Dr. Nadia Sam-Agudu, PI MoMent (Mother Mentor) Study, Nigeria. Prof. Vhumani Magezi, Co-Investigator EPAZ (Eliminating Paediatric AIDS in Zimbabwe) Zimbabwe. Mother Support Groups and Mentor Mothers to Improve PMTCT Retention-in-Care: Design and Implementation Challenges from the MoMent and EPAZ Projects

Outline Two implementation research studies examining the impact of Mentor Mothers and mother support groups on PMTCT retention in care Share outline of each study Share common challenges Discussion ….

Country PMTCT Data NigeriaZimbabwe Population (2012)170 million12.9 million HIV prevalence (2012)3.1%15.0 % Annual No. HIV+ pregnant women ,00070,000 PMTCT ARV coverage (2012) 17%56% EID coverage4%44% Annual No. new child HIV infections ~60,000~9,000 PMTCT retention-in- care No national dataNo official data

PMTCT Program Needs: Community-based interventions Nigeria (large size and population; low coverage); Zimbabwe (smaller population, high prevalence, poor retention) Peer PLHIV well-positioned to support PMTCT program Mentor Mothers (MM) and Mother Support Group (MSG) concept already established but not rigorously evaluated IR projects designed to evaluate impact of MM and MSG interventions in the context of PMTCT

MoMent Study Design Intervention Arm: engages Mentor Mothers: trained, closely supervised by MM supervisors (MMS) within structured MM program. Control Arm: engages standard-of-care peer counsellors: not formally trained, not closely supervised, not optimally structured program.

MoMent - Intervention and outcomes Mentor Mother: PMTCT-experienced HIV+ woman, ideally with HIV-negative child. –Typically recruited from MSG –Trained on basic PMTCT/MCH, counselling –Provide 18 to 24 months of support MM Supervisor: Post-secondary educated staff with basic PMTCT/MCH and programming training –Supervises MM and polices retention among MM clients MoMent outcome measures: proportion receiving EID, and mother-infant pair (MIP) retention at 6 and 12 months post-delivery

MoMent - Design and Implementation Challenges MMs: 'Human' resource intervention intended to change (health) 'human' behavior (pregnant women and mothers) Standardization and consistency of intervention and measures: –Standardized but simple English and Hausa training curriculum –Structured but feasible schedule of MM-client interactions –Outcomes-relevant data collection tools –Capturing MM supervisor’s oversight, auditing and direction of MM activities

MoMent - Design and Implementation Challenges Introducing lay – but empowered- personnel into an hierarchical healthcare system –Potential friction in HCW-MM and HCW-MMS relationship –Promote respect for, and acceptability of MMs while validating role and impact of HCWs Defining and measuring MM activities that impact on PMTCT outcomes –Frequency, quality, intensity of MM-client interactions –Home visits, phone calls  MM logbook

EPAZ (Eliminating Paediatric AIDS in Zimbabwe)

Mother Support Groups HIV-positive mothers join groups after booking and leave at 6 months postnatal MSGs meet at each clinic in Intervention Arm every two weeks Groups are led by the MSG coordinator Health information is given at each meeting by a nurse

No Curriculum Topic Key information 1Mother-to-child transmission (MTCT) 1.Likelihood & timing of MTCT. 2.Reducing the risk of MTCT. 2Anti-retroviral treatment (ART) 1.Why lifelong ART? 2.Adherence. 3.Monitoring. 4.Side effects. 3Infant delivery, testing & treatment 1.Delivery in health facilities 2.Infant testing. 3.Infant treatment. 4Disclosure 1.Pros and cons of disclosure. 2.Informing your partner of your HIV status 5Positive living 1.Healthy living 2.Psychosocial support 3.Prevention of transmission to partners 6 Family planning & sexually transmitted infections (STIs) 1.Why family planning is important 2.Family planning products. 3.Prevention and treatment of STIs. 7Infant nutrition & health 1.Breastfeeding 2.Artificial feeding 3.Growth monitoring & child health 8Male participation 1.Male attendance. 2.Male testing. 3.When your partner is HIV-negative. 4.Male participation in MRGs.

Standard format of MSG meetings 1 Opening prayer 2 Welcome new members 3 Outline the aims of the group 4 Reinforce confidentiality 5 Explain retention activities 6 Celebrate members’ new babies 7 Acknowledge HIV results of babies. 8Celebrate graduations; remind members of graduation policy 9 Introduce the information topic 10 Next meeting 11Closing prayer

Retention activities of MSGs Importance of retention stressed at each group meeting Coordinator sends SMS reminder before each group meeting to each member Coordinator sends reminder to non-attending members after each missed meeting Coordinator informs sister-in- charge after two consecutive missed meetings by a member and encourages home visiting

Improving PMTCT data monitoring The EPAZ project supports the government Health Information System as follows: –Baseline assessments of data verification at sites –Initial training of health workers (HWs) in data entry –Accompanying district health executive members on data verification and on-the-job training visits –Incentives to HWs based on data quality of ART and ante- /post-natal registers to improve data collection

MSG Design & Implementation Challenges 1.Distinction between research and NGO programme 2.Standardization and consistency of MSGs across sites 3.Unpack and quantify what MSGs actually do, and how they influence mothers’ behaviour, and how this gets incorporated into the database and analysis plan a.MSG collects data but variable quality of data b.Ability to identify and measure significant activities within MSG that influence outcome measures 4.Tension between ‘strict, highly controlled and monitored intervention’ vs. maintenance of practical low cost clinic-based model that could be scaled up

Common challenges: MoMent and EPAZ Standardization and consistency of “human resource” intervention Balance between highly controlled research vs. practical implementation of “human resource” interventions Data collection - retention outcomes ‘effect of intervention’ vs intervention ‘process’. –Measuring activities that impact on PMTCT outcomes – where do you focus? Success factor correlation: MMS and MSG Coordinator skill and innovation vs. intervention effect

Tatenda! Mungode! Thank You All!