Dr. Nadia Sam-Agudu, PI MoMent ( Mo ther Ment or) Study, Nigeria.

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

2. 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 ….

3. Country PMTCT Data

4. 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

5. 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.

6. 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

7. 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

8. 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

11. EPAZ(Eliminating Paediatric AIDS in Zimbabwe)

12. 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

14. Standard format of MSG meetings

15. 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

16. 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

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

18. 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

19. Tatenda! Mungode!Thank You All!