WINDHOEK - The rate of HIV infection from mother to baby is hitting a record low in Namibia. Health facilities across Namibia are celebrating zero new infant infections. This means that Namibia is on course to eliminate mother-to-child transmission over the next few years.
However, there are still some gaps that need to be addressed in order to achieve elimination status as defined by the World Health Organization (WHO).
The US President’s Emergency Plan for AIDS Relief (PEPFAR) began its partnership with the Namibian government in the fight against HIV and AIDS in 2003. At that time, over 30 percent of babies born to HIV-positive mothers were being infected with HIV through mother-to-child transmission.
Using the support provided by PEPFAR to the Ministry of Health and Social Services, through agencies such as the Centers for Disease Control and Prevention Namibia (CDC Namibia), much has changed in the last 15 years.
Development Aid from People to People Total Control of the Epidemic (DAPP TCE), an organization supported by CDC Namibia, is one of the community-based organizations supporting the Ministry of Health and Social Services to close the gaps.
According to TCE field officers, there are three key factors helping Namibia achieve sites that have zero cases of HIV-positive infants, namely: early HIV diagnosis; correct adherence to antiretroviral therapy (ART) medicine; disclosure of HIV status between partners and regular antenatal care (ANC) clinic visits throughout pregnancy and during the breastfeeding period.
The sooner a pregnant or breastfeeding woman is diagnosed as HIV positive, the sooner she can be put on treatment. Correctly taking ART requires the mother to take a pill at the same time every day.
This enables the mother to become “virally suppressed” – in other words living with an extremely small amount of HIV in her body – greatly reducing the risk of HIV spreading from that person to another.
This is because when HIV is virally suppressed, the virus becomes undetectable, and when the virus is undetectable, it cannot be transmitted.
Edinah, a TCE field officer, uses this analogy with her clients: “Some women are scared, because they do not understand HIV. So, I explain to them nicely that just like you can stop a sifwinkoli (a beetle) from running by putting a brick over it, you can also stop your HIV from spreading to your baby, but you must take your strong ARV medication every day, like the strong brick, to stop that virus.”
In order to end mother-to-child transmission of HIV, one of the biggest gaps to address is focusing more attention on women who stop taking ART while pregnant or breastfeeding. Known as “defaulting,” this can be prevented by encouraging women in various ways.
“Our most important task is to visit the mother and baby often, just like visiting your friend or family, supporting the mother and baby with love,” explained Josephine.
TCE field officers know the pregnant women and breastfeeding mothers in their communities well and monitor them very closely to ensure that they attend all clinic appointments and take their ART correctly. Most of the cases of mother–to-child transmission in Namibia occur during the breastfeeding period because the mothers stop taking their ART medication for one reason or another.
However, when ART medication is taken properly during the breastfeeding period, there is a very low risk of passing the virus to the baby.
In Namibia, healthcare providers offer all pregnant women an HIV test at their first ANC visit. Partners are also strongly encouraged to get a HIV test, regardless of the woman’s status. According to TCE field officer, Charity, “One challenge is when a pregnant woman learns that she is HIV positive during her ANC visit. She will normally be scared and might delay telling anyone. Then, she will often default on taking medication.” Charity and other TCE field officers work to establish “trios,” or a group of three people that includes one person living with HIV and two treatment supporters, often family or close friends, who encourage good adherence to medication and a more comfortable environment free from hiding pills.
Antenatal care visits are an important part of any pregnancy for overall observation of a healthy pregnancy, STI screening, and any necessary counselling. If a woman attends ANC visits, she is also more likely to give birth in a health facility.
Home births without sufficient medical support and access to hospital services can be unsafe, especially for a woman with HIV, because complications may occur and, without the correct medical resources, the risk of HIV transmission to the baby and anyone assisting with the birth is increased. Women should visit a health facility and register for ANC as soon as they know that they are pregnant in order to monitor the entire process of pregnancy closely.
TCE field officers routinely travel door to door in their catchment areas for the majority of their work: testing and tracing clients. During these visits, they routinely ask whether anyone in the household is pregnant. This procedure helps identify women who may not have visited the health facility yet for their first ANC visit. Field officers then offer to accompany the soon-to-be mothers to the clinic to register for ANC. “Immediately when they start ANC,” explains Josephine, a TCE field officer from the Zambezi region, “we are with them. We monitor, support, and educate the women about how to be healthy.”
People in the Zambezi region are extremely mobile and tend to shift frequently between distant fields and homesteads, therefore attending a variety of clinics.
To strengthen the support for these mobile mothers, the Ministry of Health and Social Services, through support from CDC Namibia, is rolling out innovative technology called Patient-Tracker, or P-Tracker for short. P-Tracker is able to track women across different facilities, so if a woman attends ANC services at a different clinic, the system will allow the nursing and clinic staff to see that she has visited another clinic.
This helps to reduce the number of cases considered lost to follow-up. Additionally, all infants that are at high risk of contracting HIV from their mothers are entered into the P-Tracker system as soon they are identified.
“High risk” includes a variety of reasons, such as a mother who did not know her HIV status and was not on ART medication when she became pregnant or had a high viral load prior to delivery or during the breastfeeding period. Through the electronic P-Tracker system, when the mother and baby visit a clinic – whether their home clinic or another clinic that uses the technology – the medical history for the mother is available on the computer. The Zambezi region is rolling out P-Tracker at 17 clinics and the main hospital and the system is being rolled out to more than 215 MOHSS health facilities across Namibia, with roll-out completion expected by March 2019.
Achieving an HIV-free generation
The successful implementation of Namibia’s test-and-treat policy is another of the reasons why Namibia is moving towards the elimination of mother-to-child transmission of HIV. Test and treat is where a person who is tested and found to be HIV positive is immediately started on ART.
For pregnant HIV-positive mothers, when the baby is born, healthcare providers start the infant on ARV medication for HIV prevention for extra protection during the first four weeks. Nurses test babies for HIV at birth, 6 weeks, 9 months and 18 months of age.
Support for the mothers is vital and the success of this support is worth celebrating. For example, after a negative HIV test at 18 months, TCE invites the mother and baby to celebrate the very high chance that this baby will live free from HIV.
In Zambezi region in 2017, TCE celebrated this achievement with 29 mothers and babies.
Edinah concluded, “The most important thing is that the mother knows that you care about her life and her baby’s life.”