Susan’s Lifesaving Pouches

Could a pouch the size of a ketchup packet revolutionize HIV preventive treatment in infants?

When Susan delivered her first baby at the local health center in southwest Uganda, she had no idea she had HIV. Susan had not attended any antenatal care visits. When she was diagnosed as HIV-positive, her baby was given Nevirapine as a prophylaxis, which she administered from a plastic bottle and with a syringe. The Nevirapine was meant to help prevent transmission of HIV through breastfeeding.

However, through testing, Susan learned that her baby boy had already acquired HIV while she was pregnant, and both mother and son were enrolled into antiretroviral treatment (ART).

When Susan fell pregnant again, she was careful to follow through on her antenatal visits. Through counselling and support from health care workers, she adhered to treatment in order to keep her viral load suppressed. After giving birth to her second son, once again she administered a regimen of Nevirapine.

While Susan welcomed the prophylaxis, she found it difficult to give Nevirapine to her infants.

“I was scared that I may not measure properly, especially when the numbers (calibration) became lighter on the syringe,” says Susan. “Sometimes I was just guessing. Boiling water on firewood to clean the syringe would take long. Also, when I would go on family visits or on the bus, everybody could tell what I was doing with this big bottle and syringe. They would talk about me and my baby, and it made me so sad. Sometimes I even delayed giving the medicine because we wanted to hide it.”

Ultimately, Susan’s second son tested negative for HIV, which made the precaution worthwhile.

Again, Susan fell pregnant with her third son. This time the situation got even better for her. While she was still pregnant, Susan was given starter pouches of Nevirapine. The health care workers explained this was to ensure mothers who may not give birth at the health center could start protecting their babies as soon as they were born.

Baby Isaiah is a “Pratt Pouch baby,” as Susan’s midwife, Annet, calls him fondly. This time Susan did not have to use the cumbersome bottle and syringe—instead she had sleek polyethylene packets, about the size of a ketchup packet, with pre-measured Nevirapine.

Susan smiles as she says, “When I pull these out, nobody knows what I am doing. I do not worry anymore about mistakes. There is no washing and boiling water and worrying about whether it is clean.” She says they are also easy to carry in her pocket if she has to travel with the baby.

Innovation in pediatric HIV care

Kabwohe Clinical Research Centre in Sheema district has fully embraced the Pratt Pouch innovation and the benefits it has brought to mothers and babies in their community.

Annet Buramye, a midwife at the center says that before the pouches mothers were stigmatized. She adds that most women found it difficult to dispense the Nevirapine from bottles using syringes.

”Even in the wards, the mothers were stigmatized,” says Annet. “Now when you think of a mother in the village with many children, [has] a lot of chores, travels far—[when] we are asking them to ensure they keep the bottle and syringe clean and measure correctly, it’s too much. By the time they put the fire on to boil clean hot water to wash the syringe and bottle, they have gone through a lot.”

“I remember we got many babies with infections because the bottles and syringes were not being washed properly,” says Nurse-midwife Pamela Atuhaire. “We were also worried about whether the dose was enough. When mothers came back for review we had no way of knowing whether they had measured the doses properly. Now when mothers come we take time to talk to them using the step-by-step guide on how they should use the pouches and when they should return for new pouches. We tell mothers to keep the old pouches so that we see and help them keep track how much medicine they have given, before giving them new medicine.”

With a seed grant from Saving Lives at Birth, Duke University’s Pratt School of Engineering developed the Pratt Pouch, a foilized polyethylene packet that can safe store antiretroviral medicine for up to 12 months. Integrating this technology into existing maternal and child health services is expected to simplify dosing and ensure that all HIV-positive women have access to the infant Nevirapine suspension for their HIV-exposed infants.

The easy-to-use pouches will empower women to immediately initiate antiretroviral treatment after delivery and/or bring their infants for postnatal care within 14 days. The primary endpoint will be the proportion of HIV-exposed infants receiving the full Nevirapine regimen from birth to 6 weeks of age.

The Elizabeth Glaser Pediatric AIDS Foundation (EGPAF), the Ugandan Ministry of Health, and Pratt Pouch Consulting are scaling up the Pratt Pouch innovation as an improved antiretroviral prophylaxis delivery mechanism in Uganda’s antenatal care, delivery, and postnatal care services. The initiative is expected to reach 11,000 infants in its pilot year across 262 health facilities in 17 districts in southwest and central Uganda.