SCALING UP PPTCT
IN AFRICA
A case study
SC A L I N G U P P P TC T I N A F RI C A
Contents
Introduction
1
A unique approach
3
Tearfund partners scaling up PPTCT
4
The process
5
Progress of partner programmes
8
Challenges to effective PPTCT programmes
9
Trends in PPTCT programmes
10
Key examples of best practise in PPTCT
11
Conclusion
12
Glossary
12
Appendix A – Baseline standardised
template for Lusaka Seven PPTCT study
13
Appendix B – Generic action plan
16
Author: Dr Rena Downing
Cover photos: Alice Fay / Tearfund,
Torleif Svensson, Mike Tsang
Edited by: Maggie Sandilands
Designed by: Wingfinger
© Tearfund 2009
John Downing
Tearfund contact: Alice Fay
Email: alice.fay@tearfund.org
Website: www.tearfund.org/hiv/response
Tearfund is a Christian relief and development
agency building a global network of local
churches to help eradicate poverty.
The Lusaka Seven field trip at the second workshop in 2008
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Introduction
Global estimates suggest that 1,000 infants become infected with HIV each day. Most of these
infections occur in Africa and the majority could be avoided if parents had access to effective
prevention of parent-to-child transmission (PPTCT) services. The United Nations General Assembly
made a commitment in 2001 to offer prevention services to at least 80 per cent of all pregnant
women and so reduce the proportion of HIV-infected infants by 50 per cent by 2010. In many African
countries churches and faith-based institutions provide 40 to 60 per cent of all healthcare services
and many Christian denominations and networks provide a vital link in the chain of PPTCT services.
To provide the best quality care for the people they serve, they need to ensure that their PPTCT
services are efficiently run and properly evaluated. This case study describes a process which enabled
14 Tearfund partner organisations working in ten African countries to improve the provision and uptake
of their local PPTCT programmes.
Tearfund partners
provide various
components of
comprehensive
PPTCT services
Counselling
and testing
Medical
interventions
Supporting
HIV-positive
families
Training
midwives
Procuring
treatments
and tests
LOCAL
PPTCT
SERVICES
Sensitising
the
community
Without any interventions to prevent transmission, mothers who are HIV-positive pass the virus to their
baby in about 30–45 per cent of cases. Transmission can take place during the antenatal period, during
delivery or whilst the mother is breastfeeding. It is more likely if the mother has a high viral load in her
blood, such as when she is newly infected with HIV and at periods when her immunity is low.
Outcome for 100
HIV-exposed babies
without medical
interventions
55 – 70 babies
HIV-negative
5 –10 during
pregnancy
100 babies
30 – 45 babies
HIV-positive
10 – 20 during
delivery
10 – 20 during
breastfeeding
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Key medical measures to reduce the risk of transmission depend firstly on identifying which mothers
are HIV-positive. Then it is important to lower the mother’s viral load using antiretroviral therapy (ART),
especially during labour when the skin of the baby will be directly exposed to her blood and may be
injured. The simplest regime is to use Nevirapine. The mother receives a single tablet at the start of
labour and her baby a post-exposure dose in syrup form within 72 hours. More complex regimes are
being developed to limit the risk of transmission more effectively and reduce the risk of drug resistance.
Two or three antiretrovirals are used and treatment started some weeks before delivery and continued
for a few weeks after delivery. HIV-positive mothers with low immunity may commence life-long
treatment with antiretrovirals. WHO recommends that safer delivery practices are followed up with
counselling and support concerning infant-feeding. This cascade of interventions becomes more difficult
to administer with each successive step and the number of mothers who remain engaged in the process
diminishes without careful monitoring and follow-up.
(Unidentified) HIV-positive mothers registered
Cascade of
interventions to
prevent tranmission
of HIV to exposed
babies
HIV-positive mothers identified
HIV-positive mothers given ART
Exposed babies given ART
Exposed infants fed appropriately
HIV-positive infants identified
2
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A unique approach
There is an abundance of research on the prevention of mother-to-child transmission in Africa but little
that documents either church-based action or a focus on men. There is a strong case for testing both
parents, for both medical and social reasons. A mother may test HIV-negative in the antenatal clinic but
still be at risk of infection from her husband during the pregnancy or whilst breastfeeding – especially
if he is unaware of the risks. A newly acquired HIV infection causes an initial high viral load, increasing
the risk of transmission to the baby. A mother who tests HIV-positive may find it difficult to disclose her
status and engage with the necessary interventions for fear of discrimination, so her baby will remain at
risk. Unfortunately, the usual terminology ‘prevention of mother-to-child transmission’ tends to exclude
men from the process of counselling and testing. During the course of the work documented in this case
study, Tearfund partners adopted the term ‘prevention of parent-to-child transmission (PPTCT)’. They
wanted to encourage both parents to share the responsibility of protecting the next generation from HIV.
PPTCT rather than
PMTCT clearly marked
on the hospital sign at
Mount Kenya Hospital
Tearfund facilitated community-based research for the case study, rather than using an external
researcher. Tearfund’s partner organisations fully involved providers and beneficiaries in their local
settings. The aim of the process was to bring about change to benefit everyone involved. This model
of research is based upon problem-solving and involves cycles of reflection and action. The research
template can be found in Appendix B. The participating partners gained skills by undertaking the work
themselves and will be able to continue the reflection–action cycle and improve their programmes in
the future. The first group to start the process was the ‘Nairobi Seven’, so called as seven partners met in
Nairobi for their workshops. A second group of partners, the ‘Lusaka Seven’, are now going through the
same process.
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TEARFUND PARTNERS
SCALING UP PPTCT
showing the countries in
which they work
Democratic Republic of the Congo
HEAL Africa
Stop SIDA
Ethiopia
Medan AIDS Control, Treatment
and psychosocial Support,
Kale Heywet Church
Kenya
Christian Community Services
Mount Kenya, East Anglican
Church of Kenya
Côte d’Ivoire
Groupe Biblique des
Hôpitaux Côte d’Ivoire
Tanzania
Anglican Church
Kagera Diocese
Nigeria
Faith Alive Foundation
The Evangelical Church of
West Africa AIDS Ministry
Zambia
Evangelical Fellowship of Zambia
Brethren in Christ Church
Malawi
Zimbabwe
Family AIDS Caring Trust
Livingstonia Synod AIDS
Programme, Presbyterian Church
of Central Africa
Evangelical Association of Malawi
Mozambique
KEY
Kubatsirana
Partners in the Nairobi Seven
Partners in the Lusaka Seven
4
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The process
1
Initial research
A desk review of the literature helped to structure the process and the following objectives were refined
after the first research process with the Nairobi Seven:
2
■
To facilitate seven partners in Africa in undertaking an audit of their PPTCT programmes, focusing
specifically on testing both parents. The audit would also look at the provision of PPTCT interventions
for HIV-positive mothers and their exposed infants, including uptake of infant feeding advice and the
care and testing of exposed infants.
■
To facilitate a forum for the partners to critically assess their work together and formulate a plan for
further action.
■
To assist partners in identifying key areas of weakness in programmes and drawing up action plans in
response.
■
To assess the prevalence of different infant feeding methods by interviewing mothers attending EPI
clinics.
■
To explore, through discussions with key focus groups, how the church might support optimal infant
feeding within their communities.
■
To identify trends in PPTCT.
First workshop to agree the template
A common template of questions was developed by each group to guide both qualitative and
quantitative data collection, relating to issues such as:
■
Background information about available PPTCT services and national policy.
■
Social mapping to show the field of study, including churches and PPTCT facilities.
■
Retrospective activity levels over a 12-month period for each of the main PPTCT interventions,
including fathers’ uptake of testing.
■
Reported infant feeding practice for the two weeks prior to the third immunisation at three months.
■
Focus group discussions to contextualise community interventions and address misunderstandings
and unhelpful attitudes.
Tearfund made every effort to engage francophone and lusophone partners by translating materials into
French and Portuguese and providing translators for these five-day workshops.
KEY
A social map
showing the
health facility and
churches in the
locality
Anglican
Church Roman Catholic
Pentecostal
Hospital
Primary school
Market
Village boundary
River
Bananas
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3
Baseline data collection
Partners were given three to four months to collect their data, including PPTCT activity levels for the
previous 12 months as recorded in the antenatal and maternity unit registers. Support was given by email
during this time. In addition, the Lusaka Seven received support from Tearfund field workers and training in
the use of tape recorders to help facilitate their focus group discussions.
4
Second workshop to reflect on the data
This five-day worksh op allowed partners to present their findings and formulate recommendations for
church-based action for PPTCT in Africa. A field trip was organised to visit a local Tearfund partner involved
in delivering PPTCT services, as part of the workshop. At the end of the workshop, partners drew up action
plans to increase provision and uptake of their local PPTCT services.
Template for
partners’ action
plans
Present situation
(weak area)
Where would I
like to be in six
months?
What SMART
steps will I take
to achieve this?
How will
I measure
progress
(indicators)?
Long-term
vision
Uptake of HIV testing
Interventions for
HIV-positive mothers
Interventions for
HIV-exposed infants
Infant feeding
5
Implementation of action plans
The Nairobi Seven decided to collect data for a second 12-month period but this commenced before they
had implemented their action plans. This design problem has been addressed by the Lusaka Seven who
chose a six-month window to implement their action plans before collecting further activity data. This
was achieved by reducing the second period of data collection to six months and deferring its start by
six months.
6
Repeat audit
The purpose of the second data collection, or repeat audit, was to evaluate the impact of action plans
implemented. The repeat audit was identical to the baseline data collection but without further focus
group discussions. Support for the repeat audit was given entirely by email and latterly from in-country
Tearfund advisers.
7
Third workshop to reflect on the data
This five day workshop enabled progress to be mapped for each programme, by using the data gathered to
compare PPTCT activity levels before and after any planned interventions. Again, recommendations were
made and new action plans developed. A second field trip to a PPTCT service provider was organised and
very much appreciated.
6
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Initial
research
Cycles of reflection
and action
First
workshop
Intervention
Third
workshop
First audit
Second
workshop
Second audit
Intervention
Impact on participants
The Nairobi Seven were very positive about the benefits of evaluating their PPTCT programmes and
sharing their findings together. Comments on the value of the process included the following:
‘It has given me the desire to work harder.’
‘It allowed some of the programmes to adopt good practice.’
‘The workshop was such an eye-opener to me in terms of the amount of information.’
‘I am so happy to be linked and hope there can be a way of maintaining professional contact on PPTCT
that goes on till we have an HIV-free generation.’
‘You have made us experts in PPTCT.’
‘It was very practical, particularly the aspect of relating to our situations in the church.’
Partners in both groups were unanimous in wanting to prioritise infant feeding and male involvement in
future planning for their PPTCT programmes.
Representatives of
the Nairobi Seven at
the third workshop in
October 2007
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Progress of partner programmes
The table below summarises the progress of the Nairobi Seven PPTCT programmes by comparing the
number of programmes in the baseline and repeat audits that reached a target of 50 per cent uptake
for each of the key PPTCT interventions. Figures were adjusted for the failure to identify all HIV-positive
women in the initial group of antenatal women.
Intervention
Baseline audit:
programmes achieving
50% uptake
Repeat audit:
programmes achieving
50% uptake
HIV test for mother
4
7
HIV test for fathers
1
2
Prophylactic ARV/ART
3
5
Prophylactic Cotrimoxazole for mother
1
4
CD4 count for mother
1
4
Nevirapine syrup for infant
0
3
Cotrimoxazole syrup for infant
0
4
These significant improvements were attributed to:
■
improved government policies on access to testing, treatment and provision of supplies
■
better training for PPTCT service providers
■
increased support from donors
■
better quality of personal support for parents (including community visits, stigma reduction,
family support and spiritual care)
■
increased knowledge and awareness within the community.
It was not possible to attribute the improvement to any individual intervention.
8
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Challenges to effective PPTCT
programmes
The main challenges faced in ensuring effective PPTCT programmes were:
Procurement of test kits and treatments
Although most of the Nairobi Seven partners demonstrated improvements in service provision, three
programmes suffered from erratic government supplies of HIV test kits and Nevirapine. Regions of conflict
were most affected. One partner found supply drying up because of poor planning at national government
level – even after a particularly successful countrywide promotion of universal HIV testing.
Poor access to services
Rural programmes with scattered populations tended to have poor access to local CD4 monitoring
equipment and hence to Highly Active Antiretroviral Treatment (HAART) for pregnant women. Mothers
who were unable to deliver at a health facility because of distance or cost were unlikely to bring their babies
for Nevirapine syrup within 72 hours of birth. Many programmes were not providing Polymerase Chain
Reaction (PCR) testing to improve care of exposed infants. This expensive test detects the virus in the baby
at six weeks, making it unnecessary to wait for an antibody test, which is not reliable until the baby is 18
months old.
Unhelpful beliefs and practices
Focus group discussions with women, men and church leaders held during the baseline audits by both groups
highlighted challenges in community understanding and practice, including:
Gender and PPTCT
■
Women lack power in relation to men: for example, it is often difficult for a woman to ask her partner to
be tested, particularly if she has already tested HIV-positive.
■
Men are left out of programmes and lack knowledge about PPTCT. Also, they are reluctant to be tested
for fear of being shamed, being sick or weak, or dying.
■
Unhelpful gender norms can increase the vulnerability of men, women and infants in different contexts.
The church and PPTCT
■
In many places, the church is ignorant about HIV and especially about PPTCT.
■
The church regards PPTCT as a medical problem, not the church’s problem.
■
The church is not trusted because it links HIV with sin. Confidentiality is also an issue.
■
The church is reluctant to talk about sex or HIV.
■
Church attitudes to single mothers can alienate them and discriminate against their children.
■
The church is ill-equipped to help even when its members are willing.
■
Church doctrines about healing are confused.
■
The church is confused about condoms.
■
The church may insist that women who are living with HIV should not have children.
■
Church authority structures can be an obstacle to change at community level.
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Infant feeding and PPTCT
■
HIV-positive mothers often risk being stigmatised if they follow infant feeding advice to avoid
transmission (which is that they should breastfeed their infants exclusively for six months, then
instantly wean them off the breast). Most mothers mix-feed and continue to breastfeed well beyond
six months.
■
Even where donated infant formula is available to HIV-positive mothers, it may encourage mixed
feeding if replacement feeding is not socially acceptable and the mother feels she has to breastfeed
in front of the family.
■
Unhelpful beliefs around infant feeding often reduce uptake of exclusive breastfeeding with instant
weaning off the breast at six months. For example, some believe that babies will not grow if they are
exclusively breastfed; that porridge is necessary to supplement breast milk, especially if the mother is
malnourished; that instant weaning off the breast at six months means the mother has an evil spirit;
and that goat’s milk cannot be used after instant weaning off the breast.
■
Mothers and those who advise them about infant feeding are confused about the best option,
especially when the mother is HIV-positive.
10
Prevalence of
1
12
different feeding
20
practices found in
70
60
partner research.
10
2
Stop SIDA
EAM
38
* Where data is
missing this reflects
13
10
Faith alive
BICC
problems in the field
collecting data
GBH-CI*
KEY
Exclusive breast BF
ECWA
Kubatsirana*
Exclusive formula F
Mixed breast and formula
Trends in PPTCT programmes
Since the Nairobi Seven audited their local PPTCT activity in 2005, medical interventions for PPTCT in
African nations have been improving progressively. Compared with the Nairobi Seven, more of the Lusaka
Seven programmes are using the opt-out policy for testing and as a result baseline uptake of HIV testing
has increased. There is better access to CD4 monitoring and hence to HAART treatment for pregnant
women; there are innovations to increase access to Nevirapine syrup for home deliveries; there are more
effective ARV prophylactic regimens for both women and exposed babies; and more programmes have
access to PCR testing for exposed infants. Sometimes, however, success can bring its own challenges.
Two programmes witnessed an increased proportion of women living with HIV registering at their clinics,
which stretches their capacity to meet demand. If living positively now includes enjoying normal family
life with children, programmes need to plan for an increased workload.
Sadly, men’s uptake of testing for PPTCT is still at a low level. No programme in the Lusaka Seven
portfolio was achieving more than 25 per cent uptake during 2007 and most programmes had no means
to promote or record uptake.
Stigma, gender inequality and lack of knowledge about PPTCT in the church and wider community
still appear to be at a similar level to that found by the Nairobi Seven in 2006. Fathers still need to be
better engaged in the process to enable mothers to follow the more complex ARV regimes and to make
the best choices around infant feeding. Until men are as well informed as their partners, they will not
understand the importance of testing and behaviour change that will protect their children before birth
and during breastfeeding.
10
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Key examples of best practice in PPTCT
Testing parents for HIV Infants are best protected if routine testing of both parents is promoted.
This involves a radical change in cultural practice and government policy. It requires a process of group
counselling, followed by same-day testing and couple or one-to-one counselling when giving results. There
needs to be a reliable source of testing kits.
Involving men Programmes need to come up with imaginative ways of getting men involved in prevention
of parent-to-child transmission of HIV. These could include: issuing invitation cards, giving priority to couples
attending the antenatal clinic together and community outreach initiatives e.g. parents’ clubs, promoting
men’s health issues, working with local leaders, church groups, sports clubs, community groups.
Issuing Nevirapine for mothers Best results are achieved if a mother is given a tablet in the antenatal clinic
as soon as her positive status is known, in case she fails to return. She should receive another tablet if she
goes into false labour. There needs to be a reliable source of Nevirapine.
Issuing Nevirapine for infants Best results are achieved by ensuring that mothers who are HIV-positive
deliver in a health facility where the infant can be weighed and given the correct dose of the syrup within
72 hours. For home deliveries, best results are achieved when newborn babies are brought to the under-fives
clinic within 72 hours of birth for BCG vaccination, so those with HIV-positive mothers can be identified and
given Nevirapine syrup. There needs to be a reliable source of Nevirapine syrup.
Clarifying infant feeding messages according to WHO guidelines In the first six months after birth,
mothers have two choices – either exclusive breastfeeding or replacement feeding. It is important to support
mothers in their choice. After six months, mothers should stop all breastfeeding as soon as a nutritionally
adequate and safe diet can be introduced.
Accessing CD4 tests and ART Best results are seen in urban areas where CD4 machines are available.
Those mothers not currently accessing CD4 tests need information on how to get affordable CD4 tests and
antiretroviral treatment. Where these are unavailable, there should be advocacy for wider access.
Supplying Cotrimoxazole This is not expensive and should be given to all HIV-positive mothers and their
infants as a matter of national policy. This requires supportive policies, training and supplies.
Ensuring safer delivery Best results for HIV-positive mothers are achieved through delivery in a health
facility, as this reduces the risk of blood contact between mother and child. There is also a need to ensure
that traditional birth attendants and community workers are available to support safer delivery.
Integrating PPTCT activities with other MCH and community activities PPTCT activities must link up
with the many activities in antenatal clinics, under-fives clinics and family planning clinics. PPTCT awareness
and knowledge should be a focus of community days (e.g. Africa Day, World AIDS Day).
Monitoring PPTCT programmes for improved programme performance Indicators should be developed
and used to measure programme effectiveness in repeated rounds of evaluation.
Reflecting on the quality of PPTCT programmes Weak areas of service provision should be identified and
means of improving quality of services considered, through increased technical or financial support.
Sensitising church leaders to PPTCT There is a strong need to increase church leaders’ knowledge,
awareness and commitment to supporting PPTCT within church ministry and community outreach. Couple
counselling should be offered and lay volunteers supported as they work in church-related outreach.
Scaling-up This involves covering more communities. Service providers must decide on the size of the
population to be supported in PPTCT programmes and implement programmes accordingly.
Communicating what the church is doing and achieving The church should use its meetings, symposia
and websites to show the PPTCT activities it is involved in and their impact.
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Conclusion
This case study documents how Tearfund is working with partner organisations to scale up good practice
interventions that reduce parent-to-child transmission of HIV. The Nairobi Seven have demonstrated
improved service provision and uptake of PPTCT services and the Lusaka Seven are undertaking the
same process with an additional evaluation of infant feeding practice. Both groups are able to continue
improving their responses as they implement their action plans to address weaknesses in their local
PPTCT programmes. They are making a vital contribution to HIV prevention by highlighting the
importance of engaging fathers in PPTCT services whilst most national policy is still focused solely on
mothers. Furthermore, all the partner organisations are linked to the local church, which has a key role in
community sensitisation and in providing care and support to affected families. Tearfund and partners
are working towards the goal that one day in Africa there will be a generation born free of HIV.
Glossary
AFASS
AIDS
Acquired Immunodeficiency Syndrome
ART
antiretroviral therapy
ARV
antiretroviral
CD4
cell count
DRC
EPI
HAART
HIV
IF
PCR
a measure of HIV disease progression
Democratic Republic of Congo
Expanded Programme on Immunisation
Highly Active Antiretroviral Treatment
Human Immunodeficiency Virus
infant formula
Polymerase Chain Reaction
PMTCT
Prevention of Mother to Child Transmission of HIV
PPTCT
Prevention of Parent to Child Transmission of HIV
SMART
SMS
TB
WHO
12
Acceptable, Feasible, Affordable, Safe, Sustainable
Specific, Measurable, Achievable, Realistic, Time-bound
short message service (on a mobile phone)
Tuberculosis
World Health Organisation
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Baseline standardised template
for Lusaka Seven PPTCT study
APPENDIX A
Obtain this data from colleagues and the District Medical Officer
100
BACKGROUND INFORMATION
101
What is the name of your programme providing PPTCT services?
102
What sort of services do you provide for PPTCT e.g. community sensitisation, antenatal care with PPTCT, training of midwives,
provision of tests and/or Nevirapine? Include the date each service was started.
103
Where is your programme and what sort of population does it serve? (urban, rural, slum etc)
104
List all the antenatal sites serving the study population and indicate which provide PPTCT and when PPTCT was started.
105
What is the estimated size of the study population?
106
Draw a social map showing site of churches, antenatal clinics, PPTCT facilities, VCT, HIV care clinic etc.
107
What is the most recent figure for HIV prevalence for women attending antenatal clinics in the study population?
Obtain this data from key informants at each of the study health facilities and include the date the service was
started in your response
200
201
PROVISION OF PPTCT BY HEALTH FACILITIES
What system of HIV testing do you use?
1 Opt-in testing when only women who agree are tested
2 Opt-out testing when women routinely get tested but can chose to opt out of knowing the result
202
What do you do to encourage fathers to be tested?
Can mothers and fathers be tested as couples and receive their results together?
203
How do you reduce mother-to-child transmission of HIV in positive mothers who are not receiving highly active antiretroviral
therapy (HAART)?
1 Give single-dose Nevirapine (sd-NVP) to positive mothers at the onset of labour and to their babies within 72 hours of birth
2 Give short-course ARV prophylaxis to positive mothers and their infants? Please describe the protocol followed
204
What policy do you follow for giving prophylactic Cotrimoxazole to HIV-positive mothers?
What policy do you follow for giving prophylactic Cotrimoxazole to their exposed infants?
205
How accessible are CD4 tests for HIV-positive mothers?
Is there local testing? If not, how far does the mother have to travel?
How much in dollars do mothers pay for a CD4 test?
206
Is long-term Highly Active Antiretroviral Therapy (HAART) available for mothers with low CD4 counts?
What does the mother pay in dollars/year for HAART?
207
What written protocol do you follow to advise HIV-positive mothers on infant feeding? Please summarise this.
What support do you provide mothers in their chosen feeding method?
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Obtain this data from key informants at each of the study health facilities based on records kept by the facilities
300
PPTCT ACTIVITY LEVELS IN THE 12 MONTH PERIOD JANUARY 1 2007 – DECEMBER 31 2007
301
How many mothers registered for antenatal care?
302
How many mothers had an HIV test?
303
How many fathers had an HIV test?
304
How many mothers had a positive HIV test?
305
How many HIV-positive mothers started taking or already took Cotrimoxazole?
306
How many HIV-positive mothers were given a CD4 test?
307
How many HIV-positive mothers started taking or were already taking HAART?
308
How many HIV-positive mothers (not taking HAART) were given single-dose Nevirapine to take at the start of labour?
309
How many HIV-positive mothers (not taking HAART) were given short-course ARV prophylaxis in the last trimester, during
delivery and in the post partum period?
310
How many mothers (positive and negative) delivered their babies at the health facility in the 12 month period?
311
How many HIV-positive mothers (see 304) delivered their babies at the health facility?
312
How many exposed babies had mothers receiving HAART and so did not need Nevirapine syrup within 72 hours of delivery?
313
How many exposed babies whose mothers were not on HAART were given single-dose Nevirapine syrup within 72 hours?
314
How many exposed babies received a PCR test at six weeks?
315
How many were found to be positive?
316
In the absence of PCR testing, how many exposed babies received Cotrimoxazole at six weeks and follow-up care?
Obtain this data from key informants in antenatal and child health clinics
400
401
INFANT FEEDING
Who gives advice on infant feeding to HIV-positive women in the clinic/hospital?
Which written policy do they use? Please bring a copy.
402
Is infant formula (IF) given to HIV-positive mothers at your clinic? What problems do you experience? In 2007, how many
HIV-positive mothers delivered their babies? How many chose not to breast-feed at all and were started on IF?
403
Obtain this information by interviewing up to 80 HIV-negative and 80 HIV-positive women when they bring their infants for
the third diphtheria, polio and tetanus injections at 12–14 weeks.
Ask this question: ’In the last seven days, what methods of infant feeding did you use?’ If infant formula has been used, ask if it
was bought or donated. Complete the following table.
Number of HIV-negative
mothers
Number of HIV-positive
mothers
B Exclusive infant formula (IF)
Bought IF
Donated IF
Bought IF
Donated IF
C Mixed feeding – breast milk + IF /
soya milk / animal milk / juices/porridge
Bought IF
Donated IF
Bought IF
Donated IF
A Exclusive breast-feeding
Target total
14
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SC A L I N G U P P P TC T I N AFRICA
Obtain this data from focus group discussions with men’s groups, church leaders and women with children
500
501
MEN AND PPTCT
What do men do about being tested for HIV when their wives are pregnant?
What can be done to encourage them?
502
How are sexual relations affected by pregnancy and breast-feeding?
503
What should a wife do if she knows her husband is unfaithful?
What can be done to support women facing this issue?
504
What difficulties does a pregnant woman face when she discloses her HIV status to her husband?
505
What should couples do if one of them is HIV-positive?
600
THE CHURCH AND PPTCT
601
How does the church inform parents about the importance of PPTCT?
602
How does the church support pregnant women, including those who are unmarried?
603
What advice is given to HIV-positive members who ask for prayer and healing?
604
1,800 babies are infected with HIV each day globally. How could the church help to prevent babies from becoming
HIV-positive?
700
INFANT FEEDING AND PPTCT
701
Who advises HIV-positive mothers on how to feed their infants, at home, in the clinic and in the church? What is the advice?
702
What role do peer support groups, mothers’ groups and church groups play in supporting appropriate infant feeding by
HIV-positive mothers?
703
What are the main problems facing HIV-positive mothers in their decisions about how to feed their infants in relation to
exclusive breast-feeding, formula feeding and weaning off the breast early?
704
What local examples are there of breast milk replacement (e.g. animal milks, soya milks and infant formula)?
© TEARF U ND 2 009
15
SC A L I N G U P P P TC T I N A F RI C A
Generic action plan
APPENDIX B
Uptake of
antenatal HIV test
POLICY
Antenatal
interventions
for HIV-positive
mothers
(table continues on opposite page)
Interventions
for HIV-exposed
infants
Provision and
uptake of infant
feeding advice
Support of HIVpositive families
For example:
opt-out testing for both
mothers and fathers
• Confirm national
policy on PCR testing
at six weeks
Advice and supplies for
family planning
• Advocate for a change
in policy at federal,
state and hospital
level, and in Christian
Health Associations
• Confirm policy on
take-away Nevirapine
• Raise awareness
of the dangers of
donated infant
formula
Provide condoms for
HIV-positive mothers/
fathers
• Build skills of senior
church leaders to
negotiate with
government
• Support churches to
develop and write
HIV policies including
PPTCT
SERVICE
PROVISION
For example:
sustainable supply of
testing kits
• Train staff to be able
to implement policy
properly
• Provide transport for
women and blood
samples for CD4
count
• Provide viral load test
to help decide about
Caesarean section
• Plan to develop
‘father-friendly’ clinics • Combine with other
programmes (e.g. TB)
• Plan and access
to access CD4 count
sustainable funds to
buy kits (DRC)
• Set up a reference
laboratory for Elisa
• Plan for increased
supply in kits if testing HIV test
of fathers increases
• Train staff to be able
to implement policy
• Plan and access
properly
transport for mobile
• Request national AIDS • Clarify for service
committee to provide
providers the dangers
take-away Nevirapine
of using infant
formula
• Procure smaller
bottles of Nevirapine • Improve knowledge
of and advice about
• Teach women to
the dangers of
demand Nevirapine
early introduction
for their babies
of porridge (mixed
• Involve trusted friends feeding) and the
to support mothers
process of stopping
when their partners
breastfeeding at six
do not attend
months
• Avoid formula if
conditions of AFASS
are not fulfilled
• Provide appropriate
advice for infant
feeding after six
months
clinics
COMMUNITY
/ CHURCH
INVOLVEMENT
• Plan to educate men
about the need for
testing in the context
of fatherhood
• Train the home-based
care volunteers to
support pregnant
mothers
• Include PPTCT
message in church
meetings
• Establish referral link
with antenatal clinic
• Train pastor and wife,
or husbands/wives of
existing volunteers to
counsel couples on
PPTCT
• Support volunteers
after training
• Sensitise church
leaders and
community leaders
about PPTCT
• Hold parties for
couples with PPTCT
education component
16
© TEARF U ND 2 009
• Increase demand for
service provision
• Support women living
with HIV to feed
appropriately
• Grants for groups of
HIV-positive people.
• Income-generating
• Increase church and
activity
community awareness
• Vocational training
of infant feeding
• Nutrition promotion,
practices for HIVgardens, seeds, dry
positive women
porridge
SC A L I N G U P P P TC T I N AFRICA
MALE
INVOLVEMENT
Uptake of
antenatal HIV test
Antenatal
interventions
for HIV-positive
mothers
Interventions
for HIV-exposed
infants
Provision and
uptake of infant
feeding advice
Support of
HIV-positive
families
• Plan to explore
the value of gifts /
incentives for men
• Post- test couple
counselling
• Include teaching on
infant Nevirapine at
the time of couple
counselling
• Infant feeding advice
given at couple
counselling and
follow-up
• Design activities
appealing to men
• Plan special
invitations / reception
for mothers and
fathers
• Special focus on the
partners of single
mothers
• Male-focused churchled community
sensitisation involving
village headmen
• Use partner contact
form for mothers
on HAART or
prophylactic ARVs
• Men from support
group to do home
visits to encourage
fathers to be involved
• Male-focused churchled community
sensitisation involving
village headmen
• Novel ways of
communicating with
men e.g. SMS
• Encourage men to
‘leave the breast for
the infant’
• Train male peer
educators to promote
testing of fathers
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