Supporting Women and Children Access to HIV Services to Prevent Vertical Transmission of the Virus and to Improve Adherence to Antiretroviral Therapy in Mozambique

Project location: MOZAMBIQUE, Beira
Project start date: July 2013 - Project end date: July 2014
Project number: 2013-073
Beneficiary: Fondazione di Religione Opera San Francesco Saverio C.U.A.M.M.

 [2015-039]

Doctors with Africa Cuamm is well integrated in Mozambique and has been known to both the national and local authorities since 1978. The organization has been the Ministry of Health's main partner in the decentralization of HIV services from Beira Central Hospital to the peripheral health centres since 2003. It was also one of the first organizations to apply the peer-to-peer model leading to the creation of the Kuplumussana Association. This group of HIV-positive mothers is active in the community and complements the health system in promotional work, counselling of HIV+ mothers and tracing patients lost to follow-up. Being HIV positive women who have already experienced the disease first hand, and understanding the associated problems and difficulties, we consider the mothers of Kuplumussana to be the best, most appropriate, most effective "social workers" to talk to and convince mothers to be tested, get proper treatment if found positive and, where necessary, trace and find those lost to follow-up, including mothers and children, in order to convince them to resume treatment. Data on community activities (active findings and reintegration) show that 56% of children and pregnant women traced by the group have been reintegrated. Therefore involvement of HIV positive mothers will not only improve the effectiveness of PMTCT (Prevention of Mother to Child Transmission) and ARV(Antiretroviral) treatment services, but will also empower these women by giving them a role in the community.

Finally, as an active, empowered group of mentor mothers, the group could further improve the rate of children and women reintegrated to the programme while developing into a fully-fledged organization. This represents a cost-effective model to ensure a higher rate of compliance with PMTCT and pediatric ARV treatment in resource-limited settings across Mozambique and other African countries.

In order to expand access to pre/postnatal HIV care, Doctors with Africa Cuamm supported the decentralization of basic pre/postnatal care (comprising ARV treatment), including the building in Beira of a network of 6 health centres around the pediatric day hospital. Nevertheless, according to a 2009 sero-behavioural study, Sofala Province still shows one of the highest HIV prevalence rates in Mozambique (13.1% among the 15-24 age group). Under-five mortality in the province is as high as 138/1000, with AIDS accounting for 9.9% of deaths (2008 child mortality study). In 2012 the number of patients on ARV was 25,698 adults and 2,760 children. The drop-out rate was about 18% (MISAU- Mozambican Ministry of Health Dados Nacionais 2012 TARV).
Despite the effectiveness of PMTCT interventions and ARV therapy in mitigating the impact of the disease, achievement of the expected results can be hindered by implementation challenges. The project will address the issue of poor compliance and adherence among HIV+ pregnant women and their children, through a community-based approach to empower a group of HIV-positive mothers. This approach stems from the concept that peer support is the optimal model for effective social empowerment, and that mothers are particularly well-suited to providing support to other mothers. In 2011, around 95% (20,668) of the pregnant women attending the 1st ANC visit were tested for HIV, of whom 21% were positive; 83% of them joined the PMTCT programme and around 65% started prophylaxis with AZT, 44% with NVP and 18% with ARVT. Only 58% of HIV-positive pregnant women were tested for CD4, and 18% of them were put on ARV treatment. Despite high enrolment among children on the PMTCT programme, only 59% were tested for PCR after the 4th week. The percentage of exposed children found to be HIVpositive on PCR testing was 10%. Despite the encouraging results in terms of PMTCT enrolment in Beira, the number of dropouts failing to adhere to the whole treatment (including ARV) is still unacceptably high. According to our data and experience, the biggest barriers are the following: social stigma, discrimination and lack of knowledge about HIV among women.
Many women avoid HIV testing or refuse to enroll in the PMTCT programme for fear of being abandoned by their partner or of social marginalization should they reveal their HIV status. This renders the entire programme ineffective in achieving its main goal of preventing transmission of the virus from mother to child. The project is fully in line with the Foundation's goals as it aims to achieve the right to health of the population's most disadvantaged, most vulnerable groups, who are exposed to marginalisation and poverty and have poor access to affordable, quality healthcare services. Further to the promotion of children and women's rights, the project is consistent with the Foundation's commitment to local and disadvantaged communities, as the group of HIV+ mothers and vulnerable children.

The overall goal of the project, which received a grant fron the Nando Peretti Foundation, is to tackle the issue of poor compliance with the PMTCT (Prevention of Mother to Child Transmission) programme and ARV (Antiretroviral) treatment among mothers and children through a community-based approach to empower a group of HIV-positive mothers - the Kuplumussana Association - and render them self-sustainable. Specifically, the project aims to: o Improve adherence to the PMTCT programme and reduce the number of mothers and children lost to treatment through awareness-raising activities, provision of psychosocial support by the Kuplumussana Association, the active search for women and children who drop out, and reintegration strategies (nutritional support and on-the-spot material support to the cases most in need) o Improve the self-sustainability of the Kuplumussana group through technical assistance, management training, monitoring and evaluation, dissemination of best practices and results.

The following activities will be carried out over a period of 8 months in order to achieve the specific objectives mentioned above:
3.1 Awareness-raising and sensitization in communities and at health centres, by preparing and printing specific material, and sending representatives of the Association to the city's neighborhoods and health centres to build awareness on issues related to HIV/AIDS prevention and treatment
3.2 Provision of nutritional and material support to HIV+ mothers and children living in poverty, supplying, where necessary, dietary supplements, clothing and materials for hygiene
3.3 Support in the active search for HIV+ mothers and children who have dropped out of treatment or fail to adhere to the programme, through transport and communication incentives, as well as active search work
To implement these activities, the project envisages the involvement and active supervision of the organization's internal staff, providing technical assistance to the group in order to improve organizational capacities, service delivery and to monitor and evaluate the impact of community activities on the target population (10% of their salaries have been included in the budget). Furthermore, the staff involved shall provide training and capacity building for group and financial resource management, data collection skills and activity report drafting.

Methodology
The methodology is community-centred and based on the concept that peerto- peer groups are the ideal model for improving adherence and increasing uptake in PMTCT services at community level, in a resource-limited setting such as Africa, where human resources are scarce and the capacity to follow up patients and reintegrate those who have dropped out of the programmes is low. The project will be implemented in partnership with the Kuplumussana (literally, "to help each other") Association, which is also the direct beneficiary of the project. The group was created in 2005 as an informal peer-to-peer network, consisting of HIV-positive mothers. Its aim was to mitigate the impact of the disease within the community and to support healthcare intervention. The group, with the assistance of Doctors with Africa CUAMM, started its activities as a formal association of HIV positive mothers in 2009. Since 2010 the group has also started to work in health centres in an effort to bring services closer to the community.
The activities, carried out by the group in a clinical setting, focus on psychological and social support to HIV positive women (who are pregnant or have recently given birth). They help them to cope with sociocultural barriers and discrimination and to comply with antiretroviral treatment. Particular emphasis is also laid on the most vulnerable children, usually orphans and the poor, who find it more difficult to adhere to therapy because of their poor family conditions. Today, the Association is composed of 40 mentor mothers acting as a liaison between the PMTCT programme, health centres and HIV-positive women. It also promotes the integration of maternal and infant health services with those of HIV control. Over the years, the community-based approach has proven to be effective in following mothers and children "across the cascade" (prevention of transmission of the virus), with a reintegration rate of 56% (2012 data). In 2012, a total of 939 drop-out women were traced by the group; among these, 921 have been reintegrated, with a recovery rate of over 88%.
As regards exposed children, 993 out of a total of 2461 children have been traced and re-registered for treatment, with a re-recruitment rate of 40% (loss among children is higher than among pregnant women and may be caused by the death or transfer to other facilities/districts and being discharged as HIV negative). On the basis of these data, the community based approach has proven to be a cost-effective option of improving access and adherence to the programme. The overall objective of the project is therefore to enhance access to, and the quality and equity of the PMTCT programme and ARV treatment for HIV-positive mothers and children in Beira. This will be achieved through the empowerment and meaningful engagement of a self-sustainable group of HIV-positive mothers who form an integral part of the healthcare programme.

Through implementation of the above-mentioned activities, the project aims to produce the following expected results:
- Increased HIV testing, adherence to ARV therapy, and a lower number of programme dropouts (among women and children);
- Improved community knowledge and leadership on sexual and reproductive health, and themes related to HIV/AIDS;
- Increased adherence to ARV therapy through psychosocial support, and nutritional and material support to the most disadvantaged groups;
- Improved group capacity in terms of management of activities and improved ability to autonomously sustain own activities in order to optimize response to the needs of the Beira community.

Implementation shall have a multiplier effect, unlocking its anticipated impact at different levels, starting from the group and working up to the community at large. Firstly, through the support provided, the group of HIV+ mothers will go from being "only" patients to becoming active members of the community, emancipating them from social marginalization. Secondly, thanks to improved knowledge on PMTCT and greater leadership capacity, the group members will be better "equipped" to deliver messages within the community through peer-to-peer communication, while promoting adherence to health programs. Thirdly, strengthening the partnership between the group and health centers will further promote integration between mother and child care services and HIV treatment or prevention. Fourthly, their knowledge of and position within the community will make them the best means of tracing those lost to follow-up and dropouts, in addition to getting these women and children back on treatment.
Moreover, project-led information and communication activities shall further reduce stigma and marginalization at community level and promote health-seeking behavior among the beneficiaries. Finally, the development of organizational capacities and knowledge will enable the group to integrate.

This project  received a grant from the Nando and Elsa Peretti Foundation in 2016