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Bulletin of Medicus Mundi Switzerland No. 105, July 2007

Prevention, care, treatment and support: Experiences from a rural context in northern Mozambique

A "woman’s disease"

The implementation of a successful program for reduction of HIV transmission from mother to child depends upon many factors. In our experience we can highlight a few of them that are significant within the context of northern Mozambique. Some of them are in relation to the patients’ lives, while others are related to the organisation of the services and the human resources available.

By Marleen Dermaut * (Médecins Sans Frontières (Switzerland))

HIV/AIDS is one of the biggest problems Mozambique is facing at the moment, with an overall prevalence of 16 percent in the reproductive age group. The government of Mozambique has taken action to fight the problem only over the past few years, and policies have been formulated – not least with pressure and support from Médecins Sans Frontières (MSF).

The Lichinga project

Lichinga is located in one of the most isolated provinces of Mozambique, Niassa, in the northern part of the country. MSF was the first actor to provide medical care to persons infected with HIV. The Lichinga project of MSF aims to improve access to and quality of care for HIV positive patients, as well as reduce transmission of HIV. The set-up of the project was designed in such a way that step-by-step activities would be integrated into and finally handed over to the existing Ministry of Health structure.

The project started in July 2001 with the rehabilitation of the facilities for the Voluntary Confidential Counselling and Testing (VCCT), staff recruitment, training and activities to improve hospital hygiene. The VCCT centre, situated next to the paediatric ward in the Provincial Hospital of Lichinga, has been functional since January 2002. The program for reduction of HIV transmission from mother to child (PMTCT) began in October 2002: mother and baby are given antiretroviral drugs in order to reduce the risk of transmission. Both receive care for one and a half years with medical, psychological and nutritional support. At the end of May 2003 a second VCCT for PMTCT was opened at the city’s Health centre next to the prenatal consultations, which increased the number of pregnant women counselled and tested. Since November 2003 antiretroviral treatment (ART) is offered to patients in an advanced stage of the disease. Since the beginning of the program almost 2.617 files for HIV positive patients have been opened and 775 patients initiated ART: of these, 528 are still being successfully followed (as of December 2006).

As for non-medical activities, training has taken place for various target groups, i.e. hospital staff, other health workers and community leaders. Information, Education and Communication activities have been integrated into the program such as for e.g. theatre plays in rural contexts and ”palestras” (health talks) for various target groups.

Medical and non-medical activities have increased steadily throughout the project period, although the current perception of the field team is that more could be done with the existing resources. There are three MSF expatriate volunteers currently working in Lichinga (medical doctor, midwife, field coordinator), and approximately 20 national staff (not including guards and domestic staff). It must be noted that a number of human resources problems, gaps in expatriate volunteers’ positions and fluctuations occurred in the Lichinga HIV project. In terms of funding, the project is financed by the Irish Cooperation as well as MSF funds.

The PMTCT program

Since October 2002, 369 pregnant women have gained access to the program for reduction of HIV transmission from mother to child. The prevalence of HIV in the antenatal care service is of 6.6%. From 2005 onwards, the care provided within the program follows the Ministry of Health protocol, which is subdivided into the three following steps:

Prenatal care: Voluntary Confidential Counselling and Testing is offered to all pregnant women at first consultation using an ‘opt-out’ strategy. When the test result is positive, CD4 count is done and decision making is based upon the CD4 count value. Women in need of antiretroviral treatment are then referred to the HIV clinic, where they receive the full package of ART care, including adherence support, biological and medical follow up.

Women, who do not need antiretroviral treatment for their own health, receive the antiretroviral drug Azidothymidine (AZT) from 32 weeks onwards, and one tablet of another antiretroviral drug, Nevirapine, is given to the women to take home at 36 weeks. Once the women receive the tablet, it is important to explain that they have to take said tablet at the onset of labour.

Intrapartum care: during delivery women receive extra doses of AZT every three hours and extra care is taken to make sure that the women take their tablet of Nevirapine. Invasive manouvers are avoided during delivery to reduce the risk of HIV transmission. Soon after delivery, the newborn receives a single dose of Nevirapine; mother and baby then go home with the necessary doses of AZT for a week. AZT is given to the mother to reduce the risk of induction of Nevirapine resistance, whereas the baby receives AZT as part of the post-exposure prophylaxis to avoid HIV transmission.

Post partum follow up: positive mothers will be followed in the HIV clinic while the babies should come regularly to the child clinic for follow-up. During the monthly visits, the newborns are checked for normal growth and early detection of opportunistic infections. At six weeks the cotrimoxazole prophylaxis is started and at 18 months a rapid test is offered to detect eventual transmission of HIV. Exclusive breastfeeding is recommended for positive women until six months.

Main difficulties and constraints

The implementation of a successful PMTCT program depends upon many factors. During pregnancy women are requested to come regularly to follow-up visits, something that is complicated by the many constraints of their daily lives. The efficacy of prophylactic treatment is very much dependent on good adherence to the daily intake of antiretroviral drugs. Factors influencing adherence vary during time and with respect to the social context of the women, as in e.g. the involvement and support given by the women’s partners. Such support is an important factor that can help these women to maintain their adherence to the antiretroviral treatment program. However, in this specific context, adherence is difficult to maintain due to the weak social position of these women: often they are scared to disclose their status to their partner and/or family due to fears related to rejection.

In Mozambique the last WHO recommendations are not yet included in the national protocol: therefore MSF with other implementing actors are advocating towards the Ministry of Health to update said protocol. Staff working in the antenatal care is often not enough and/or not sufficiently trained. To make things worse, low salaries and high workload contribute to low motivation and high absenteeism.

The possibilities of intervention during delivery depend upon the attendance of the women to health services, which in rural areas is far from being common practice. In general, women prefer to deliver at home attended by family members and an untrained traditional birth attendant.

Another difficulty is related to nutrition: the optimal feeding option to avoid transmission – applied in rich countries – is total substitution of maternal breast with artificial milk. The cost and the little feasibility of AFASS conditions (affordability, feasibility, acceptability, sustainability, safety) proposed by WHO to have safe replacement feeding forces the Ministry of Health and implementing partners to give little possibility of choice to these women. This inevitably leaves as sole option exclusive breastfeeding. Such a choice is complicated by cultural and social constraints, since the women are used to introduce at a very early stage other liquids or solid food.

In order to improve our activities, we realised that we needed to have a clearer idea on the patients’ perception of our services. MSF therefore set up an anthropological study related to local cultural and social constraints.

One of the major points that came out of this anthropological study was that the perception and knowledge of HIV and AIDS amongst the general population is still very much associated with death. The information they have is mainly about the ways of contagion, preventive measures and the fact that one can die from such a disease. There seems to be still very little knowledge about the evolution of the disease and of a possible treatment. Many men arrive late to the Lichinga HIV-clinic and die even before initiating ART. New Information Education Communication strategies have been elaborated to increase the knowledge and change the perception of the disease in terms of acceptability, to convince people to come to get tested and treated.

This study also revealed that AIDS is very much perceived as a ”woman’s disease”, because the prevalence is higher among women. Women are considered to be responsible for its transmission, are the main target group (in Information Education Communication programs, within the health system and from the empowerment point of view) as well as being the first and more visible AIDS sufferers (PMTCT visibility). Women are often young, married and under fertility pressure. The socio-cultural obligation to have children appears to outweigh fears and risks associated with the prospects of deteriorating health, of giving birth to infected infants and the fear of leaving children orphaned. Information Education Communication projects therefore need to change this way of thinking. The position of women should be highlighted in a positive manner when fighting discrimination and giving messages to the population.

Integration into the routine health consultation

Until the end of August 2006, the PMTCT program managed by MSF was facing an important rate of patients lost to follow-up. The suspected reasons for this situation were problems related to the structural organisation of the services, as well as the unfavourable social condition of women. As a consequence, both problems were addressed by the program.

Structural organisation of the services: After August 29th, 2006, the PMTCT program was officially integrated into the routine mother and child health consultation given in the Lichinga Health Centre. Before, the program was physically located in rooms next to the routine consultations, therefore women were advised to go there after the prenatal consultation. As a consequence, many women either did not come to test themselves for HIV, or if they did, they would not come back for a following consultation. Since the integration, MSF workers noticed that practically no women were denying to take the HIV test and were also going quite regularly to prenatal consultations. Therefore the physical integration of PMTCT activities into the routine prenatal consultations of the Health Centre has significantly reduced the risk of stigma.

Unfavourable social condition of women: The hypothesis was that the social condition of women did not allow them to freely choose whether they wanted to take the HIV test and if positive, to commit to a medical follow-up. However we later realized that this first hypothesis was partially biased from a westernized approach. The concept of giving a choice to women to decide whether they want to undergo the HIV test or not, is an occidental, imported concept, more related to the individual rights that partially form patient/medical staff relations in westernized countries. For historical reasons, the afore-mentioned relationship is clearly asymmetric. In the case of Lichinga, nurses are generally considered to be the ones who know what pregnant women should do. It is therefore normal for them to integrate into their routine recommendations for the pregnant women to also take the HIV test. An example:

“The woman, who is pregnant, told us that in the CS the HIV test is compulsory and that she thought it was a good thing in order to protect the baby health.” (reported by a nurse of our Lichinga local staff concerning one of the patients)

Integration has also got other effects. On the one hand, with a media of 55 consultations per day divided between three nurses, counselling has decreased both in time and quality. On the other, because of the shortage of health professionals in the national health system, there are fluctuations on the number and quality of knowledge of the nurses attending the services.

Moreover, the new ”opt out” protocol of routine HIV testing, based upon WHO recommendations, states that ”women must indicate in the case she does not want to be tested for HIV” (Ministry of Health 2006). Such an approach allows for the maintaining of a degree of choice for pregnant women, in a context where beneficiaries are used to accept and not to decide. Therefore, HIV testing can, in this way, be normalized like the rest of blood testing, nutritional supplements and malaria prophylaxis. By ”normalised”, we intend the increase of its frequency, its inclusion into mainstream prenatal protocol and in the normative perception that women have of HIV testing.

Conclusion

Looking back to the experience of this PMTCT intervention, MSF can draw some lessons concerning the set-up of this kind of services. Integration of HIV care for pregnant women into the usual routine antenatal care definitely helps in ensuring an optimal acceptability and a feeling of reduced discrimination.

However, to do so it is important that the health staff involved in the implementation exists in due number, is well trained and fully aware of the social constraints for positive women. Community awareness is fundamental in creating an enabling environment through the involvement of partners as well as the participation of pregnant women who have successfully followed the program, who may pass the message to other women at the beginning of the process.

Finally, it must not be forgotten that full and active participation of all actors such as members of the aidsfocus.ch network to the scaling up of PMTCT programs is pivotal to a future generation free of AIDS.

*Marleen Dermaut is a midwife and worked with Médecins Sans Frontières Switzerland in Lichinga Project in Mozambique. She now lives and works for Médecins Sans Frontières Switzerland in Brussels. Contact: www.msf.ch, marleen.dermaut@gmail.com