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IAS 2015: Peer or Community Interventions Improve Outcomes for Mothers with HIV

Peer- and community-based interventions can significantly increase retention in care of mothers with HIV and improve attendance at early prenatal clinic visits, according to results from 2 large multi-country studies presented last month at the 8th International AIDS Society Conference on HIV Pathogenesis, Treatment and Prevention (IAS 2015) in Vancouver.

[Produced in collaboration with Aidsmap.com]

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 a prenatal clinic early in their pregnancy can ensure that HIV is diagnosed far enough in advance of labor and delivery that antiretroviral therapy (ART) can be started and HIV fully suppressed before giving birth.

A pair of large studies, one evaluating the mothers2mothers (m2m) mentor mother model, the other a randomized comparison of a community-based intervention with a standard-of-care group, showed that retention in care, infant HIV testing, and prenatal clinic presentation can be improved.

Mothers2mothers

The m2m mentor model involves mentor mothers living with HIV who have recently used services aimed at preventing mother-to-child transmission (PMTCT). These experienced mothers are 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 and AIDS Response in East-Central Uganda [STAR-EC] program) was undertaken to determine whether maternal and infant PMTCT outcomes and maternal psychosocial wellbeing outcomes were linked to contact with m2m mentor mothers.

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 at 31 intervention sites and 31 matched control facilities. The m2m mentor mothers provided peer education and psychosocial support at the intervention sites, whereas no peer education or psychosocial support was available at 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 6 Option B+ (lifelong ART for pregnant and breastfeeding women with HIV) countries in sub-Saharan Africa, the m2m model was associated with a remarkable increase in retention in care among HIV-positive women w 12 months after starting ART compared to the control group (90.9% vs 63.6%; p<0.001).

The difference in the proportion of HIV-exposed infants given a PCR test at 6 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 pediatric ART compared to just 27.8% in the control group (p<0.001), and more were given an HIV test 18 months after delivery (60.9% vs 27.8%; p<0.001)

Additionally, women in the m2m program reported increased coping self-efficacy as well as HIV disclosure and safer sex self-efficacy compared to the control group (86% vs 64.5% and 71.7% vs 50.7%, respectively). Women in the m2m were also more likely to report 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.

Kathrin Schmitz, presenting the results, recommended the integration of peer education and psychosocial support into clinical PMTCT standards of care.

Improving Early Antenatal Clinic Visits

Another presentation at the same session raised the important issue of the timing of the first prenatal clinic visit for pregnant women living with HIV, a critical step for maternal and child health and for PMTCT. In sub-Saharan Africa, this averages 24 to 25 weeks into the pregnancy (gestational age). The earlier in pregnancy HIV diagnosis is made or confirmed and treatment initiated, the better for the health of the mother and the greater the reduction in the risk of HIV transmission to the infant. 

According to Mary Pat Kieffer, presenting on behalf of the ACCLAIM study group (Advancing Community Level Action for Improving MCH/PMTCT), community-based interventions resulted in a significant 13% increase in the proportion of first prenatal clinic visits at 20 weeks gestation or less 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 behaviors, and health-seeking behaviors for all women may improve PMTCT performance, 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 3-arm randomized trial in 45 clusters in Swaziland, Uganda, and Zimbabwe, is to improve access, uptake, and retention in maternal and child health and PMTCT services.

Three interventions were evaluated:

1.    Community leader engagement: participation in a community leaders Institute and mentoring to engage community action.

2.    Community days and structured dialogs, using maternal and child health and PMTCT data to develop community action plans with community stakeholders to address barriers to prenatal care and PMTCT, community advocacy to encourage families to protect the lives of children and mothers, and emphasizing early prenatal clinic visits for facility delivery.

3.    Male and female maternal and child health classes: a set of 4 peer-led structured sessions.

While a baseline survey showed awareness among the community of the need for early prenatal care, this was not reflected in practice.

In this sub-study, baseline gestational age data at the first prenatal clinic visit were collected from July through September 2013 (January through March 2014 in Uganda) from health facilities before implementation of the interventions and every 3 months thereafter. Kieffer and colleagues then compared the proportions of women attending prenatal clinics at 20 weeks gestation or less at baseline and 6 to 12 months after the interventions were implemented.

Of 5030 women, at baseline 45% attended their first prenatal clinic visit at 20 weeks gestation or less. At 12 months after implementation this increased significantly to 51% (p<0.0001).

The proportion of women attending their first prenatal clinic during the first trimester (at or under 12 weeks gestation) increased from 12% to 14% in Swaziland and Zimbabwe (both p<0.0001); in Uganda it increased from 16% to 19%.

Data analysis is ongoing. Kieffer concluded that preliminary results suggest community leader training and engagement is associated with a positive trend toward an earlier first prenatal clinic visit.

8/31/15

References

K Schmitz, E Scheepers, E Okonji, et al. Retaining mother-baby pairs in care and treatment: the mothers2mothers Mentor Mother Model. 8th International AIDS Society Conference on HIV Pathogenesis, Treatment, and Prevention. Vancouver, July 19-22, 2015. Abstract TUAD0201. 

MP Kieffer, G Woelk, D Mpofu, et al. Improving early ANC attendance through community engagement and dialogue: project ACCLAIM in three African countries. 8th International AIDS Society Conference on HIV Pathogenesis, Treatment, and Prevention. Vancouver, July 19-22, 2015. Abstract TUAD0206LB.