Rachel Chapman, Ph.D. Javelina Aguilar, CD Beatriz Thome, M.D., MPHc Wendy 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
May 27, 2015
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)
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
HF Providing HAART (new) 2 (1)
PLWHA Registered (%) 7,300 (2)
Eligible in HAART (%) 600 (1)
HIV Treatment Expansion Plan2004
2003
2004
Guro Tambara
Chemba
MaringueMacossa
Sussundenga
Machaze
Machanga
Muanza
Cheringoma
Chibabava
HF Providing HAART (new) 5 (3)
PLWHA Registered (%) 18,600 (5)
Eligible in HAART (%) 2,500 (4)
HIV Treatment Expansion Plan2005
2003
2005
2004
Guro Tambara
Chemba
MaringueMacossa
Sussundenga
Machaze
Machanga
Muanza
Cheringoma
Chibabava
HF Providing HAART (new)
17 (13)
PLWHA Registered (%) 36,270 (9)
Eligible in HAART (%) 5,250 (9)
Children <15 y in HAART (% of those in HAART)
420 (8)
HIV Treatment Expansion Plan2006
2003 2004
2005 2006
Guro Tambara
Chemba
MaringueMacossa
Sussundenga
Machaze
Machanga
Muanza
Cheringoma
Chibabava
HF Providing HAART (new)
47 (30)
PLWHA Registered (%) 63,390 (16)
Eligible in HAART (%) 13,225 (22)
Children <15 y in HAART (% of those in HAART)
1,323 (10)
HIV Treatment Expansion Plan2007
2003 2004
2005 2006
2007
Guro Tambara
Chemba
MaringueMacossa
Sussundenga
Machaze
Machanga
Muanza
Cheringoma
Chibabava
HF Providing HAART (new) 53 (7)
PLWHA Registered (%) 100,490 (25)
Eligible in HAART (%) 23,903 (40)
Children <15 y in HAART (% of those in HAART)
3,585 (15)
HIV Treatment Expansion Plan2008
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)
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