An Early Intervention:
Prevention of Mother-to-Child Transmission of HIV
Introduction
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A new mother rests quietly next to her sleeping newborn baby.
Source: USAID/Mozambique |
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One of the tragic consequences of HIV infection in women is the
transmission of the virus to their children, which can occur during
pregnancy, at the time of delivery, or through breastfeeding. In
fact, mother-to-child transmission represents a major cause of
morbidity and mortality among young children in developing
countries with a high prevalence of HIV infection. It is estimated
that more than 90 percent of children living with HIV acquired the
virus before or during birth, or through breastfeeding. The result
is staggering: An estimated 2.5 million children are currently HIV infected,
and 1,000 children under 15 are newly infected every day.
For the past decade, the U.S. Agency for International Development
(USAID) has sought to strengthen health systems and communities
to deliver prevention of mother-to-child transmission
(PMTCT) services to women through support of a wide variety
of complementary interventions. These include improvement of
antenatal services, HIV counseling and testing for pregnant
women, administration of antiretroviral drug prophylaxis for HIV-positive
pregnant women, and support for safer infant feeding
practices. USAID programs also provide multiple types of other
psychosocial, clinical, and nutritional support to women who are
identified as HIV positive in the course of PMTCT programs.
Multifaceted Approach to PMTCT
Efforts to reduce mother-to-child transmission (MTCT) of HIV require
a multifaceted approach. The World Health Organization
(WHO) recommends a comprehensive strategy, including:
- Primary prevention of new infections
- Prevention of unintended pregnancies among women living
with HIV
- Prevention of HIV transmission from mothers living with HIV
to their infants
- Care, treatment, and support for mothers living with HIV, their
children, and families
| A key component of USAID-supported PMTCT
activities is the use of support groups and patients
or trained “expert clients” at PMTCT
service sites to help pregnant women better
understand and access HIV/AIDS services. |
Introducing HIV Counseling and Testing
in Antenatal and Maternity Settings
HIV counseling and testing of pregnant women is critical in identifying
pregnant women who are living with HIV and in preventing
transmission of the virus to infants during labor and delivery. Yet
the majority of pregnant women in the developing world have
never been tested for HIV and do not know their status. According
to UNICEF estimates, only 18 percent of all HIV-positive pregnant
women receive testing in antenatal care clinics. Many others
deliver at home or arrive at health facilities for labor and delivery,
unaware of their HIV status.
USAID has introduced programs to help increase the number of
pregnant women tested for HIV. Through outreach programs,
USAID has worked with traditional birth attendants and community
health workers to identify and refer women to HIV counseling
and testing and antenatal care. USAID has also supported programs
that provide counseling and testing services to women during
labor and delivery. USAID-supported projects work closely
with sites to provide training, mentorship, and close supervision to
multidisciplinary teams of providers. Among the Agency’s priorities
is support for the integration of PMTCT services into maternal
and child health (MCH) settings.
Providing Antiretroviral Therapy
for HIV-infected Pregnant Women
USAID supports the implementation of HIV counseling and testing
for pregnant women as a routine part of MCH. For women who
test positive, USAID supports increased access to one of the following,
depending on the individual medical condition of each
woman: short-term prophylaxis beginning at 28 weeks gestation or
initiation of highly active antiretroviral therapy (HAART). Timely
administration of antiretroviral drugs significantly reduces the risk
of MTCT. With the increased focus on PMTCT, recent epidemiological
estimates suggest that coverage of antiretroviral prophylaxis
for HIV-positive pregnant women for PMTCT in low- and middle-income
countries increased from 9 percent in 2004 to 33 percent
in 2007.
USAID-supported projects have led on-site workshops and
HIV/AIDS medical education meetings and provided intensive clinical
mentorship while working at the same time with staff to realign
job responsibilities. In many of these projects, nurses and nurse clinicians
were supported to initiate patients’ use of HAART, which
enables more women in need to be started on therapy at locations
where a physician is not always available.
The expert clients serve as integral members of multidisciplinary
teams and provide an array of patient support services, including
treatment adherence counseling and assistance with referrals. They
also lead both individual and group counseling sessions.
Supporting Safe Infant Feeding Practices
USAID-supported projects work with host country governments
to incorporate the WHO Consensus Statement on HIV and Infant
Feeding (2006) into national policies and guidelines. The WHO
Consensus Statement on HIV and Infant Feeding states that the
only certain way to completely avoid the risk of HIV transmission
through breast milk is for women living with the disease to abstain
from breastfeeding and provide replacement feeding instead.
However, replacement feeding is not recommended unless it is acceptable
to the family, feasible, affordable, sustainable, and safe. For
example, families must have reliable, uninterrupted access to nutritionally
appropriate formula, as well as the clean water and fuel for
cooking required to prepare it. In cases where families lack these
resources, mothers are advised to breastfeed their infants until the
age of six months, even if they are HIV positive. In order to reduce
the risk of MTCT, the Consenus Statement stresses that HIV-positive
women should never use mixed feeding – giving a baby
foods or other liquids as well as breast milk – because it carries the
greatest risk of such transmission. Regular breastfeeding up until
the sixth month also protects women from getting pregnant; after
that point, however, they should begin taking a contraceptive to
avoid unintended pregnancy.
USAID ensures that countries have up-to-date policies and guidelines,
which helps health care workers and community members
promote optimal feeding. USAID also works with country partners
to develop or revise nutrition training curricula and courses that address
the latest WHO guidance. The resulting materials are used to
train health workers at PMTCT sites, as well as community workers
and volunteers, to counsel HIV-positive pregnant women and mothers
on improving nutrition during pregnancy and lactation and to
ensure optimal and safe infant and young child feeding practices.
Strengthening Family Planning and
Safe Motherhood Programs
Worldwide, women of childbearing age account for more than half
of the people living with HIV/AIDS. In 2002, a WHO meeting
identified the prevention of unintended pregnancy in HIV-infected
women as a key strategy in preventing the transmission of HIV to
infants. Combined with other approaches, including primary prevention of HIV infection in women; prevention of transmission
from women living with HIV to their infants; and provision of care,
treatment, and support for women living with HIV and their families,
this could dramatically reduce MTCT.
USAID has been working to integrate family planning and HIV
activities. USAID supports the formulation of policies that facilitate
the implementation of family planning and HIV service integration
at the national level, which leads to a greater change in practice at
the facility level. In addition, USAID supports provider training to
ensure HIV-positive women receive correct and unbiased counseling
related to family planning, particularly during antenatal care, delivery,
and postpartum follow-up. USAID has also trained peer educators
to establish family planning and support groups for HIV-positive
couples. In addition, USAID partnering organizations have developed
a resource, Increasing Access to Contraception for Clients with
HIV: A Toolkit, which responds to the demand for in-depth training
and performance support materials by program managers who
want to provide family planning services for their clients with HIV.
There is a small percentage of HIV-positive women who want another
child. Because these mothers are at risk of giving birth to
low birth weight and premature infants, the 2006 WHO policy
brief on birth spacing is relevant to their family planning decisions.
After a live birth, WHO recommends a 24-month interval before
another pregnancy is attempted.
“I Can Make a Difference in One’s
Family Life”:
Preventing Mother-to-Child
Transmission of HIV
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Source: ESHE |
Sister Abiyot Bedane lives in the Arsi Zone of Oromiya Region in Ethiopia. As a maternal and child health
nurse at the Alem Tenna Health Center, she works a busy schedule caring for local mothers and children.
Until recently, though, her health center has not been able to help mothers who are HIV positive avoid
passing on the virus to their children.
From February 18 through April 9, 2008, the USAID-funded Capacity Project conducted in-depth, on-the-job
training sessions for health providers in the four regions of Amhara, Tigray, Oromiya, and SNNPR.
Through these sessions, 212 providers were trained in comprehensive antenatal care and PMTCT, including
Sister Abiyot.
Sister Abiyot received training at the Geda Health Center in Nazareth, about 100 kilometers east of Addis
Ababa and not far from Alem Tenna, where she works. “The depth of the 10-day on-the-job training made
us capable of launching PMTCT services in our health center,” she explains. “The training gave us the capacity
to counsel, test for HIV, determine the infection stage, provide treatment follow-up for the mother
and the child, and a lot more.”
The training sessions also incorporated information on pediatric HIV so infected babies will be able to receive
services at the health center level rather than needing to travel to hospitals. In February and March
2008, the Capacity Project trained 90 providers in integrated management of neonatal and childhood illness
in 45 health centers in Amhara, Tigray, Oromiya, and SNNPR regions.
The Capacity Project is also expanding the successful Mothers Support Group program for HIV-positive
mothers; scaling up health extension workers’ involvement in PMTCT; conducting training for pediatric
HIV/AIDS linkages and referral; and providing support for PMTCT in private facilities.
The knowledge and skills Sister Abiyot learned are already making a big impact – not just on the services
she is able to provide, but on her own outlook as well. “Now I see pregnant women differently,” she says.
“When I find an HIV-positive pregnant woman, I will be sad just like any other person, but my frustration
for not providing a solution is gone now. I am capable of counseling for HIV testing and keeping the
mother in medical follow-up toward institutional delivery, which most women in our area are not willing to
do,” she points out. “ This way, I can make a difference in one’s family life.” |
Results
Comprehensive Programs Help Mothers and Children
In Lesotho, USAID-funded projects support the family-centered
MTCT-Plus model, which provides HIV testing, care, and treatment
to pregnant women, their children, and partners. Since October
2007, program sites in Lesotho have provided HIV testing services
to nearly 3,000 pregnant women. During the same period, a total
of 457 HIV-positive pregnant women received prophylaxis for
PMTCT, and 482 women were enrolled in comprehensive HIV
care and treatment programs.
Improving Nutrition for Women and Children Through National Policy
In order to incorporate the WHO Consensus Statement on HIV
and Infant Feeding into Haiti’s national policies, a USAID-funded
project coordinated a workshop, in collaboration with the Ministry
of Public Health; WHO; and UNICEF, to bring together key stakeholders
from more than 100 institutions in the public and private
sectors. The stakeholders discussed fully accepting WHO’s recommendations
on infant feeding in the context of HIV. As a result of
the meeting and additional support, Haiti now has a clear national
policy and is in the process of validating standards of care and developing
job aids for health care workers on infant feeding, with an
emphasis on feeding in the context of HIV/AIDS.
The U.S. Agency for International Development works in partnership with the U.S. President's Emergency Plan for AIDS Relief.
June 2009
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