Uganda: Reproductive health, family planning and PMTCT

Reproductive health, family planning and PMTCT

Mildmay Uganda offers a range of services to young men and women, parents, and families with newborn children – these include a prevention of mother to child transmission (PMTCT) clinic, family planning services, breast and cervical cancer screening, screening for and treatment of sexually transmitted infections (STIs) and reproductive, maternal and newborn health services.

Joan Nangiya is the coordinator of reproductive health services at Mildmay Uganda. “If they have urgent questions they can be answered,” she said. “We mainly work with women, but more and more we are also encouraging male involvement in these services.

“For PMTCT particularly we need the father’s support. Men also need to come and find out how the babies can get infected. This is because in the African setting, it is the men who decide what happens in a family and without their support what we advise can end up being ignored.

“Women are so dependent on the men, so if we involve the men in PMTCT it will be a success. We are really trying hard to reach men. If the men make this move things are much easier for women.”

Around 70 couples every month are currently receiving PMTCT education and support at Mildmay Uganda.

Indeed, Mildmay Uganda’s reproductive health services are all about educating people and helping them make the right choices. The services are open to all clients cared for by Mildmay’s HIV programmes.

“We have people living with HIV who are wondering whether they can have a child. We work with them, partner with them through this process.”

Joan told of one HIV-positive woman, Gertrude, who had come to Mildmay with her husband and had initially wanted to terminate her pregnancy. Her CD4 count was high and the Mildmay team made sure she had all the information and knew all the risks. She carried on with her pregnancy. The baby, Edna, is now six months old and her first HIV test came back negative.

“First I wanted an abortion. I was scared because I have HIV and I was worried I would pass it to the baby,” said Gertrude, who has received care at Mildmay Uganda for three years.

“I came straight to Mildmay. My husband Moses came along too. We were given psychosocial support. In the end I had a normal delivery.

“I was very happy to find out that Edna was negative when she had her test at six months.”

Mildmay Uganda’s voluntary counselling and testing unit immediately refers any pregnant women to the PMTCT team which works to strict World Health Organisation guidelines.

“We give them letters to take to the hospital where they will give birth,” said Joan.  “We offer all PMTCT services here but one thing we can’t do is actually be there at the birth. That is out of our hands but we are trying to make sure they go to a reputable health facility.

“Ours is a holistic approach and it is the right approach. So far so good.”

However, some of the women who come to the PMTCT clinic have not disclosed their HIV status to their spouses. “That makes our PMTCT services a challenge – these women will not, or sometimes cannot, practice what we teach them.”

ACASI programme – The Last 1000 Infections

An exciting new project at Mildmay Uganda is The Last 1000 Infections – a research project with a day-to-day use backed by American donor Centers for Disease Control (CDC).

ACASI  stands for audio-computer self-aided interview. The system – effectively a counselling session with a computer – is designed to allow clients who have just tested for HIV to give frank answers to questions about their lifestyles, with particular reference to sexual behaviour, the buying and selling of sex, multiple partners, sexual preferences, the use of condoms, drug and alcohol use. The idea behind ACASI is that you can ‘discuss’ sensitive issues with a computer that you may not be willing to discuss in person.

The results of the CDC-devised interviews – which have different sets of questions for men and women – are used by researchers to analyse trends in new infections and develop a profile of groups most at risk of HIV in this region of Uganda. Only interviews with clients who test HIV-positive and whose answers suggest they have been infected recently are fed into the research. Strict consent must be given by clients for data to be used.

“The aim is to use this data to try to get the Ministry of Health to provide the relevant health services for these groups of people by demonstrating there is a need,” said Moses Ogwal, a data manager for the ACASI programme.

“At the end of the survey we are looking at producing a national report which we will publish and it will be for the benefit of the public.”

The ACASI programme runs on the same days as the Mildmay VCT (voluntary counselling and testing) tent – Mondays, Tuesdays and Thursdays. So far, more than 600 people have completed the interview since the project began in September 2010. It will run for about two years.

Interviews of those who test negative are discarded from the research, but a report is still attached to each client’s test results so the counsellor who tells them those results can also give the right advice and support to the client for the future based on their lifestyle.

“For the most part they appreciate the initiative,” said Mr Ogwal. “It’s entertaining, it’s private and they are comfortable with the questions. It’s a very good project, because it leads us to some concrete deductions.”

The Last 1000 Infections is a pilot project in Uganda and is run in partnership by the Ugandan School of Public Health, Makarere University, Mildmay International, CDC, the Ugandan Ministry of Health and the Office of the President.

Questions are in English and Luganda. For clients who cannot read, an spoken version is available.

MUTUNDWE HEALTH CENTRE

Once a month, a team of seven from Mildmay visits the Mutundwe Health Centre, on a steep hillside on the southwestern edge of Kampala.

The team that comes to Mutundwe includes two doctors, nurses, counsellors and a pharmacist delivering a range of HIV care, distributing lifesaving antiretroviral medication, and offering other services such as play therapy for HIV-affected children. It has been coming here for three years as part of Mildmay’s CDC-funded programme.

Mutundwe is one of nine health centres that receives a similar service from Mildmay’s peripatetic team. The outreach approach came about because the number of patients at Mildmay’s main centre at Lweza was becoming too large to handle in one location.

But taking HIV services to local communities also has distinct advantages, not least because many clients struggle to afford transport costs to access care and treatment in clinics far from their homes.

“I’m so glad Mildmay extended services to people around here,” said Barbrah Magoba, the manager of the Mutundwe Health Centre. “Previously people would have to go to other places but they could not afford the transport so they would not be able to access these services.

“People were very happy when services are extended to their home village – they can walk up here.”

Unsurprisingly, demand for HIV services at outreach clinics on the Mildmay day is overwhelming. The system would not be possible without the help of community-based volunteers (CBVs) trained on HIV counselling and drug adherence. By Mildmay, who else? There are 12 CBVs in Mutundwe who help organise the clinic day, which caters for well over 100 clients most of them (shopkeepers, motorcycle taxi riders, small business owners and smallholders) living on or below the poverty line.

Change and uncertainty, however, is afoot. Mildmay’s work in Uganda is moving into a new phase where the focus is on technical support rather than hands-on care and treatment. Indeed, in Muntundwe, the CBVs – who also make vital regular visits to those living with HIV in the community – have already switched to being managed by the Ministry of Health. Eventually, responsibility for the clinic days will also be handed over.

While acknowledging that the transition is a natural one, and that Mildmay cannot be around to support the Mutundwe Health Centre forever, Barbrah Magoba fears that quality of services may be affected by the handover.

“The clients don’t feel well because their services are going to change,” she said.

But Jolly Nakintu, a member of the Mildmay team, was on hand to offer reassurance: “Support will still be there.”

Nsubuga and Nampija

Nsubuga is 11 years old and is living with HIV.

His mother Nampija, who works as a news vendor, first received care for her HIV in 2005.

Her husband, Nusbuga’s father, died – although they had separated – and soon after she too became bedridden. That’s when she realised she was HIV-positive. She had TB as well and wondered if she would ever get better.

While Nampija received care, young Nsubuga fell through the cracks in the system and did not start treatment until much later. Thankfully, today, with Mildmay’s family based approach this could and would not happen, as when one family member comes into care for HIV, members of their family are also fully assessed.

Now the family is visited regularly at their home in Mutundwe by Grace, a Mildmay-trained CBV. Although things are still not easy, they are generally healthy, stick to their HIV drugs, and know where to turn to when they have problems.

Sophia and Douglas

Sophia, 31, was told she had HIV in 2007. Her son Douglas, six, was confirmed as HIV-positive at the same time. Sophia had not been tested during her pregnancy – which can prevent the transmission of HIV from mothers to their children.

At first, Sophia was in denial about having HIV – she started developing rashes, which she covered with extra clothes. Douglas, then only a toddler, also became very ill.  Sophia felt it was best to keep her illness a secret because of discrimination.

In fact, her fears were not unfounded. Despite her efforts, people around their home in Mutundwe saw her losing weight and looking unhealthy. She lost her job, and the man she had been dating promptly broke off the relationship. Douglas was treated “like a child with a disability”, Sophia remembers.

Then someone told her about the services offered by Mildmay Uganda. She went to a Mildmay run clinic and soon after she and Douglas began antiretroviral treatment.

They both returned to good health. When people first saw Douglas after treatment they could not believe it was the same boy. The fact that they both looked healthy seemed to reduce the discrimination they experienced.

“Discrimination comes with visible sickness – if you look well it doesn’t happen, even if they know they are HIV-positive,” says Grace, the Mildmay-trained community-based volunteer who visits regularly to offer counselling and drug adherence support to the family.

Today, every mother-to-be who visits Mutundwe Health Centre is tested for HIV, and if the test is positive is given Prevention of Mother to Child Transmission Support.

Sophia occasionally falls sick again now. She has a blood transfusion every now and then, and has had to change her ARVs. She has recently begun to lose weight again and, as a result, the discrimination has resurfaced. She cries because people point fingers at her. The neighbourhood still doesn’t know Douglas’ status.