Preventing Mother-to-Child Transmission of HIV/AIDS in Africa: Opportunities and Challenges
- 1. Prevention of Mother to Child Transmission of HIV/AIDS in Africa: Challenges and Opportunities Lisa Bohmer, Former HIV/AIDS Director UNICEF/Ethiopia
- 2. Presentation Summary • Role of the Program Manager • HIV/AIDS epidemic and MTCT • PMTCT Summary and program components • Key issues and progress in Sub-Saharan Africa with a focus on Ethiopia • Challenges • Opportunities • Selected photos
- 3. My background • Domestic social work – homelessness and domestic violence during the later 1980s • International focus on reproductive and sexual health for past 12 years: adolescents, abortion, HIV/AIDS, empowerment of girls and women • Work throughout East and West Africa: research and program management • Spent the past two years with UNICEF in Ethiopia (five years resident in Ethiopia total) • MPH from UCLA in 1994
- 4. UNICEF’s HIV/AIDS Program in Ethiopia • Prevention of HIV/AIDS among young people (10-24 yrs) • Care and support for people infected and affected by HIV/AIDS– including orphans • Prevention of mother-to-child transmission of HIV/AIDS (PMTCT) • HIV/AIDS annual budget for Ethiopia was 3 million – total annual country budget was 45 million USD (rose to over 60 million in 2003 drought)
- 5. PMTCT Program Manager Roles • Utilize experts: Ob/Gyn and Pediatricians and research • Launch and sustain programs at large scale • Incorporate training, follow-up technical assistance and provision of equipment, drugs and supplies – lots of logistics • ADVOCACY – all levels • Building partnerships with government, NGOs, donors, clinical experts etc.
- 6. HIV/AIDS Epidemic • 38 million infected worldwide over past 20 years – young people 15-24 years now account for nearly half of all new infections worldwide • In 2000, an estimated 800,000 children were newly infected and over 90% live in Sub-Saharan Africa • Most infection (95%) in children occur as a result of mother-to-child transmission • HIV is reversing past gains against infant mortality in many countries
- 7. HIV/AIDS in Sub-Saharan Africa• SSA has just over 10% of the world’s population but 2/3 of all those living with HIV • New infections continue to increase – lots of country/regional variation • Women account for 57% of all people living with HIV/AIDS in SSA • Young women most disproportionately infected: ratio of young women to men is 4 to 1 in Kenya and Mali (we have data to same effect in Ethiopia)
- 8. HIV/AIDS in Ethiopia • Infection rates are believed to be increasing – 2nd most populated country in Africa: 71 million people • 1993: 3.2% adults infected – 6.6% in 2002 – ages 15-24 most infected • Urban areas most affected but spreading to rural areas (85% rural) • By 2001, 2.2 million people living with HIV/AIDS – 200,000 children under 5 • 1.2 million children under 15 orphaned by HIV/AIDS • Female Face of HIV/AIDS: More women than men are HIV infected • Ethiopia is one of the poorest countries in the world and less than 50% of the population has access to modern health services, 1/3 of the population lives on less than $1/day • TFR is 6.75%, MMR 1,800 per 100,000
- 9. Timing of Mother-to-Child HIV Transmission with Breastfeeding and No ARV Pregnancy Late Postpartum (6-24 months) Early Postpartum (0-6 months) Adapted from N Shaffer, CDC 5-10% 10-20% 10-20% Labor and Delivery Breastfeeding (24mos)
- 10. Of 100 HIV+ pregnant women, what percent of babies will be infected? 0 20 40 60 80 100 # uninfected # infected during BF for 2 yrs # infected during delivery #infants infected during pregnancy 63 babies will not become infected 15 15 7 # Babies Piwoz & Ross, 2002 63%63% 37%37%
- 11. 3. Prevention of Mother to Child Transmission • in late pregnancy • during labor • through breast- • feeding 2. Prevent unintended pregnancies in HIV+women Program Strategies- 4 Prongs 1. Primary HIV prevention in parents to be 4. Care and support
- 12. Prevention of transmission from an HIV-infected pregnant woman to her infant • Antiretroviral therapy - various regimens recommended; selection mainly based on cost and operational practicalities • Replacement feeding - when affordable, feasible, acceptable, safe and sustainable • Elective caesarian section - In European randomized trial transmission dropped from 10.7% to 1.7% • Making vaginal deliveries safer- Limiting episiotomies, avoidance of traumatic deliveries, delaying rupture of membranes • Screening and treatment of STD and malaria
- 13. PMTCT Services include • Education, Voluntary Counseling and Testing for all women as part of Ante-natal care within hospitals and health centers • Counseling on breastfeeding choices • Referrals to community-based care and support • Continued care and support after delivery
- 14. Anti-Retroviral Treatment • A drug called nevirapine is given to the mother at the onset of labor (self-administered by most Ethiopian women) • Neviripine is given to the newborn baby in the first 3 days of life – this may decrease the risk of infection to the baby by half! (now only available in health facilities despite concern that many infants will not be brought on time) • It is not a treatment or cure for the mother • On-going anti-retroviral treatment for the mother is currently being planned for (PMTCT+) – a number of SSA countries currently initiating • Free donation program exists to Ministries of Health • Other regimens are also used (AZT and nevirpine), but current neviripine only most commonly used in low resource settings
- 15. Counseling on infant feeding • Breastfeeding is best but can lead to the baby getting HIV. The risk of not breastfeeding must be balanced with the risk of breastfeeding • Breastfeeding provides protection from death due to diarrhoeas and respiratory infections – during the first two months of life a child receiving replacement feeding is nearly 6 times more likely to die from infectious diseases compared to a breastfed infant • Women are counseled to assess their situation and make their own choice • If breastfeeding is chosen, they are instructed to give ONLY breast milk without other food or liquids for six months and then to wean – mixed feeding is very common and a real concern • Formula is a safe option for infant feeding only when it is affordable, safe (clean water) and acceptable to the mother and others in her household
- 16. Care and Support • HIV positive women and their families need care and support to live well with HIV. Care includes: • Treatment of infections • Good nutrition • Social support: counseling, acceptance from family and community members • ARVs when available • Plan for care of children when the mother or fathers becomes sick and dies: including memory books • Home-based care when family member is bed-ridden with AIDS (in SSA 4.3 million need HBC, but only 12% are receiving it) • Currently this area is not well addressed – particularly the area of social support
- 17. 11 UN-Supported Pilot PMTCT Programs Initiated 1999-2000 Honduras Ivory Coast Botswana Uganda Zimbabwe Zambia Kenya Rwanda Burundi Tanzania India
- 18. What have the outcomes been so far? Cascade of interventions and challenges Pregnant Results given HIV positive ARV initiated ARV completed Safer infant feeding Infections averted Test accepted Pre-test counselling ANC Communication can contribute to improving this cascade 0 20 ,000 40 ,000 60 ,000 80 ,000 100,000 120,000 140,000 160,000 ANC 137,575 Counselled (62%) 85,980 HIV tested (70%) 59,985 HIV infected (16%) 9,842 Mothers on AZT/NVP (40%) 3,941 Numberofpregnantwomen Source: UNICEF Oct 2001
- 19. PMTCT in Ethiopia: • UNICEF and MOH began in four sites during June – October 2003 (it took nearly 3 years to launch following development of guidelines and an ARV policy). As of mid-2004: • 2,272 pregnant women counseled • 1,203 tested, 122 tested positive • 42 women received NVP, 25 delivered • 22 infants received NVP (RESULT) • These sites are now expanding to 20 satellite sites – mainly health centers • Generally – update has been slow due to various factors • An additional 23 sites started in 2004 funded by the USG – rapid expansion is taking place given these funds and Global Funds
- 20. Challenges: Stigma • Fear of disclosure and stigma means low uptake of VCT and ART • Without availability of ARVs – many don’t want to know their status • Beliefs may include idea that first person to be tested will be blamed for bringing HIV into relationship • Male partners may react with violence if a woman discloses that she is HIV+ • Stigma associated with not breast feeding and with not exclusively breastfeeding also a concern • Community-level activities, work with the media, etc. key for addressing stigma
- 21. Challenge: Safer Labor and Birthing Practices • Ideally pregnant women with HIV deliver in a hospital or health center • The doctor, nurse or midwife can use practices in labor and delivery which will reduce the risk of MTCT • Need to work with community-based health workers such as TBAs in places where most deliveries are at home such as Ethiopia • Opportunity to link with safe motherhood efforts
- 22. Counseling on infant feeding • This area is still confusing – need clear messages, good counseling and the research is still in progress • Not all health workers make good counselors despite training efforts • Most pregnant HIV positive Ethiopian women chose to continue breastfeeding as replacement feeding was not feasible • Lots of education and advocacy necessary so that policy makers and program managers understand the appropriate use of formula within PMTCT programs • Opportunity to increase exclusive breastfeeding in resource poor settings such as Ethiopia
- 23. Some key challenges • Keep focus on women and children as programs shift from PMTCT to ARVs for all • Ensure that ARV efforts adequately address nutrition • Coordination of programs by different actors at the national level • Avoid erosion of the national health care systems as NGOs establish parallel systems • Reaching women and children in rural communities • Addressing gender discrimination that puts girls and women at risk • Increasing low rates of antenatal care attendance • Limited ability of some governments to utilize HIV funds
- 24. Key challenges continued • Ensuring that newborns receive a dose of ARV within 72 hrs after birth • Addressing stigma, gender and promoting care and support so that PMTCT programs don’t increase the burden on women • Unrealistic targets imposed from Washington for the Pepfar initiative of the US Government (Ethiopia is very different from Botswana) • Ensuring a steady supply of key supplies and equipment such as test kits and drugs
- 25. Opportunities • Increased funding now available • Use PMTCT funds to improve antenatal care services • Integrate PMTCT as part of other efforts such as safe motherhood, malaria control, integrated management of childhood illness, voluntary counseling and testing in the broader community • Integrate family planning and HIV/AIDS prevention efforts • Improve care and support for positive women and their families • Integrate within existing youth-driven prevention activities, Anti-AIDS clubs etc.
- 26. Opportunities continued • Use the fact that more women and girls are HIV+ to direct attention to the role that gender discrimination and gender-based violence in increasing risk • Provide PLWAs with opportunities to gain skills in counseling and other care and support activities (move from victims to key actors) • Prioritize pregnant positive women for free ARVs
- 27. Roles for communities • Strong community participation component beneficial although not very common: community dialogue approach showing good results in Southern Ethiopia • Outreach education should target men as well as women • Engage People Living with HIV and AIDS to promote positive living and reduce stigma • Encourage all pregnant women to receive antenatal care • Encourage voluntary counseling and testing for all • Encourage short-term exclusive breastfeeding
- 28. Conclusion • Much is happening to increase access to ARVs – soon HIV/AIDS will not mean a death sentence! • PMTCT is a challenging, complex program that can make a difference and improve MCH overall – needs to be part and parcel of other prevention and care efforts • Despite the devastation caused by HIV/AIDS in African countries- there is much to be hopeful about – many talented and committed Africans are leading innovative efforts that could be scaled…..