International Center for AIDS Care and Treatment Programs

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2007 ICAP Annual Meeting
Care and Treatment in the MCH Retaining Pregnant
Women Queen Elizabeth II National Referral
Hospital Maseru, Lesotho

Esayas A. Okubamichael, MD, MScClinical
AdvisorICAP-Lesotho
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Background

• QEII Hospital (est. 1954)
• National referral hospital with 400 beds
• Only source of advance care in Lesotho
• 2003 pMTCT program launched
• 2004 ART services launched
• 2007
• 2,127 Pregnant women made first visit to QEII ANC
  clinic
• 42 HIV prevalence among pregnant women attending
  ANC clinic of the hospital
• 5,779 deliveries in the hospital per year

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Objectives of QEII MTCT-Plus Support

• Enhance pMTCT services
• Identify HIV positive pregnant women eligible for
  treatment and initiate treatment at the MCH
• Integrate pMTCT and HIV/AIDS care and treatment
  services
• Follow up HIV exposed infants and provide care,
  including early infant diagnosis and rapid
  enrollment into care and treatment
• Promote male partner testing and provide family
  centered HIV/AIDS care and treatment services
• Evolve services from an acute care MCH clinic to
  a chronic care MCH facility

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ICAP QEII MTCT-Plus Assessment Findings (March
2006)

• Low HIV testing uptake at ANC clinic (20)
• No HIV counseling testing services at maternity
• CD4 count test not done routinely
• Poor record keeping
• No linkage with chronic HIV care and treatment
  services
• No postnatal follow up of HIV positive pregnant
  women and exposed children
• Shortage of human resource to provide MTCT-Plus
  services and lack of training

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Site Support Approach

• Gentle persistent pressure (GPP)
• Sensitization and training of health care workers
• Mentoring
• Technical assistance
• Supportive supervision
• Improving the record keeping (developing
  registers)
• Infrastructure enhancement and renovations

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MTCT-Plus Activities Achievements (I)

• Offer routine HIV counseling and testing at ANC
  clinic and maternity with same day CD4 count
  testing
• Conduct routine clinical and immunological
  assessment of HIV positive pregnant and lactating
  women
• Initiate aggressive follow-up and care for
  HIV-exposed infants including early infant
  diagnosis and the rapid initiation of care and
  treatment for HIV-infected babies

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MTCT-Plus Activities Achievements (II)

• Integrate and offer HIV care and treatment at the
  MCH
• Provide family centered HIV care and treatment
  services at ART and MCH
• Enrolling all women not yet eligible for
  treatment into HIV care

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Why Care and Treatment Services in the MCH?

• Overcrowded ART clinic
• Long waiting time in ART and MCH
• Delayed CD4 results (lt5 received results)
• No special arrangement for pregnant women
• Needed to streamline the care and minimize
  healthcare visits between MCH and ART clinic
  during period of pregnancy
• Different review dates for MCH and ART
• High loss to follow-up at ART clinic by pregnant
  women
• Stigma

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Initiating of HIV positive pregnant women on
HAART at MCH and entry in to MTCT-Plus

• 1st
  visit at ANC
• Routine HIV counseling and testing
• Immediate CD4 count testing
• Counseling on infant feeding and pMTCT
• Essential antenatal care
• 3-day follow up appointment for CD4 count
  results

Counselors Nurses

• 2nd
  visit at ANC
• Conduct immunological and clinical assessment
• Initiation of Cotrimoxazole prophylaxis
• Baseline laboratory investigation for ART
• ART preparatory and adherence counseling
• 1 week appointment for those eligible for ART

Counselors, Nurses, Doctors
Counselors, Nurses, Doctors, Pharmacy tech

• 3rd
  visit at ANC
• 2nd ART preparatory/adherence counseling
• Recording in ART file, clinical evaluation, drug
  education
• Initiate ART for eligible pregnant women

Counselors, Nurses, Doctors, Pharmacy tech

• Regular
  follow up visits at ANC
• Follow up visits every 2 to 4 weeks
• On-going adherence counseling assessment and
  support
• Counseling and support on ART prophylaxis
• Clinical follow up, refilling of Cotrimoxazole
  and ARVs
• Routine ANC and postnatal care

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Challenges in Retaining HIV Women in MTCT-Plus
and Beyond

• Lost to follow-up
• Drop-out from antenatal clinic to delivery 40
• High proportion of home deliveries
• Post-natal re-location of mothers
• Weak referral systems
• Inadequate psychosocial support
• Weak community services

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Engaging MTCT-Plus Clients Throughout the
Continuum of Care

• Strengthening patient education and counseling
  and follow up system
• Using expert patients to augment staff at
  facilities
• Addressing psychosocial problems
• Establishing linkages to community based services
• Introducing community follow-up and support for
  women and their families in collaboration with
  community based organizations and support groups
• Decentralizing MTCT-Plus services closer to the
  community

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• Thanks

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Acknowledgements

• Elaine Abrams ICAP-NY
• Cristiane Costa ICAP-NY
• ICAP-Lesotho Team
• QEII Hospital MCH Team
• MOHSW Lesotho