Integrated Approach to Improving Maternal and Child Health among HIV Positive Pregnant Mothers and Exposed Infants in Eastern and CentralKenya

Rosemary Njogu; Jonesmus Wambua; Anthony Gichangi; Mildred Mudany

doi:10.4172/2376-127X.1000210

ISSN: 2376-127X

Journal of Pregnancy and Child Health

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Integrated Approach to Improving Maternal and Child Health among HIV Positive Pregnant Mothers and Exposed Infants in Eastern and CentralKenya

*Rosemary Njogu^, Jonesmus Wambua, Anthony Gichangi and Mildred Mudany**
Jhpiego, Nairobi, Kenya - an Affiliate of Johns Hopkins University
Corresponding Author :	Rosemary Njogu Jhpiego, Nairobi, Kenya - an Affiliate of Johns Hopkins University Tel: (+254) 732 134 000 E-mail: rnjogu@aphiapluskamili.org
Received: November 24, 2015; Accepted: December 09, 2015; Published: December 16, 2015
Citation: Njogu R, Wambua J, Gichangi A, Mudany M (2015) Integrated Approach to Improving Maternal and Child Health among HIV Positive Pregnant Mothers and Exposed Infants in Eastern and Central Kenya. J Preg Child Health 2:210. doi:10.4172/2376-127X.1000210
Copyright: © 2015 Njogu R, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
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Abstract

To achieve elimination of pediatric Human Immunodeficiency Virus (HIV) through mother-to-child transmission, more focus is required on accelerated maternal Highly Active Antiretroviral Therapy (HAART) for HIV positive pregnant women and monitoring of Elimination of Mother-to-Child Transmission activities. This paper articulates integrated approach used by APHIAplus KAMILI project to improve Maternal and Child Health (MCH) services in eleven counties Eastern and Central Kenya. The main gaps at baseline included lack of integrated HIV services to MCH, low maternal and infant prophylaxis, lack of follow-up for mother-baby pairs. APHIAplus KAMILI has put interventions to ensure integration of HIV services in MCH. These include mentorship, training of the health care providers and mentor mothers, and offering of comprehensive services to HIV positive pregnant mothers. Methodology Data collection A retrospective data review was conducted in 153 health facilities where APHIAplus KAMILI had been working from 2011 to 2014. Data on was collected using government reporting tools at the facility, aggregated and uploaded to District Health Information System (DHIS) and A+K database for electronic storage. Data on early infant diagnosis was obtained from NASCOP EID website. Data was analyzed using MS excel and presented in bar graphs and line graphs. Findings Over 85% of HIV positive pregnant mothers received HAART and their infants received prophylaxis between 2011 and 2014. During this period, 80% of HIV exposed infants were exclusively breastfed. The number of HIV exposed infants who were positive and on ARVs increased from 9.3% in 2011 to 52% in 2014. Over the same period, there was a drop of 2.1% in the number of HIV exposed infants who turned positive. Conclusion of health services and integration of HIV services to MCH lead to improved management of HIV positive pregnant mothers and their infants and significantly contributes to elimination of pediatric HIV.

Keywords

Integration; Exposed infants; HAART

Abbreviations

A+K: APHIAplus Kamili; AIDS: Acquired Immune Deficiency Syndrome; ART: Anti-Retroviral Therapy; ARV: Anti-Retroviral; DBS: Dry Blood Spot; DHIS: District Health Information System; EBF: Exclusive Breast Feeding; EID: Early Infant Diagnosis; EMTCT: Elimination of Mother-to-Child Transmission (of HIV); HAART: Highly Active Antiretroviral Therapy; HEI: High End Instrumentation; HIV: Human Immunodeficiency Virus; MCH: Maternal and Child Health; MOH: Ministry of Health; NASCOP: National AIDS and STI Control Programme (Kenya); PCR: Polymerase Chain Reaction; PMTCT: Prevention of Mother-to-Child Transmission (of HIV); PSSG: Psychosocial Support Group; UNAIDS: The Joint United Nations Programme on HIV/AIDS; USAID: United States Agency for International Development; WHO: World Health Organization

Introduction

The UNAIDS Gaps Report of 2014 [1] estimates that globally, 15% of all women living with HIV are young women 15–24 years old. Of these, 80% live in sub-Saharan Africa. In this region, women acquire HIV infection at least 5–7 years earlier than men. To achieve elimination of perinatal HIV, acceleration and monitoring of HAART for the HIV positive pregnant women activities are required [1]. Globally, Kenya is ranked among the priority countries targeted to reduce new infections [2]. Kenya HIV estimate report for 2014 [3] approximates 192,000 children under 15 years are HIV-infected, a majority of these due to mother-to-child transmission.

The AIDS, Population and Health Integrated Assistance (APHIAplus Kamili) program supports eleven counties in Central and Eastern Kenya namely Nyeri, Nyandarua, Kirinyaga, Kiambu, Murang’a, Embu, Machakos, Meru, Tharaka-Nithi, Makueni and Kitui. The key components of the APHIAplus Kamili project are family planning, maternal/child health, nutrition, and HIV/AIDS prevention, care and treatment services.

The aim of this paper is to assess the program implementation outcomes using integration of HIV services to MCH. Kenya adopted 2013 WHO guidelines on option B+ giving more emphasis to the implementation of HAART for all HIV positive pregnant mothers.

The APHIAplus KAMILI Programme

Baseline assessment

The APHIAplus KAMILI program carried out baseline assessment to identify the key gaps affecting PMTCT within the region. The gaps identified were as follows: capacity of the health care providers to carry out quality PMTCT services, poor adherence to ART by the HIV positive mothers, vertical management of the HIV positive pregnant mothers, lack of proper documentation and follow-up for the exposed infants including laboratory networking for dry blood spot (DBS) and viral load.

Interventions

Training and mentorship of health workers

The program held meetings involving the National AIDS and STI Control Program (NASCOP) to develop materials for the Prevention of Mother-to-Child Transmission (PMTCT) mentorship teams within the region. County mentors were trained to ensure the health workers were offered the mentorship at facility level. The health facility incharges and the nurses working at the MCH were trained on PMTCT using the PMTCT guidelines. Printing of resource materials was done to ensure the health workers could refer to them while managing the clients. Continuous quality meetings were held with the facilities to ensure the data generated was of high quality. Mentorship on Early Infant Diagnosis (EID) was done frequently to ensure the health workers gained skills in bleeding DBS for polymerase chain reaction (PCR) testing. The program supported transportation of viral load and DBS samples to central testing sites since not all PMTCT sites have laboratory capacity to test.

Integrating of HIV to MCH

To ensure HIV integration in MCH, sites with challenges in infrastructure were supported with renovations. Lockable cabinets were purchased and distributed to testing sites to facilitate storage of the ARV drugs. Resource materials on the benefits of HIV integration at MCH were printed and placed in all MCH centers.

Mentor mothers placement

Mentor Mothers are HIV positive mothers who have undertaken PMTCT services education and are trained to support other HIV positive mothers. The criteria for their selection was: HIV positive mothers who had undertaken PMTCT services training and had a child below one year, possession of a Kenya Certificate for Secondary Education and a willingness to disclose their HIV status to the mothers during peer support counselling. Fifty three Mentor Mothers were selected and trained for 12 days. They were then placed in the Maternal and Child Health unit (MCH). The key roles for the Mentor Mothers included: offering one-to-one peer counselling to the HIV positive clients, follow-up of the mother and the baby to ensure they adhered to ARV drugs, formation of psychosocial support groups (PSSG), cofacilitating group health talks in facility waiting areas on key messages on PMTCT, and facilitating group pre-test HIV education for pregnant women, among others. The PSSG meetings were held monthly at the facility and were meant for HIV positive mothers and breastfeeding mothers to share issues related to care of the babies, use of ARV drugs and Exclusive Breast Feeding (EBF). These groups were guided by the Mentor Mothers and nurses working at MCH.

Methodology

Data collection

A retrospective data review was conducted in the153 health facilities where APHIAplus KAMILI had been working from 2011 to 2014. Data on maternal and infant prophylaxis and on modes of breastfeeding is usually collected through the government reporting tools at the facility. It is then aggregated and uploaded to the District Health Information System (DHIS) for electronic storage and access by the public. The maternal and infant prophylaxis data used in the paper was extracted from the A+K database which replicates the information uploaded in the DHIS system. Data on early infant diagnosis was obtained from the NASCOP website.

Data analysis

Data was analyzed using MS excel and presented in bar graphs and line graphs.

Findings

There was a steady increase in the number of HIV positive pregnant mothers put on HAART from 23.53% in 2011 to 88.64% in 2014 (see Figure 1).

In addition, there was a remarkable rise in the number of HIV exposed infants issued with infant prophylaxis from 55.88% in 2011 to 87.36% in 2014 (see Figure 2).

The percentage of mothers who reported having Exclusively Breastfed their infants at 6 months among the HIV positive infants was at 80%.

According to the EID website data review for the APHIAplus KAMILI sites in 2014, there was a reduction in the HEI turning positive from 8.6% in 2011 to 6.5% in 2014. The HIV positive children put on treatment in 2011 was 9.3% compared to 52% in 2014. Over the same period, there was a drop of 2.1% on the number of HIV exposed infants who turned positive (see Figure 3).

Discussion

Training, capacity building and mentorship of health care providers and mentor mothers have been shown to be effective in rolling out quality services to HIV positive mother-baby pairs. Ninety eight percent (98%) of the health care providers in APHIAplus KAMILI were mentored on EMTCT interventions. This led to integrated HIV services within MCH units. This agrees with a study conducted on the effectiveness of training programs to increase the capacity of health care providers to provide HIV/AIDS care and treatment in Swaziland, which showed that capacity building is key in smooth implementation of activities within the health facilities [4].

Baseline assessment for the programs showed that only 40% of the health facilities were able to offer HAART for the pregnant and breastfeeding mothers. Currently, after the interventions have been put in place, over 95% of the health facilities have integrated the HIV services within MCH. These include: issuing HAART for the HIV positive pregnant women, carrying out DBS for the exposed babies, ART treatment for the babies who turn HIV positive and PSSG support and follow-up for the mother-baby pairs. Evidence shows that integration of PMTCT to maternal and reproductive health services has a positive effect in improving the follow-up of the HIV positive mothers and their infants [5].

The increase in the maternal HAART and infant prophylaxis can be attributed to the adaptation of the WHO 2013 HIV management guidelines which emphasized on HAART for pregnant mothers and breastfeeding mothers and the need for team work by the health care providers and mentor mothers. The mentor mothers played a big role in ensuring the HIV positive mothers adhered to the treatment, using the psychosocial support groups. Mentor mothers help HIV positive clients through a process of reducing stigma and also ensuring reduction of abuse to HIV positive mothers. Evidence shows that HIV positive mothers are at high risk of intimate partner violence which affects the adherence to care and treatment [6].

There is evidence of improvement in the documentation and reduction of transmission on the NASCOP EID website. In 2011, KAMILI zones showed high HIV transmission of 8.6% at 6 weeks from mother to child due to poor documentation on the indicators and low initiation on treatment of HIV exposed infants who turn positive to avert mortality. Currently, the HIV transmission rate is at 6.5% at 6 weeks and 52% HIV positive infants put on ARV treatment. However, we have put in place rapid initiative strategies to ensure we are able to put all the HIV positive infants on treatment before the end of the program.

Conclusion

Acceleration of health service and integration of HIV services to Maternal and Child Health (MCH) lead to improved management of HIV positive pregnant mothers and their infants and elimination of pediatric HIV.