LEGETAFO and ALEM BANK, Ethiopia—In 24 months, 1,919 babies have been delivered in government health centers in these two communities, and only one of them has been found HIV-positive. That’s a pretty good performance, even in a country with a relatively low 1.5% adult HIV prevalence.
It’s not that no HIV-positive mothers were detected. On the contrary, 30 HIV-positive women delivered babies in Alem Bank and 11 in Legetafo. But only one of the babies was HIV-positive (although there were a number of HIV-positive pregnant women who had not yet delivered as of May 1). This baby is on antiretroviral treatment and doing fine.
Though I have been deeply involved in HIV prevention for almost 20 years, this was my first time to see a prevention of mother-to-child transmission (PMTCT) program up close and personal. It happened while I was visiting IntraHealth’s program in these two communities: Alem Bank, an urban clinic in the Kolfe/Keranyo neighborhood of Addis Ababa serving 127,447, and Legetafo, a peri-urban clinic in Oromia Region about 22 kilometers northeast of Addis serving 14,580.
Findings from the 2011 Demographic and Health Survey (DHS) for Ethiopia show the need for PMTCT:
- Only 11% of women received HIV counseling, an HIV test, and the results during antenatal care for their most recent birth in the two years preceding the survey.
- Overall, 42% of women and 47% of men know both that HIV can be transmitted through breastfeeding and that HIV-positive women can reduce the risk of mother-to-child transmission by taking special drugs during pregnancy (this knowledge has increased dramatically since 2005, when it was 20% for women and 26% for men).
Before IntraHealth started its PMTCT work in Ethiopia in 2003, such services were not available at any government health center in the country. Now they are available at 499 facilities. Alem Bank and Legetafo are two of those health centers that help newborns stay HIV-positive and give prospective and new mothers the care and counseling they need if they are HIV-positive.
How have they done it? I don’t know all the secrets to their success, but I was impressed by three things:
- Mothers’ Support Groups: IntraHealth has introduced Mothers’ Support Groups at most of the 511 centers it supports in the country, a peer education initiative that utilizes two HIV-positive “mentor mothers” in each center to help other HIV-positive mothers care for themselves and their children. As soon as a woman is tested HIV-positive, she is enrolled in the program, and after the birth of her child, the woman is visited at home weekly by one of the two HIV-positive mentor mothers on staff at each center. The mentor mothers have a tracing mechanism to track down women who disappear from the program.
- A focus on HIV testing: The health centers I visited have a singular focus on counseling and testing of all partners involved—the woman, her husband/partner, and their child—at all stages of the process. Women are strongly encouraged to be tested, as are the partners, if they can be found. Ideally, this happens before delivery but, if necessary, can be done right up to childbirth, a practice known as “couch counseling.” Getting the partners tested is a major challenge but Zebene Tefara, the manager of the Legetafo center, told me it has improved since PMTCT was introduced. It used to be zero. In the last 10 months, 260 partners were tested at Legetafo, and only 4 of those were found HIV-positive.
- Innovation in customer service: The concept of “keeping the customer happy” is too often alien to the public health cultures of many African countries. But it seems to be catching on in Ethiopia, at least in Alem Bank and Legetafo, where the health centers are making sincere and surprising efforts. At Legetafo, Tefara and his staff proudly showed me around the center and described steps they are taking to improve customer service. He pointed out a suggestion box (an innovation in Ethiopia) that has been installed as well as monthly ratings of his staff—based on the comments dropped into the suggestion box—which are posted prominently. Also unusual are the traditional coffee ceremonies that have been introduced for the pregnant woman and her partner just before childbirth in both health centers. It’s the little things like these—along with simple respect and courtesy toward the patient—that IntraHealth hopes will bring people back to the center again and again.
And getting them to come to the center is a major goal of these health centers, especially for PMTCT and for antenatal, childbirth, and postnatal care but also for family planning, immunization, laboratory services, and other types of outpatient services.
The 2011 Demographic and Health Survey indicates that only 10% of deliveries take place within health facilities (although that represents a doubling of the 5% who did so in 2005). Clearly, these two centers are on the leading edge of that positive trend.