Mary, 33 years old, is HIV positive and a mother of two, a girl aged 7 years and a 3-year-old boy. She acquired HIV from her husband and only found out when expecting her second child. The infection brought her a great deal of stigma both from her family and the community. Among the Giriama community of the Kenyan coastal region, HIV is associated with promiscuity; because Mary was the partner who tested positive, she was the focus of associated stigmatisation. After the birth of her second child, her husband gave into the societal pressure and abandoned her permanently. She is now a single mother. Mary’s second baby was expected to be born HIV positive.
The vertical transmission rates in rural Kenya were previously high when expectant mothers were not given proper care. But thanks to the prevention of mother-to-child transmission (PMTCT) programme, many HIVpositive mothers like Mary are giving birth to HIV-negative babies. Health-care workers, especially at Kenyan government hospitals and clinics—where the cost of treatment is cheaper—are often overwhelmed by the sheer number of patients. They have very little time to give advice on nutrition and better care to HIVpositive expectant mothers. Through the PMTCT programme Mary was lucky to have a mentor mother at the health facility where she received prenatal care. According to UNAIDS data from 2022, Kenya has made great progress in preventing new HIV infections among children, which fell from an estimated 17 000 in 2010 to 5200 in 2021. This has been possible through programmes such as the mentor mother initiative, which supports and cares for women living with HIV, the mother-and-baby pair approach, which synchronises appointments for mothers and their children at the health facility, and audits of every child exposed to HIV in order to identify barriers in accessing health facilities.
Mary told The Lancet HIV that her mentor mother, Jane, strictly ensured that she adhered to the medication and helped her deal with the stigma mentally. Mary got additional information about the antiretroviral drugs she was receiving, viral load, and drugs for children. Their mentor sessions often lasted for between 2 hours to 5 hours. Most were held at Mary’s home. A confirmatory HIV test for her child at the age 2 years showed that he was HIV negative. “My baby is a very normal baby, free of HIV despite the fact that I am HIV positive. This makes me happy as a mother all the time”, Mary told The Lancet HIV. Jane, 42 years of age has been a mentor mother for the last 9 years. Her joy and experience of giving birth when HIV positive to an HIV-negative baby was crucial in leading her to become a mentor mother.
The role of mentor mothers in the PMTCT programme is to help reduce vertical transmission rate in rural Kenya.
UNAIDS estimates that HIV transmission rates where mentor mothers are present in a community are three times lower than where they are none. The mentor mother programme also has a knock-on effect. It is helping spread PMTCT care. “We have two different mentor mothers, the community mentor mothers and those stationed at the health facility”, Jane told The Lancet HIV. “As a community mentor mother, you do home visits, talk to the mothers about HIV and adherence to the medication and ensure that they are taking the antiretroviral drugs as prescribed.” She added that the mentor mothers’ job is a voluntary role that she is happy to have, especially when she sees a young mother who was depressed about her HIV status living healthier and happier after disclosing her status.
“The biggest joy is also when a mother I have mentored delivers a baby free of HIV despite her being HIV positive”, said Jane. She noted that there are challenges, such as some mothers stop taking their medication after delivery and some even stop breastfeeding their babies for the fear of infecting them. “Most mothers default so much. Some mothers don’t follow the instructions given to them at the health facility and thus they infect their babies”, she said One of the greatest challenges for HIV-positive expectant mothers is their husbands not allowing them to disclose their status or not allowing them to take their antiretroviral drugs. Agnes, age 22 years, is HIV positive whereas her husband is HIV negative. They are serodiscordant parents to their 1-year-old son. Agnes found out that she was HIV positive when she went to the health clinic for her antenatal care. “I broke into tears not because of my status but because I knew my marriage was over”, she told The Lancet HIV.
Mentor mothers stopping vertical transmission in Kenya Peer support, advice, and counselling for pregnant women living with HIV and their partners are preventing new HIV infections in Kenya one child at a time, Christabel Ligami reports. “The role of mentor mothers in the PMTCT programme is to help reduce vertical transmission rates in rural Kenya.” Her husband was in denial and didn’t let her take her medication as prescribed by the doctor. To save her marriage she agreed to her husband’s demand and did not take her HIV treatment. She even changed her antenatal clinic. Fortunately, luck was on her side. When she visited her new clinic there was a group of mentor mothers on hand.
Agnes was introduced to one of them, a single mother of three kids. “Her story and counselling was an encouragement to me. I left the hospital with an open mind, that if my husband denies it and decides to leave, I will have no option but to let my marriage break and if he accepts it then we shall go through this together”, she said. “One thing the mentor mother told me was either way I have to decide if I want a healthy HIV-negative baby or an HIV-positive baby who will have a 50-50 chance of surviving”, she said. “I decided that all I wanted was to have a healthy baby.” Her mentor and two others visited Agnes at home to meet her husband and talk to him. After a long discussion and counselling her husband agreed to go for a HIV test. It came out negative. “It was such a relief to him”, Agnes said. Agnes’ mentor has been with them throughout the journey leading to the delivery of a baby boy. The couple are now waiting for another HIV test to be done when the baby is a year and a half old and at 2 years. “I am lucky that my husband has become so supportive and is willing that after 2 years we can have another baby”, Agnes said.
Kenya adopted the Mentor Mother Model as national policy as one of the core strategies in Kenya’s national framework for the elimination of mother-to-child transmission of HIV through the National AIDS and STI Control Programme (NASCOP). The mentor mothers facilitate HIV education through group health talks; provide advice and support to HIVpositive women and couples; follow up with HIV clients who have missed clinic visits for PMTCT; refer clients to PMTCT, maternal and child health, and HIV care. George Kesinger, the PMTCT lead at Kenya’s coast region told The Lancet HIV that mentor mothers support each other to have HIV-free babies, and healthy families.
In Mombasa there are around 45 mentor mothers. “The programme partners mothers in the community who are living with HIV with newly pregnant or breastfeeding women, to counsel and empower the new mothers to get tested for HIV, initiate treatment, reduce the risk of passing HIV to their children”, said Kesinger adding that for one to be a mentor mother, she has to be HIV positive whose child has, in the terms of the programme, “graduated”—or been declared HIV negative. “This means that the HIV mother followed the process and her child declared HIV negative at the age of 24 months. The mother too must disclose her status to her family and the public. She should be over 18 years.” The mentor mothers, he said are trained and employed partly by health facilities to support, educate and empower pregnant HIV-positive mothers and new HIV-positive mothers about their health and that of their newborn babies.
According to Kesinger, mentor mothers are important as they provide a safe, confidential and nonjudgmental space for mothers and their partners to receive information on how to live positively, protect and care for their infants and navigate the health system. Florence Murila, a paediatric doctor at Nairobi Hospital told The Lancet HIV that, vertical transmission of HIV is responsible for a significant majority of infections among children up to age 14 years. “In the absence of antiretroviral treatment [ART] and care for a HIV positive pregnant and lactating woman, the likelihood of passing on the virus to her child is 15–45%”, said Murila. “ART and other interventions such as the peer and mentor mother programme reduce this risk to below 5%.” This risk she said is reduced through the implementation of the PMTCT programme which provides a range of services to women and infants such as offering lifelong ART, supporting adherence to treatment, provision of safe childbirth practices, and appropriate infant feeding.
Within the PMTCT programme, infants exposed to HIV are also provided with virological testing after birth and during the breastfeeding period. In 2014, Kenya implemented WHO’s recommended option B+ guidelines in which all newly diagnosed HIVinfected pregnant women are immediately eligible for triple ART for life regardless of CD4 count. According to UNAIDS, Kenya has reduced the number of new paediatric HIV infections by 55% since 2009. An estimated seven of every ten pregnant women living with HIV are receiving ART, and national scale-up of the option B+ strategy for lifelong treatment is underway. Paediatric care is increasing, with 44% of infants exposed to HIV receiving early infant diagnosis and 73% of children living with HIV receiving treatment. Removal of maternity user fees has led to a 50% increase in institutional deliveries, and a rapid response initiative to identify and re-enroll pregnant women living with HIV who were lost to follow-up is among the innovations that have been implemented.