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Outline of ZVITAMBO'S PMTCT work
ZVITAMBO
February 2004

Introduction
Since the start of the HIV epidemic, nearly 4 million children have died of AIDS throughout the world. More than 90% of these infants acquired the infection from their mother during pregnancy. Not only is MTCT the primary cause of AIDS in children, it accounts for more than 10% of all new infections each year.

In Zimbabwe, the epidemic has escalated at an alarming rate resulting in the country having one of the world's highest HIV infection rates: 25% of its adult population (25-45 yr) are infected. Among antenatal women the prevalence is even higher. Among HIV positive pregnant women, about 30% will transmit the virus to their infant sometime during pregnancy, delivery or breastfeeding. Thus, of the 372,000 babies born in Zimbabwe each year, some 120,900 are born to HIV positive mothers and 36,270 will be infected with HIV unless interventions to reduce MTCT are implemented.

Over the past five years, affordable, feasible, and effective interventions for reducing MTCT and prolonging quality survival among infected infants and women in resource-limited settings have become available. These include provision of antiretroviral drugs to HIV+ mothers and their babies, modifying infant feeding practices, micronutrient supplementation, and prophylaxis against opportunistic infection. A critical requirement to success of these programs will be increasing awareness of MTCT issues among men (husbands, partners, fathers) and gaining their involvement in and support of the process. What remains is to build the systems to deliver these interventions.

ZVITAMBO
The ZVITAMBO project started life as a randomized clinical trial of the effect of large dose post-partum vitamin A supplementation on infant mortality, breast milk transmission of HIV, and new maternal HIV infections among 14,110 mother-baby pairs recruited shortly after delivery in health facilities in and around the City of Harare. Enrolment was completed in January 2000, and clinical follow up ended in April 2001; data analysis, laboratory analysis, and reporting of findings continue. To carry out ZVITAMBO, a physical infrastructure of laboratories, clinics, and data management was established, and, more importantly, a multi-disciplinary team acquired expertise and experience relevant to addressing the complex problems of women and children affected by HIV/AIDS. At peak workload, ZVITAMBO employed 175 people including nurse-counselors, laboratory technologists, and information managers working together in an integrated system. Of these, 10 people formed the leadership: 2 nurse midwives, a social worker/counselor/nurse/midwife, 3 data management and analysis experts, a paediatrician, a public health scientist, and an administrator/accountant.

Since October 2001 this group has been offering technical assistance to hospitals wishing to incorporate, into their regular services, work directed at preventing mother to child transmission of HIV. ZVITAMBO started work with St Theresa's Hospital (Roman Catholic, Dominicans) in Chirumhanzi (Midlands) towards the end of 2001, then with a group of three mission hospitals (RC and Elim Pentecostalist) in Nyanga North in October 2002, and with another group of three mission hospitals (RC and Anglican) in Mutasa District in July 2003. Towards the end of 2003 we began training and "jumpstarting" the three Methodist hospitals of Mutambara (Chimanimani District), Nyadiri (Mutoko) and Old Mutare (Mutasa). All these hospitals are all now delivering "PMTCT" as an integral part of their services.¹

The primary objective of ZVITAMBO is to provide technical and material support to about 20 rural mission hospitals for HIV care and prevention services for women and children. The services provided include:

1. HIV counseling and testing for antenatal women and their husbands.
2. Infant feeding education and counselling for all couples (HIV positive, negative, and of unknown status).
3. Nevirapine prophylaxis for HIV positive women and their infants.
4. Cotrimoxazole prophylaxis for pregnant women with clinical AIDS and for babies born to HIV+ women.
5. Micronutrient supplementation, to be reviewed in light of on-going research findings.
6. Infant HIV testing (by PCR) at 6 months.

Funding
After initial "bridge" funding from Catholic Relief Services (CRS), a 3 year grant was agreed with the Canadian International Development Agency (CIDA) starting in April 2003. A mid-term review of the project is expected to lead to a substantive extension.

Roles and Responsibilities of Each Partner

ZVITAMBO

1. Training
ZVITAMBO provides training on counselling, technical information on MTCT, clinical care specific to HIV/AIDS in women and children, administration of drugs in the PMTCT program, care of the care-giver (special focus on helping nurses cope with how HIV/AIDS affects them personally), analysis of blood specimens by approved rapid HIV test kits, preparation of infant blood samples for infant HIV diagnosis; accurate and confidential record, and monitoring and evaluation procedures and systems. Both intense initial training and follow-up supportive training are provided.

2. Procurement of supplies and equipment needed for PMTCT services
ZVITAMBO will facilitate delivery of HIV test kits and nevirapine, both currently provided free to the GoZ. In extreme cases of shortages, when the government is unable to supply, ZVITAMBO will make up the shortfall. ZVITAMBO will provide other required supplies and equipment needed for HIV testing, counselling materials and training tools, cotrimoxazole and other priority drugs, and monitoring and evaluation equipment and supplies, TV and video.

3. Monitoring and evaluation
ZVITAMBO will provide on-going monitoring and evaluation of PMTCT services delivered at each of the sites we support, providing rapid feed back to the site, the PMTCT coordinator at the MoH, and the donor, and taking swift action to rectify errors encountered.

4. Research
ZVITAMBO will conduct, as appropriate and relevant, and with partners who are willing, operational and clinical research to learn how to deliver PMTCT services better.

5. Logistics
ZVITAMBO will arrange transport of specimens from the sites to Harare for external quality control and infant diagnosis.

6. Salary support
ZVITAMBO provides salary support for 2-4 local staff - especially auxiliary staff local to the area who can relieve nurses and lab technologists, freeing them to carry out PMTCT activities.

Partner Hospital

1. Implementation
Assume responsibility for implementing the program: recruit and pay salaries of most staff to carry out the additional responsibilities of the MTCT program.

2. Negotiations
Carry out all negotiations with local and national authorities (government and church).

3. Liaison and Community mobilisation
On-going liaison with health clinics in the district in collaboration with the District Nursing Officer, Community Sister, Provincial Medical Director (PMD), and community leadership, keeping them informed about the PMTCT program and updating them on its progress.

4. Integration
Integrate PMTCT activities into other HIV/AIDS programs as planned with ZVITAMBO support. Liaise with other local ASOs. Refer clients from PMTCT to other services as appropriate.

5. Reporting
Generate and submit statistical reports to ZVITAMBO. Generate and submit other reports as required by local ministry, government, or church authorities.

Successes
Hospitals which have severe resource limitations have enthusiastically and successfully integrated PMTCT work into their regular MCH/FCH work.

Uptake (ie proportion of mothers accepting HIV testing) has been 80-90% in some hospitals with 90+% of HIV+ mothers and their babies being given nevirapine.
Progressive collaboration with the district teams involved in PMTCT work at government hospitals and clinics has occurred.

Hospital staff have reported that after some months of PMTCT work at the hospital the level of stigma surrounding HIV/AIDS in the community has perceptibly lessened.

Challenges
The degree to which the Community has been sensitised has been a significant factor in uptake in some areas.
Postnatal follow up during the critical phases of infant feeding is very difficult.
In some hospitals staff shortages are so extreme that the additional burden of PMTCT counseling is problematic.

ZVITAMBO's philosophy aims to embrace

• (1) Ownership - of the work by the hospital,
• (2) Partnership - between hospital and ZVITAMBO,
• (3) Integration - of PMTCT activities into regular hospital work,
• (4) Quality - of work,
• (5) Investment - by both partners, especially in energy and time at the outset,
• (6) Sustainability - such that if ZVITAMBO left, high quality PMTCT work would continue.

The field of PMTCT work is new and changing rapidly, both in terms of scientific advances and in the attempt to "scale up" services to full national coverage. ZVITAMBO intends to maintain a flexible approach to the development of partnerships in terms of their scope and their detailed content. The intention is to work with mission hospitals to incorporate into their regular services, effective high quality work aimed at mitigating the effects of the HIV epidemic.

1 As of May and June 2004 ZVITAMBO has begun working with 4 Mission Hospitals in Masvingo Province: Morgenster (Reformed Church, Masvingo District), Musiso (Catholic, Zaka), Silveira and Mashoko (respectively Catholic and Church of Christ, Bikita).

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