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

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

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)

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.

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

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)

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

Timing of Mother-to-Child HIV Transmission with Breastfeeding and No ARV Early Postpartum (0-6 months) Late Postpartum (6-24 months) Pregnancy Labor and Delivery Breastfeeding (24mos) 5-10% 10-20% 10-20% Adapted from N Shaffer, CDC

63 babies will not become infected Of 100 HIV+ pregnant women, what percent of babies will be infected? # Babies 63% 63 babies will not become infected 15 37% 15 7 Piwoz & Ross, 2002

Program Strategies- 4 Prongs 2. Prevent unintended pregnancies in HIV+women 3. Prevention of Mother to Child Transmission in late pregnancy during labor through breast- feeding 1. Primary HIV prevention in parents to be 4. Care and support

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

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

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

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

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

11 UN-Supported Pilot PMTCT Programs Initiated 1999-2000 Honduras Ivory Coast Botswana Uganda Zimbabwe Zambia Kenya Rwanda Burundi Tanzania India

What have the outcomes been so far?

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

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

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

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

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

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

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.

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

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

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…..