By Joyce Chimbi (Lead Writer)
Homabay County has been the face of HIV/Aids in Kenya as it has the country’s oldest and largest HIV treatment programme. Nearly a quarter of the county’s entire population lives with HIV. “Six years ago, with an overall HIV prevalence-for all adults and children- of 25.7 percent against a national average prevalence of 6.04 percent, for mothers living with HIV the miracle was in giving birth to an HIV negative baby”, said Elisha Arunga Odoyo, a clinician with the Prevention of Mother to Child Transmission (PMTCT) programme at the Homabay County Teaching and Referral Hospital. In 2015, the pediatric HIV prevalence rate in Homabay County was at a 16.8 percent high.
According to the Centers for Disease Control and Prevention (CDC), Kenya is among 22 countries that collectively account for 90 percent of pregnant women living with HIV. Without proper intervention, 40 percent of all babies born within this cohort acquire the virus. In 2019, of the 1.4 million people living with HIV in Kenya, 90,000 were children under the age of 14 years and an estimated 11 percent of these children were in Homabay County.
As a result, a PMTCT programme was implemented to offer a range of services for women of reproductive age living with or at risk of HIV to maintain their health and to prevent their infants from acquiring HIV. In spite of the existence of the programme and the availability of free antiretroviral (ART) therapy care and treatment in all corners of Homabay County, as many as four children acquired HIV in every 100 children tested, according to National AIDS and STI Control Programme (NASCOP) statistics.
Addressing missed opportunities and mothers ‘lost to follow up’
The Ministry of Health and partners began an investigation into why the programme wasn’t working and discovered that mothers were interrupting ART treatment and the factors behind this were outside the scope of health facilities. Mothers were not missing out on treatment because antiretrovirals (ARVs) were unavailable, but because of social factors like fear of stigma and discrimination, denial of HIV status, lack of transportation to access health facilities, and domestic violence. “I am an HIV positive mentor mother. Denial and loss of hope can lead someone to refuse treatment. Others do not know that not taking medication as advised is likely to lead to transmission of HIV. Others self-stigmatise while others lack social support to help them stay on track”, said Imelda Akoth.
At Homabay County Teaching and Referral Hospital for instance, Odoyo said as many as 100 mothers living with HIV were lost to follow-up annually. These were mothers who were out of the critical ART treatment and care for at least 30 days to their last clinic visit. “In addition to mothers lost to follow up, we had at least 100 missed opportunities every year. These were high-risk mothers who tested positive for HIV but were not enrolled into HIV care and treatment and at great risk of transmitting HIV to their babies”, he added. Eventually, often three months after delivery, these high-risk mothers would present themselves at the referral hospital, extremely sick and accompanied by equally sick HIV positive babies.
Peer and mentor mothers to the rescue
To help address factors that interfered with the success of the programme and bring all pregnant and lactating mothers with HIV to health facilities to receive treatment and care, in 2016, the Ministry of Health and its partners introduced the peer and mentor mother programme in Homabay County. “The mentor model was designed to help improve adherence to treatment”, said Odoyo. Women were selected and trained as peer and mentor mothers to provide solutions to the social barriers responsible for high mother-to-child transmission of HIV in the County.
The mentorship structure is the bridge between HIV-positive pregnant and lactating mothers and PMTCT services. The mothers undertake home visits and are in constant touch with their assigned mentees through phone calls and text messages. They use a specially designed and easy-to-navigate Ushauri (Swahili for advice) app that enables them to review a patient’s treatment history, appointments, and treatment regimen in a matter of minutes. After an appointment, mentors update the app by confirming that the patient made a scheduled clinic visit and input the details of their next visit.
The peer and mentor mothers say the magic is in ensuring that any problem that could hinder a PMTCT high-risk mother from accessing services is addressed right from the onset. “We are trained to look for problems outside the treatment program itself. ART is available free of charge and health workers are at the facilities waiting to serve people. But they will not come looking for you at home so that you can receive services. This is where mentorship comes in”, Akoth explained.
Adolescent and teenage mothers and mothers across all ages newly diagnosed with HIV and newly widowed pregnant and lactating mothers are often a high-risk group in need of mentorship. The mentorship structure, therefore, takes age into consideration before pairing up mentors and mentees. At Homabay County referral hospital, for instance, peer mothers at the referral hospital include 24-year-old *Dorcas Otieno, a mother of an HIV-negative baby attached to adolescents and young people below the age of 24. There is also 41-year-old *Imelda Akoth, a mother of three HIV-negative babies attached to those older than 25 years old.
When a PMTCT mother visits the health facility for her routine visit, she first meets with her mentor — who is always in the health facility when not on a home visit — before seeing a clinician or nurse. Any issues that emerge from these sessions are reported to the clinicians and nurses for action as they may interfere with treatment outcomes. Mothers who are not able to visit their preferred health facility due to distance and lack of transportation are referred to other health facilities and assisted by their mentors to assimilate into a PMTCT programme nearer to their residence. Onyango, a beneficiary of the peer mentor programme confirmed that mentor and peer mothers are the backbone upon which the success of the programme rests.
Achieving zero new pediatric HIV infections
Since the introduction of the programme, transmission of HIV from mother to child has reduced from a high of 16.8 percent in 2015 to a low of 9.1 percent in 2019. Since 2018, not a single mother who receives PMTCT services directly from the referral hospital as their primary health care provider has delivered an HIV-positive baby. Now, all HIV-positive babies recorded at the referral facility are of referred cases from other health facilities within Homabay County. They include a total of three HIV-positive babies in 2018, two HIV-positive babies in 2020, and another two in 2021 as per Homabay County and Referral Hospital records.
The primary limitation of the mentorship programme is that it is heavily dependent on donor support. Mentors depend on donor support for payment for their services. Infrastructure to run the programme including, tablets and internet connectivity, transportation for home visits as well as regular training to help mentors keep up with the PMTCT guidelines, are all funded by donors. Homabay County is grateful for donor support, but this is not sustainable because this support can be terminated at any time. Plans must be put in place to ensure that this programme receives a stable source of funding to protect the success it has achieved.
Today, Onyango’s success story is one of many across health facilities within Homabay County including Obunga dispensary, Kitare health facility, Rangwe sub-county hospital and Homabay County Teaching and Referral hospital. Homabay County seeks to sustain the mentorship structure towards raising an HIV-free generation by achieving zero new pediatrics HIV infections one HIV-negative baby at a time.
The names of HIV-positive women have been changed to protect their identities.