Virtual elimination of mother-to-chilfd transmission of HIV:

progress, remaining challenges, opportunities and way forward

Rene Ekpini ESenior Adviser

UNICEF, New York

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Botswana

Mozambique

Haiti

Cote d'Ivoire

Rwanda

PMTCT Total prevention Care & Treatment

Expenditure in HIV care and treatment, prevention and PMTCT in selected

countries

Source: UNAIDS 2008 Global Report

Source: UNAIDS 2008 Global Report

Remaining challenges-1

• Lack of translation of political commitment into

catalytic

actions with accountability mechanisms at the

country

level between central and sub-national authorities

and

health management structures

• Donor-driven programmes with limited national

ownership, parallel funding, M&E and PSM systems

with

concentration in limited urban settings

• Weak health systems with low access to and

uptake of

services, the use of less efficacious interventions

(e.g. Sd-

NVP) and poor continuum of care for mothers and

children

• Lack of translation of political commitment into

catalytic

actions with accountability mechanisms at the

country

level between central and sub-national authorities

and

health management structures

• Donor-driven programmes with limited national

ownership, parallel funding, M&E and PSM systems

with

concentration in limited urban settings

• Weak health systems with low access to and

uptake of

services, the use of less efficacious interventions

(e.g. Sd-

NVP) and poor continuum of care for mothers and

children

0

20

40

60

80

100

120

Countries

Perc

enta

ge

ANC HIV T&C

The gap between antenatal care The gap between antenatal care coverage and HIV testing and counseling coverage and HIV testing and counseling

in the context of PMTCT in selected in the context of PMTCT in selected countries – 2007countries – 2007

Building up PMTCT on weak health systems in resource-limited settings

9196

6874

60.5

43.4

0

20

40

60

80

100

120

Malawi Zambia

1+ visit 4+ visits Births with skilled attendant

Sources: 1- ANC coverage: Antenatal care in developing countries-Promise, achievements and missed opportunities – An analysis of trends, level and differentials, 1990-2001 updates 2- Skilled attendant at birth 2006

Coverage of antenatal care and skilled attendant at birth

50

65

32

47

1721

1216

0

10

20

30

40

50

60

70

Malawi Zambia

HIV T&C ARV for PMTCTInfant ARV for PMTCT CTP for infant by 2 months

Coverage of PMTCT services

8

2.2

25 25

19.5

17.2

0

5

10

15

20

25

30

Sd-NVP AZT/ Sd-NVP

tran

smis

sion

ra

te (

%)

In PMTCT programme Outside PMTCT pg All

Current system performance (KZN province)

Attend ANC clinic 92%

Counseled and tested for HIV, CD4 75%

Get ARVs (pre- and perinatal) 50%

Adapted from Pierre Baker & Nigel RollinsAdapted from Pierre Baker & Nigel Rollins

8

2.2

25 25

11.1

6.1

0

5

10

15

20

25

30

Sd-NVP AZT/ Sd-NVP

tra

nsm

issi

on

ra

te (

%)

In PMTCT programme Outside PMTCT pg All

95% efficiency of the system (KZN province)

Attend ANC clinic 92%

Counseled and tested for HIV, CD4 95%

Get ARVs (pre- and perinatal) 95%

0

10

20

30

40

50

60

70

80

90

nutritionduring

pregnancy

Familyplanning

Preventionof STIs

Measurefoetal

heart rate

Partographever filled

in

Checkuterine

retraction

Perc

enta

ge

Before PMTCT After PMTCT

Individual counsellingIndividual counselling

Quality of antenatal and delivery care before and after the implementation of

PMTCT; Cote d’Ivoire

Therese Delvaux et al.Therese Delvaux et al.

Impact of PMTCT on institutional deliveries in Rwanda – HIV-positive

women

69%

72%

80%

87%

89%

31%

28%

20%

13%

11%

0% 20% 40% 60% 80% 100%

2004 (N= 412)

2005 (N=499)

2006 (N=966)

2007 (N=1,053)

2008 (N=1,253)

At health facility Home

Bangendanye, L; Price, J.E.; Micomyiza E.; Shumbusho F.; Wesson Bangendanye, L; Price, J.E.; Micomyiza E.; Shumbusho F.; Wesson

In the general population 45% of women delivered at HF (IDHS 2007-08)

In the general population 45% of women delivered at HF (IDHS 2007-08)

Remaining challenges - 2

• Insufficient integration and linkages within

maternal,

newborn and child health services, and other sexual

and

reproductive health services, including family

planning

• Limited resources and operational guidance for

effective

implementation of primary prevention and

prevention of

unintended pregnancies among women living with

HIV in

the specific context of PMTCT

• Insufficient integration and linkages within

maternal,

newborn and child health services, and other sexual

and

reproductive health services, including family

planning

• Limited resources and operational guidance for

effective

implementation of primary prevention and

prevention of

unintended pregnancies among women living with

HIV in

the specific context of PMTCT

Preventing HIV infection in women

Preventing HIV infection in women

Preventing HIV infection in all women

(and their partners)

Preventing HIV infection in all women

(and their partners)

Preventing HIV infection in pregnant women(and their partners)

Preventing HIV infection in pregnant women(and their partners)

Within national multi-sectoral

prevention strategies

Specific interventions targeting

pregnant women

PMTCT as an opportunity to operationalize combination

prevention

• Provide HIV testing and counselling at family planning clinics (on-site or through referrals)

• Provide FP services with focus on condom-based dual protection at PMTCT sites, STIs clinics and ART centers

• Provide access to emergency contraception services and post-abortion care services

• Capacity-building of service providers in addressing SRH needs and rights of women living with HIV

Prevention of unintended pregnancies among women living with HIV

Remaining challenges-3

• Lack of operationalisation of community-based

interventions (lay counselors, peer support

groups, Mother2Mother) as integral components of

national scale-up strategies

• Poor data collection, reporting, analysis and use,

and

limited capacity for operation research to inform

policy formulation, advocacy and programming

• Lack of operationalisation of community-based

interventions (lay counselors, peer support

groups, Mother2Mother) as integral components of

national scale-up strategies

• Poor data collection, reporting, analysis and use,

and

limited capacity for operation research to inform

policy formulation, advocacy and programming

Opportunities

• Current momentum for health systems strengthening (IHP+, H4, etc)

• Current momentum for virtual elimination of mother-to-child transmission of HIV

⁃ UNAIDS joint programme: focus of all the UNAIDS cosponsors on PMTCT as a priority area by making the resources of the UN work for results at the country level

⁃ The Global Fund has declared PMTCT a priority: reprogramming existing grants to accelerate scale-up in 10 countries (Ethiopia, Kenya, Malawi, Mozambique, Nigeria, South Africa, Tanzania, Uganda, Zambia, and Zimbabwe)

⁃ PEPFAR’s second five-year authorization includes as target PMTCT coverage of 80%

Global strategic vision for virtual elimination of mother-to-child

transmission of HIV - 1

1.Strategic shift from HIV infection averted and HIV-free survival focus towards the overall goal of improved maternal and child health and survival for an HIV-free and AIDS-free generation

2. Increasing access and coverage by bringing services

closer to those in need through decentralization and

devolution to subnational authorities and subnational

health management structures

Global strategic vision for virtual elimination of mother-to-child

transmission of HIV - 2

3.Using implementation of PMTCT as an opportunity to strengthen health systems with special attention to MNCH services

4. Operationalising integration and linkages within

MNCH services, other SRH services including FP and

HIV care and treatment services to ensure better

continuum of care for women and children

Way forward -1 1. Alignment and harmonization among national programmes

(HIV/PMTCT, MNCH, Nutrition, SRH, …) and partners around population-based national scale up plans and sub-national operational plans to address programme fragmentation and parallel funding

2. Promoting and supporting decentralisation and devolution: operationalizing planning, financing and implementation of decentralised delivery of services using sub-national level as unit of planning, implementation and M&E and making resources available

3. Scaling up innovations as integral components of continuum of care for children and mothers (Point of care CD4; Mother-Baby-Packs; Rapid SMS) to accelerate expansion of services

Way forward - 2•

4.Making resources available and fostering sustainability through induction of changes in resource allocation including innovative approaches such as performance-based financing

5. Improvement of infrastructure and equipment, optimizing working conditions, and improve efficient delivery of services:

- Rehabilitation and equipment of ANC, delivery care, laboratory and pharmacy facilities

- Reorganization of service delivery mechanisms

Way forward - 3

4. Closing the gap between health facility-based approach and communities through partnering with individuals, families and communities, including PLWH and male partners in service provision, curbing stigma and discrimination and demand creation

6. Closing the knowledge gap through promotion of and support to impact evaluation and operational research to inform policies, advocacy, and programming

Ways forward - 4

7. Promoting and supporting access to the best available science for all in need by:

- Scaling up more efficacious ARV regimens for PMTCT

- Early diagnosis and ART for infants and children

- Redoubling our efforts for optimal and safe infant and young child feeding practices

8. Building national capacity in M&E (data collection, analysis and use), progress tracking, and operational research (including impact assessment) to inform advocacy, programming and scale up

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