Seizing the Big Missed Opportunity: Linking HIV and Maternity Care Services in Sub-Saharan Africa

Abstract

This paper draws on two reviews commissioned by the UK Department for International Development in 2006–2007 that explore progress in linking HIV prevention and maternity services in sub-Saharan Africa. Although pilot and demonstration projects have been successful, progress in scaling up PMTCT has been slow, reaching just 11% of pregnant HIV positive women in much of Africa, less than half the percentage of coverage achieved by antiretroviral treatment programmes for adults in need. Despite ongoing efforts to promote comprehensive approaches, significant policy, financing and institutional barriers, and weak co-ordination and leadership, continue to hamper progress. Maternal health services face human and financial resource shortages which affect their capacity to integrate HIV prevention. Both HIV and maternal health programmes often receive targeted financial and technical assistance that does not take the other into account. However, proposals in 2007 from a number of countries to the Global Fund to Fight AIDS, TB and Malaria incorporate sexual and reproductive health programming that will have an impact on HIV, including certain maternity services. Moreover, Botswana, Kenya and Rwanda have shown that progress can be made where national commitment and increased resources are enabling maternal and newborn care to address HIV.

Résumé

En 2006–2007, le Département britannique du développement international (DFID) a commandité deux études sur les progrès pour lier la prévention du VIH et les services de maternité en Afrique subsaharienne. Si des projets pilotes et de démonstration ont été réussis, la PTME est lente à s’étendre, atteignant à peine 11% des femmes enceintes séropositives dans la plupart de l’Afrique, soit moins de la moitié du taux de couverture des programmes de thérapie antirétrovirale pour adultes. En dépit d’activités pour promouvoir des méthodes globales, de graves obstacles politiques, institutionnels et de financement, et la faiblesse de la coordination et du leadership, contrarient les progrès. Les services de santé maternelle manquent de ressources humaines et financières, ce qui amoindrit leur capacité à intégrer la prévention du VIH. Les programmes de santé maternelle et de lutte contre le VIH reçoivent souvent une assistance financière et technique ciblée qui ne tient pas compte de l’autre secteur. Néanmoins, en 2007, des propositions de pays au Fonds mondial de lutte contre le SIDA, la tuberculose et le paludisme incluent une programmation de santé génésique qui aura des retombées sur le VIH, y compris certains services de maternité. De plus, depuis 2005, l’Afrique du Sud, le Botswana, le Kenya et le Rwanda ont montré qu’il est possible d’avancer quand l’engagement national et des ressources accrues permettent aux soins de santé de la mère et du nouveau-né de traiter le VIH.

Resumen

Este artículo se basa en dos revisiones encargadas por el Departamento del Reino Unido para el Desarrollo Internacional en 2006–2007, que exploran los avances en vincular la prevención del VIH y los servicios de maternidad en Ãfrica subsahariana. Aunque el piloto y los proyectos de demostración fueron exitosos, los avances en la ampliación de la PTMI han sido lentos, ya que se alcanzó sólo el 11% de las mujeres embarazadas VIH-positivas en gran parte de Ãfrica, menos de la mitad del porcentaje de cobertura logrado por los programas de tratamiento antirretroviral para adultos. A pesar de los esfuerzos continuos por promover estrategias integrales, políticas significantes, barreras financieras e institucionales y coordinación y liderazgo deficientes continúan obstaculizando los avances. Los servicios de salud materna afrontan escasez de recursos humanos y financieros, que afectan su capacidad para integrar la prevención del VIH. Tanto los programas de VIH como de salud materna reciben a menudo asistencia financiera y técnica específicas que no toman en cuenta al otro. Sin embargo, en las propuestas de 2007 procedentes de varios países al Fondo Global de Lucha contra el SIDA, la Tuberculosis y la Malaria, se incorporan programas de salud sexual y reproductiva que tendrán un impacto en el VIH, incluidos algunos servicios de maternidad. Más aún, desde 2005, en Botsuana, Kenia, Ruanda y Sudáfrica se ha demostrado que se pueden lograr avances en los lugares donde el compromiso nacional y el aumento de recursos permiten que la atención materna y del recién nacido traten el problema del VIH.

Key Words:

• prevention of mother-to-child HIV transmission
• maternal and child health care
• integration of services
• scaling-up of services
• donor policy and financing
• Africa

This paper draws on two reviews commissioned by DFID UK in 2006 and 2007 that explore the slow progress in linking the prevention of mother-to-child transmission (PMTCT) and maternal health services in sub-Saharan Africa.¹² It draws on the processes of policy development and implementation of services for PMTCT of HIV, to illustrate the wider policy, institutional and financing barriers that continue to prevent the effective linking of HIV prevention, treatment, care and support with sexual and reproductive health services. The reviews were based on web scans of funding, technical and implementing agencies, literature searches using Popline and 106 key informant interviews, using a semi-structured questionnaire, carried out with officials in major technical and donor agencies, and staff in implementing organisations and government departments in countries such as Kenya and South Africa.

HIV and maternal health

Each year, there are over half a million maternal deaths, mainly in low-and middle-income countries. Mother and newborn morbidity and mortality are closely linked; preventing a mother’s death is a critical intervention for the health of the child.³ In many parts of the world, HIV infection is rising fastest in women. More than two million HIV positive women become pregnant each year (and pregnancy itself increases the chance of HIV infection, probably through a combination of physiological and behavioural factors).⁴ The HIV status of most pregnant women in high prevalence areas is not known, because only a small proportion of people have been tested, and current data are likely to underestimate the true picture.⁵ In high prevalence areas in sub-Saharan Africa, at least 1 in 10 young women is likely to be HIV positive.

AIDS increases the risk of maternal mortality with subsequent serious impact on the child and wider family. This additional maternal mortality stems from the impact of HIV on direct obstetric causes of death and its exacerbation of malaria and tuberculosis (TB) during pregnancy. In some severely affected countries, the AIDS epidemic has reversed previous gains in maternal mortality. In some high HIV prevalence locations, HIV-related TB is now the leading cause of maternal mortality.^6–11

The evidence highlights the inter-dependent nature of problems relating to HIV, HIV co-infections and pregnancy. It also points to the importance of integrated responses. Pregnancy and child care represent the two main reasons why HIV positive and HIV negative women come into contact with the health system. The overall goal must therefore be to improve maternal, neonatal and child health in the context of HIV. But there have been great difficulties in making progress in scaling up a cost-effective and simple intervention, PMTCT, as part of routine services in sub-Saharan Africa.

High-level commitments to comprehensive approaches

Pregnant women living with HIV infection are at risk of transmitting HIV to their infants either during pregnancy and childbirth or through breastfeeding. Without any interventions, 20–45% of infants from infected mothers may become infected. But this can be reduced to less than 2% through antiretroviral prophylaxis given to the woman during pregnancy and labour and to the infant in the first weeks of life,¹² obstetric interventions including elective caesarean section, and appropriate infant feeding.⁴

This set of interventions is collectively known as prevention of mother-to-child transmission (PMTCT). In most industrialised countries, where this package is now the standard of care, its large-scale implementation has led to the virtual elimination of new paediatric HIV infections. Ongoing antiretroviral treatment for pregnant women, where indicated, also improves the woman’s health.

PMTCT remains central to efforts to reduce the impact of HIV on maternal and child health, and to wider prevention efforts. The principle of providing PMTCT as part of a comprehensive response has long been recognised. In 2001, in the UN General Assembly’s 26th Special Session (UNGASS) Declaration of Commitment on HIV/AIDS, the achievement of prevention targets was linked to the delivery of an integrated set of interventions, including antenatal care, HIV testing and counselling, HIV-related care, treatment and support services, and appropriate sexual and reproductive health services across the wider health sector.¹³

At international level, over the last two years, major agreements and commitments have re-emphasised the importance of approaches that link sexual and reproductive health, maternal health, HIV and AIDS and other key services such as child health and treatment for TB.

At Gleneagles in July 2005, G8 leaders helped re-energise the fight against the HIV pandemic through a commitment to reaching as close as possible to universal access to prevention, care and treatment services for all those who need it by 2010. They gave strong support for an approach whereby HIV-related interventions are integrated with broader health services including maternal, neonatal and child health, sexual and reproductive health, and TB. This was reinforced by the June 2006 UN General Assembly High Level Meeting on AIDS, and again at the G8 Summit in 2007.¹⁴ Recent progress has been made to include universal access to reproductive health as a target under Millennium Development Goal 5.¹⁵

International co-ordination efforts have also taken shape. The Inter-Agency Task Team (IATT) on mother-to-child transmission of HIV was established in 1998. In 2001, the Task Team was renamed the Inter-Agency Task Team on the prevention of HIV transmission to pregnant women, mothers and their children, and now includes implementing and donor agencies. WHO and UNICEF are the designated lead UN organisations for PMTCT.

WHO, UNICEF, and other partners developed a comprehensive approach to the prevention of HIV infection in infants and young children, comprised of four components: primary prevention of HIV infection; prevention of unintended pregnancies among women living with HIV; prevention of HIV transmission from mothers living with HIV to their infants; and care, treatment and support for mothers living with HIV, their children and families.

In 2004, WHO and UNFPA convened a consultation in Glion to review the contributions that family planning could make to the prevention of HIV in women and children, which was followed by the New York Call to Commitment.¹⁶¹⁷ In December 2005, the Inter-Agency Task Team organised a high-level global partners forum in Abuja, Nigeria.¹⁸ Evidence presented at the Glion consultation showed that the UNGASS goals on the reduction of HIV infection in infants could not be met through a focus on prevention of transmission from mother to infants alone. Greater emphasis was needed on preventing infection in women of reproductive age, helping women living with HIV to know their status (if desired) and avoiding unintended pregnancies.¹⁹ Another analysis suggested that adding family planning to on-going services for prevention of vertical transmission of HIV (testing and counselling and antiretroviral provision) could, by preventing unwanted pregnancy, double the number of HIV positive births averted.^{20 *}

The Mailman School of Public Health, Columbia University, helped to promote the comprehensive approach by launching its PMTCT Plus initiative in 2002.²¹ This expanded upon services in ongoing PMTCT programmes by including comprehensive clinical services (including antiretrovirals as appropriate), to women during pregnancy and the post-partum period and extended HIV care to the woman’s children and partners.

Slow progress on the ground

High-level policy commitments have not resulted in rapid progress in scaling up services for HIV positive women in need of PMTCT services, however. Following the UNGASS declaration, in 2001 to 2003 the number of pregnant women being offered PMTCT more than doubled, from almost zero baseline figures. Service availability for pregnant women in middle-and low-income countries then rose from 7.6% in 2003 to only 9% in 2005.⁴ With respect to coverage, in 2003, UNICEF report that about 3% of HIV positive pregnant women received antiretrovirals, rising to 11% in 2005 (about 220,000 of an estimated two million women in need).^4,22,23 Limitations in follow-up for mother and baby meant that just 8% of all infants exposed to HIV received antiretroviral prophylaxis.

Although representing progress, this figure can be contrasted with the larger percentage of people receiving antiretroviral therapy, which arguably requires more complex clinical delivery arrangements, and over a person’s lifetime. In sub-Saharan Africa, 1.3 million people are now on treatment, equivalent to 28% of those needing it.²²

PMTCT services have been introduced in 100 low-and middle-income countries, but by 2005 were available nationwide in only 16, including only one in sub-Saharan Africa.²⁴. Services were reaching 40% or more of HIV-infected pregnant women in only seven countries, only one in Africa, Botswana. In sub-Saharan Africa, where 85% of HIV-infected pregnant women live, coverage in countries ranges from less than 1% to 54%.²²

Continuing challenges limit scale-up

The main challenges to both scaling up services and increasing coverage rates remain. PMTCT programmes tend to focus primarily on the provision of a package of services seeking to reduce mother-to-child transmission, but do not necessarily promote or finance the strengthening of existing maternal, neonatal and child health services, nor substantially meet the need for a comprehensive response.^19,24,25

The main supply-side barriers to scaling up cited by UNICEF in its evaluation of 11 pilot programmes in 2003 lie in weak health systems, limited human resources and supplies (including lack of on-site antiretrovirals).²⁵ Another review mentions the need to strengthen routine maternal, neonatal and child care as an integral component of providing enhanced services, to ensure, for example, the recommended levels of contact between the first antenatal visit and delivery, increased skilled attendance at birth in appropriately resourced facilities, and post-natal care. Family planning and primary prevention services are also not sufficiently emphasised.²⁶

More recent reports continue to describe a similar picture, such as the UNICEF PMTCT report card for 2005, which specifically comments on inadequate integration into maternal and child health services, and poor linkages with HIV care services.²⁴ In many countries, PMTCT services remain available only at secondary level, with serious impact on service availability and, hence, coverage. Recent data from UNICEF, discussed by Luo et al in this issue of RHM, show that in sub-Saharan Africa, a quarter or less of antenatal care facilities provided the minimum package of PMTCT services in 2005.²⁷

A review in 2004 commented that the emphasis was typically on PMTCT, with less stress on primary prevention, preventing unwanted pregnancies or providing care, treatment and support for mothers with HIV, their children and families.²⁶ This has continued in some programmes. For example, PEPFAR, the US President’s Emergency Plan for AIDS Relief, finances a range of policy and system strengthening activities to promote PMTCT.²⁸ However, the minimum package (by which success is measured) specifies “HIV counselling and testing for pregnant women, antiretroviral prophylaxis for HIV positive pregnant women to prevent transmission, counselling and support for safe infant feeding practices, and family planning counselling or referral” (author italics). Referral and provision of antiretroviral treatment for women in need are also reported to be challenging, in terms of both data collection and making effective service linkages.²⁷

Stigma, low levels of male involvement and weak community mobilisation also contribute to low coverage. Services continue to struggle to attract participants and achieve adequate admissions rates in some settings, in part due to continuing stigma and discrimination surrounding HIV, including by providers, families and communities. This is often gender-based, in that women may receive an HIV test before their partner and are blamed for the infection.²⁸²⁹

Routine HIV testing, offered in antenatal and delivery wards, has helped to increase uptake of HIV testing.²⁷³⁰ According to UNICEF, approximately 90% of women who received counselling also accepted testing for HIV in 1995.²⁷ But, fewer than half of the 500,000 women testing HIV positive received antiretroviral prophylaxis.²² High fall-off rates are reportedly due to fear of stigma and violence, as well as lack of antiretrovirals, transport and other barriers affecting service utilisation.²⁸²⁹

Our informants also reported anecdotally that, in Kenya and other countries, where routine HIV testing is introduced into poorly resourced antenatal settings, low awareness about being able to opt out and fear of testing positive may be deterring some women from using antenatal services. This is an important observation which deserves further investigation.

New global strategy: difficulties of co-ordination

Universal access commitments have re-energised efforts to scale up availability and coverage of services. Maternal, neonatal and child health services are recognised as a platform for scaling up of PMTCT. However, these services are themselves under-resourced, and challenged in delivering quality care for sexually transmitted infections, antenatal care, post-partum family planning and newborn infant care. Equally important therefore is strengthening the systems – including human resources, commodity supplies and the infrastructure needed to support basic service delivery.

In March 2006, the Inter-Agency Task Team (IATT) launched a process to develop a global strategy, with a focus on country-level activities, for scaling up PMTCT. The draft strategy proposes that the package should “be delivered within maternal and child health services using a family-centred public health approach”.³¹ But it will be a struggle to make that meaningful in practice. For example, while the strategy’s goal encompasses both maternal and infant mortality, the impact target for 2010 is a “50% reduction in the proportion of infants newly infected with HIV” (author italics). The inclusion of indicators specific to maternal health, such as the number of women receiving CD4 testing and treatment referrals where appropriate, would provide greater drive for implementation at country level.

One of the proposed strategic approaches is to “operationalise the linkage between the delivery of PMTCT and sexual and reproductive health services”. Key proposed actions include prevention of HIV infections in childbearing women and their sexual partners, and unintended pregnancies among HIV positive women. Yet once again, specific indicators to support the former are missing and for the latter the indicators require strengthening. A secondary priority action is to “support the strengthening of health systems”. This is fundamental to achieving any of the other objectives, however, and should be a primary focus, not secondary.

The draft strategy also proposes a “Package of Essential Services for Quality Maternal Care”, which includes malaria prevention and treatment and TB control. This is especially important within antenatal care in Africa, where HIV infection increases both the risk of contracting malaria and TB and exacerbates their adverse effects in pregnancy, increasing the risk of maternal death. Yet given the genuine challenges of joining up front-line services and building capacity to effectively deal with co-infections, it is surprising that more specific guidance is not included.

Although the strategy sets out in some detail the role and actions of partners, there is no reference as to who will lead implementation. A briefing note on PMTCT, posted on the WHO website in February 2007, states that WHO with UNICEF will lead the global response to HIV infection in infants and young children.³² How exactly this is to be done and how it relates to the mothers of these children is not articulated within the strategy. Greater clarity on the respective roles and responsibilities of the lead agencies would build confidence in the likelihood of effective implementation.

The new Global Strategy has the potential to help turn global commitment into action at the pace required. But it still requires attention to ensure sufficient balance and breadth – and very considerable efforts will be needed to drive and support change at national level.

Wider policy, financing and institutional constraints

PMTCT has rarely been made part of health services able to take the implications of HIV into account routinely, e.g. in relation to contraceptive choice, referral and treatment for the mother, and post-partum and post-natal care, including infant feeding and monitoring. HIV-related interventions continue to be financed, managed and supervised as additional or poorly integrated activities, functioning alongside often weak maternal and neonatal health services.²⁴ Significant barriers lie in policy, institutional and financing arrangements, which rarely promote co-ordination and integration. There are also programmatic and technical challenges and the need for context-specific approaches to be developed.³³

Donor financing for maternal health and PMTCT

Donor financing trends – both overall funds and financing mechanisms such as the global partnerships for communicable diseases – have implications for maternal health services, and for efforts to scale up integrated services. Financing for maternal health services is falling, according to a recent analysis of donor trends for the Countdown to 2015 project.³⁴ This study found that of about US$1.9 billion for all maternal, neonatal and child health services in 2003 and 2004, the proportion for maternal health fell from about a third to about a quarter. Over 90% of funding was project-specific (as opposed to general or sector budget support), of which less than half focused on maternal, neonatal and child health (versus funds allocated to general health care, TB and malaria). Of this, projects supporting PMTCT comprised less than 0.5%. This is compared with 55% for immunisation, for example, where additional resources have been mobilised through the GAVI Alliance, the global health partnership for vaccines and immunisation.

Total donor expenditures for population and AIDS activities (defined by the International Conference on Population and Development in 1994) have shifted dramatically over the last decade. Not withstanding problems in collecting and disaggregating donor data, reproductive health and family planning expenditures have declined as a proportion of the total spend. In absolute terms, AIDS-related funding has risen from well under US$1 billion in 1995 to nearly US$3 billion in 2004 (and a reported US$8 billion in 2006). However, expenditures on reproductive health and family planning rose to only about US$1.6 billion by 2002, with minimal increase since then.³⁵

The World Bank and the US Government are

United Civil Society Coalition on HIV/AIDS, TB and Malaria protest at proposed increase in price of life-saving HIV drugs, Nairobi, Kenya, July 2006

currently the largest donors to HIV/AIDS. The World Bank’s internal evaluation of its support to global health partnerships found that effective advocacy has driven up AIDS spending, while overall spending on the health sector has increased only to a limited extent, including limited use by governments of credits (loans linked to poverty reduction strategies) for maternal and reproductive health.³⁶

The US Government has been a major funder of reproductive health, and has financed much of the innovative programming to develop synergies between reproductive health and HIV.³⁷ But its commitments appear to be falling, with proposed decreases in the USAID budget for family planning and reproductive health.³⁸

The 2003 Act for US Leadership Against HIV, TB and Malaria, which governs US spending on AIDS is affecting US financing for PMTCT. The law requires that 20% of all PEPFAR funds be allocated to prevention, of which at least 33% must be spent on abstinence programmes. A recent analysis by the US Government Accountability Office found that earmarking requirements were challenging the ability of country teams to deliver comprehensive approaches that respond to local epidemiological contexts and social norms. These were having the effect of reducing the allocation of funds to PMTCT in some countries.³⁹

Financing mechanisms for targeted programmes can increase the separation of HIV and sexual and reproductive health services, including maternal health. The Global Fund to Fight AIDS, TB and Malaria, and the US Government, including PEPFAR, are the major funders of PMTCT, together financing services for the majority of women in low income countries currently receiving antiretroviral prophylaxis, according to 2006 data.²⁸⁴⁰ These disease-specific initiatives have ambitious targets, with funding disbursements linked to indicators that specify the HIV-related output, such as the number of HIV positive women completing a full course of antiretroviral prophylaxis. Strong incentives to deliver “quick wins” through targeted approaches have resulted in coverage increases, but at the cost of longer-term strategies to strengthen health services more generally.⁴¹

Earmarked financing also encourages new systems parallel to those set up to support basic health services and other programmes. Financing and co-ordination of supplies is one notable example. Separate and more reliable supply systems often exist for antiretrovirals and other commodities funded by the Global Fund and PEPFAR, including those for PMTCT, while drugs for essential obstetric care, contraceptives and drugs for opportunistic infections and sexually transmitted infections are subject to frequent stockouts.⁴¹

Maternal health programmes are also sometimes recipients of targeted financing and technical assistance that may not take the implications of HIV and AIDS into account. Safe motherhood programmes in the late 1990s and early 2000s in sub-Saharan Africa rarely included linkages with PMTCT pilots in the same area. For example, the evaluation report of a safe motherhood demonstration project in Kenya acknowledged that PMTCT was not a focus, but went on to emphasise that: “Increased support to integrate PMTCT within maternal and neonatal services is necessary at all levels”.⁴²

At country level, the shift from project and programme funding to budget support and sector-wide approaches, coupled with high-profile, disease-focused financing can reduce both resources for and visibility of programmes for maternal health. A review of financing in Rwanda describes a “gross misallocation” of resources, with funding distribution reflecting donors’ strategic objectives rather than country needs – the government itself manages only 14% of donor aid for health. Rwanda receives over US$47 million for HIV/AIDS, disproportionate in a country with a 3% HIV prevalence rate.⁴³

Increased funding earmarked for HIV and other communicable diseases has taken place in parallel to reduced allocations of financial (and human) resources to maternal health and other reproductive health services. There is concern that, in Uganda and Zambia, for example, where fiscal ceilings affect the health budget, earmarked funds for HIV and other communicable diseases are crowding out government allocations to priorities such as maternal health.⁴⁴⁴⁵

Linkage challenges

Policy-making and programmatic processes for HIV and maternal health at international and national levels have, for historical reasons, developed separately. Improving co-ordination is challenging, especially given the financing trends and incentive structures.

The Global Fund to Fight AIDS, TB and Malaria has, until recently, placed little emphasis on linkages between reproductive and sexual health (including maternal health) and HIV in policy documents, guidelines, proposals or reports. As late as mid-2006, very few funded programmes addressed linkages.^1,46

Two reasons explain the absence of linkages: first, the Fund is a country-driven financing instrument and processes at country level tend to be dominated by disease-specific agency and government programme staff. Despite guidelines that enable broad representation in the Country Co-ordinating Mechanism, an IPPF survey found that few organisations involved in sexual and reproductive health were represented or aware they could be, in part because of their limited engagement with HIV and AIDS.⁴⁷ Second, there was a perceived need to urgently prioritise HIV-specific interventions, as expressed by the former Global Fund director Richard Feachem:

“What would you first emphasise? Linkages, which are maybe operationally complex to achieve? Or would you emphasise firstly a blitz on prevention… and within that a focus on the high-risk groups; plus scaling-up testing rapidly, and beginning to make treatment and access to treatment a serious proposition.” ⁴⁸

Indeed, prevention is greatly lagging behind treatment in most settings. This may be one of the reasons why the performance of PMTCT grants is reported by the Global Fund to be weak in comparison to other programmes.⁴⁰

In 2006, NGO advocates began working with the Fund and its donors to improve the policy and funding environment for programmes to include integration, and progress has been made (Felicity Daly, Interact Worldwide, Personal communication, August 2007). Technical assistance has been provided by a range of agencies to over 20 countries for Round 7 proposals, and several submissions now feature sexual and reproductive health programming that will have an impact on HIV. WHO has produced several technical briefs, including one on PMTCT.¹² Several members of the Fund’s Technical Review Panel are reported to have the appropriate expertise to assess these proposals. Advocates aim for a statement supporting the case for integrated programmes to be endorsed by the Board before the end of 2007, and there is a good chance that several Round 7 proposals will be funded.

Other global partnerships and coalitions responsible for co-ordinating the technical response and mobilising resources for Millennium Development Goal priorities also have a critical role. Yet, in 2006, the Partnership for Maternal, Newborn and Child Health did not mention HIV in its core communications, a significant missed opportunity.⁴⁹ The Reproductive Health Supplies Coalition, which supports co-ordination among donors and implementors, includes some HIV stakeholders, but until recently, HIV linkages were not given high priority.

Policy and institutional disconnects

Within countries, the Three Ones approach (one national co-ordinating body, one strategic plan and one monitoring and evaluation framework) is promoting better co-ordination of the overall AIDS response. However, reproductive and maternal health stakeholders are often not included in high level national policy and co-ordination structures.

National HIV/AIDS programmes tend to be larger and better resourced than reproductive, maternal and child health programmes. HIV-related programmes such as PMTCT may be managed by the national HIV/AIDS programme at central policy level but delivered through decentralised, integrated administrative systems at provincial or district level.⁵⁰ Several departments or administrative entities therefore need to be involved in planning and organising integrated services, but collaboration between these different actors is often inadequate.

A review of 16 countries found that policy-making processes are still mainly managed and implemented separately.⁵¹ Lack of coherence in operational guidelines means inconsistencies in, for example, cost-recovery policies. For example, user fees are charged for some maternal health care services, such as contraceptives, syphilis screening and antenatal tests, but not for some HIV-related services such as HIV testing, prophylactic antiretrovirals or condoms.⁵² Staff at district and facility level are often managing separate budgets (linked to earmarked funding) and different logistical arrangements for commodity procurement and supply, as reported in Malawi,⁴¹ and for training and supervision.⁴¹⁴² Policy and regulations may prevent nurses or auxiliary staff from prescribing antiretroviral drugs.⁵³ Task delegation – the shifting of tasks to lower level health staff – is often resisted by professional associations and presents management challenges.

Given staff shortages in maternal health care in sub-Saharan Africa,⁵⁴ additional finance for HIV programming represents an important opportunity to draw staff back to the public sector while linking services. For example, in Kenya, the government and the International Monetary Fund have agreed that the Clinton Foundation, the Global Fund and PEPFAR fund the salaries of over 2,000 additional health workers for a limited period, after which the government will take over. However, the continued separation of programmes can create perverse incentives. Localised brain-drains of public sector health professionals switching to well-funded NGO HIV programmes are anecdotally reported, e.g. in Zambia. In Rwanda, doctors in the NGO sector receive six times the salary of their public sector equivalents.⁴³

Some emerging success stories

Eleven pilot countries started PMTCT in 1998, with the support of UNICEF and other agencies. Of these, Botswana, with a reasonably well-resourced and equitable health system, had made HIV testing available to nearly 100% of pregnant women by 2005. And of women testing positive, 54% now receive antiretroviral prophylaxis.²³ Other encouraging trends in access to antiretroviral prophylaxis for PMTCT have been reported in Namibia, Rwanda and Swaziland.²³ UNICEF attributes progress to a decentralised approach where regional and district health management teams take the lead in PMTCT programming.

Strong leadership and political commitment at national level also help to drive demand for and provision of increased human and financial resources. PMTCT was introduced in Rwanda at the end of 1999. By mid-2006, over half (221) of all facilities were providing services, most of the pregnant women attending antenatal care accepted HIV testing, and two-thirds of women identified as HIV positive received antiretrovirals for PMTCT.²² The Rwandan Ministry of Health is developing a referral system to link HIV and maternal and child health services at the community and national levels in Rwanda’s decentralised system. PMTCT and paediatric HIV care and treatment scale-up plans aim to address low uptake of services, linkage mechanisms, nutrition, reproductive health services and general capacity-building.

In Zambia, the MTCT Working Group requires PMTCT donors to support all elements of antenatal care. The PMTCT post funded by the Global Fund is based in the Reproductive Health Division, which is leading the incorporation of PMTCT into routine maternal health services. Recent efforts have been made in Zimbabwe (with the UN system) to bring maternal and child health stakeholders together with HIV experts to strengthen maternal health services and take HIV into account.¹

In Kenya, the PMTCT strategy and its implementation is integrated with existing reproductive services. PMTCT is one of the pillars of the safe motherhood strategy, supported by a joint AIDS and reproductive health programme technical working group and shared supervision with other reproductive health services. PMTCT services are now available nationwide and at all levels of the health system.¹

Pilot and demonstration programmes continue to show that a comprehensive approach to integrating PMTCT increases maternal health service utilisation as well as PMTCT coverage. For example, Pathfinder International’s innovative programme with nearly 200 clinics in Kenya improved basic antenatal care services and infrastructure alongside introducing PMTCT.⁵⁴⁵⁵ The number of pregnant women attending antenatal care has increased, with higher rates of acceptance of HIV counselling and testing, and increased antiretroviral uptake by mothers and babies. Key components included a sensitisation campaign (for providers, traditional birth attendants and community members), training of antenatal service providers in PMTCT and counselling skills, upgrading facilities to improve privacy, and developing two-way referral systems between community health workers and health facilities to improve follow-up.

Conclusion

These encouraging examples show that policy, financing and institutional constraints can be overcome, to enable progress in integrating PMTCT into maternal, neonatal and child health care. Progress in making other linkages with HIV prevention and care services is equally critical, including strengthening screening and treatment for sexually transmitted infections, improving post-partum care and post-natal follow-up for mother and baby, and greatly enhancing access for pregnant women and mothers in need of ongoing antiretroviral treatment. This is especially important in light of findings just reported in July 2007 showing that antiretroviral therapy during the breastfeeding period dramatically reduces the chances of HIV transmission to infants.⁵⁶ Recent moves by the Global Fund to consider funding integrated programmes are to be greatly welcomed, along with national efforts to develop strategies and proposals, and better guidance from technical and implementing agencies. Equally welcome are government and donor initiatives to address health worker shortages, especially at the peripheral level. Coupled with greater national commitment, these additional resources have great potential to support integrated services that better take HIV into account for pregnant women and their children.

Acknowledgements

DFID UK commissioned and financed the two reviews on which this article is based. However, the views expressed are those of the authors, not of DFID. The authors would like to acknowledge the contributions of the co-authors of the linkages review, [1] Clare Dickenson, Kathy Attawell, Arlette Campbell White and Hilary Standing, and to thank Catharine Taylor for helpful comments and Felicity Daly for her update on Global Fund applications.

Notes

* Over 25% of pregnancies are reported as unwanted or mistimed, a figure that may be higher among HIV-positive women.¹²