 55% lost to follow up at 36th week of pregnancy, 68% at delivery, 70% at 1st post natal visit 81% at the baby’s 6 month post natal visit

Kenya (2005): 53.6% ♀ not enrolling at HIV clinic (Moth 2005)

South Africa : Joburg -85% by baby’s 12th month visit , Gauteng - 90% of babies have no final HIV diagnosis (Jones 2005; Sherman 2004)

Mozambique: PMTCT coverage 45% (Pfeiffer 2009) 8% HIV+ pregnant ♀ started on HAART 11% infants tested at 18 months

Dueling Hypotheses:Possible reasons for high loss to follow up rates

Inadequate counseling Authorized and

unauthorized fees Poor quality, rude staff Slow or lost tests Too many appointments Poor linkages within

programs at the health facility

Cost of transport and inaccessibility of clinics

Drug stock ruptures

Stigma, and discrimination,

Gender conflict, violence

Lack of basic resources, food, social support

Distance and transport fees

Religious, cultural healing beliefs and practices

Health Systems contributing factors

Structural/Social / Cultural contributing factors

Depoliticize, Individualize, Medicalize the High Cost of Austerity Economics

Cutting public sector

Privatization Cutting services Lay-offs, salary

cuts and freezes Selective and

vertical interventions

Remove price subsidies

Fees for services Erodes social

safety nets Abolish social

security

Ignore failed structural adjustment programs (SAPS)

Overlook free market fundamentalist cost-shifting

Costs of Austerity to Women’s Health

Macro: Erosion of health system budget, facilities, staff, salaries, basic resources, services, moral

Meso: Institution of vertical,selective health programs silo-ing focus and resources fromIntegrated primary care Micro: destroys social fabric as people eek out survival from overburdened

household resources, especially social-reproductive labor of women.

HIV care and treatment scale up exposes costs of Austerity Economics

AIDS-related maternal mortality

Health systems failures

AIDS-related stigma

= tangible consequences of trickle-down politics which have immiserated African

households and public sectors that serve them.

Ethnography: Effects of inequalityIdentities of Control and Resistance1. Spirit Intervention2. The Power of Words3. Female Envy4. Strangers and Stress5. Uterine Battles6. Spirit Wives7. Inheriting Infertility8. Witches

Current costs of inequality to Maternal Health?

Women hide pregnancy Avoid prenatal care Heightened household tension and

domestic violence Men circulate informally among several

households to assure survival (and welcome)

Women cannot afford to not get pregnant to assure male support

Increased sex-work in time of increasing prevalence rates of HIV infection

counter-geography of survival (Davis 2004, Planet of Slums)

Home birth outside of biomedical surveillance,

defining health from their own experience,

balancing beliefs about social threats and spiritual protections with biomedical explanations,

participating in lively church communities that decommodify healing in powerful ways.

Women are not “lost” to follow-up

New Research Question:

What accounts for loss to follow-up?

Findings

1. Stigma and fear

2. Domestic violence and negotiation of disclosure

3. food and drug insecurity in spurring new hungers, new resistances

4. Confusion regarding pregnancy and seropositive status

5. Shock, memory, negotiating identity post-test

Where are all the pregnant HIV+ women going after they test positive?

HIV testing and treatment complicates women’s interface with clinical care.

♀g arrives for 1ra pre-natal visit with

SMI nurse

Day 1

HIVRapi

d Test

Blood is sent to lab for CD4 test

Reception activista opens a chart for

♀g+

Day 1

SMI activista accompanies ♀g+ to reception

SMI nurse evaluates the urgency of treatment and determines WHO clinical

stage (I-IV)

Day 1

Reception activista accompanoes ♀g+ back to SMI nurse

CD4 count

♀g+ returns to meet with SMI nurse to get CD4 results

≥ Day 3

I-IIStag

e

III-IV

♀g+ receives AZT & duNVP> 250

+

SMI nurse prescribes CTZ and biochemical blood

tests

≥ Day 3

Day 4 or 5TARV

committee reviews

case to determin

e eligibility

TARV ?

Evaluation with a MD or

TM (on Fridays

only)

~1-4 weeks after diagnosis

Social worker gives ♀g+ the

TARV prescription

~1-4 weeks after diagnosis

≤ 250

DOT for the first 14 days of treatment

PTV

Day 1

Day 1

no

yes

Health Center Munhava ♀g+ PTV Flow

At 28 weeks

♀g+ takes sdNVP

Contractions start

Labor Starts At Home

Duovir (AZT+3TC)

DuringlLabor

At Hospital Maternity

AZT

For one week postpartum

In The Home

Children get: sdNVP & AZT

Postpartum

Picks up medicines in the pharmacy

~ 1- 5 weeks later ♀g+ starts 3 phases of

adherence counseling with a social worker (takes

1-3 weeks)

Phase 3

Phase 2

Phase 1

New collaboration:Option B (2012 WHO Guidelines)1. Starting triple therapy ART directly after

testing rather than waiting (test and treat)

http://www.un.org/issues/gallery/Africa/pixaids10.htm

Option A vs. Option B

Pregnant woman comes to ANC visit

Woman tested for HIV

HIV chart opened in HIV

clinic

Draw CD4

CD4 <350

CD4 >350

Counseling visits,

clinician visits

Counseling visits,

clinician visits

Start ART

StartAZT+sdN

VP

Draw CD4

CD4 <350

CD4 >350Stop ART 1 week

after breastfeeding

Continue ART lifelongStart ART

Woman HIV+

Benefits

1. simplification of regimen and service delivery and harmonization with ART programs,

2. protection against mother-to-child transmission in future pregnancies,

3. continuing prevention benefit against sexual transmission to serodiscordant partners,

4. avoiding stopping and starting of ARV drugs

Not enough:Trojan Horse of ART Scale-Up Quality HIV care

and services are only possible within context of building strong, sustainable, public sector health systems

action agenda

“The is clear. To get Millennium Development Goal 5 on track by reducing the contribution of AIDS to maternal mortality, we must prevent HIV infection in women and girls, prevent unwanted pregnancies, expand HIV testing and counselling, accelerate initiation of antiretroviral treatment in pregnant women who are HIV-positive, and strengthen service delivery and integration of HIV care and obstetric services, along with data collection to track progress.” (Moodley, et al. 2011, editor’s note)

Answer to Wendy’s question: How do we balance science and advocacy? DO BOTH! They are inseparable. They are not mutually exclusive. To do one without the other challenges

the legitimacy and efficacy of either.

Scientists MUSTChallenge Austerity Politics

and Policiesmeans?1. Challenge NGO-centric model of global

health, resources go NGO rather than public sector and return to donor through phantom aid channels.

2. Challenge representations of African peoples, cultures and institutions as pathological, inferior needing management and programs that make this vision inevitable.

3. Remove hiring freezes and hire, train and adequately remunerate health care providers.

Public Health Spending – enough said

Worldmapper

BASTA!

Thank You!University of Washington

Mozambican Ministry of Health

Health Alliance International

James PfeifferWendy JohnsonBeatrice Thome

Javelina AguiarLucia Lazaro

rachel chapman: new approaches to maternal mortality in africa

Health & Medicine

hiv accounts

transmission of hiv

haart new cheringoma

haart new muanza

pneumocystis hiv infection

maternal mortalityunicef

cheringoma hf

chibabava eligible