New insights into Research and Evidence on how Investments in PMTCT and Paediatric AIDS have contributed to Health Systems Strengthening Rene Ekpini E Senior Adviser UNICEF, New York Pre-conference meeting of Health Systems Experts, HIV Researchers and Implementers Cape Town, South Africa, July 2009

PMTCT, best model of combination prevention and treatment acceleration Primary prevention Prevention of HIV transmission from an HIV-infected woman to her infant Care, support and treatment for HIV-infected women, their infants and their families Prevention of unintended pregnancies among HIV-infected women Individuals, families and communities

3 PMTCT and paediatric HIV care, support and treatment: an opportunity to improve MNCH services Reaching MDGs 4,5 and 6 requires a paradigm shift from the rhetoric of “the good, the bad and the ugly” toward the prospect of using scaling up of PMTCT and paediatric HIV care, support and treatment as an opportunity to improve maternal and child health and survival Maternity of Inongo

Expenditure in Care and treatment, Prevention and PMTCT in selected countries Source: UNAIDS 2008 Global Report

Building up PMTCT on weak health systems in resource-limited settings Sources: 1- ANC coverage: Antenatal care in developing countries-Promise, achievements and missed opportunities – An analysis of trends, level and differentials, updates 2- Skilled attendant at birth 2006 Coverage of antenatal care and skilled attendant at birth Coverage of PMTCT services

From proof of principles to implementation at large scale Expansion of quality antenatal and delivery care Expansion of provider initiated HIV testing and counselling in antenatal, delivery and child health care settings Scaling up more efficacious ARV regimens for PMTCT, including building capacity for CD4 cell count and ART for pregnant women Cotrimoxazole prophylaxis for HIV-infected pregnant women, HIV-infected mothers and their infants as a standard of care

From proof of principles to implementation at large scale Scaling up early infant diagnosis and ART for infants Scaling up innovations to service delivery, including use mobile phone technology to expand EID and ART for infants Strengthening national M&E systems

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 Rollins

95% efficiency of the system (KZN province) Attend ANC clinic 92% Counseled and tested for HIV, CD4 95% Get ARVs (pre- and perinatal) 95%

Six building blocks of health systems Strong leadership and governance Good health-financing system Responsive health care force Effective, safe, and high-quality health services Equitable access to essential medical products, vaccines, and technologies Well-functioning health information system

How investments in PMTCT and paediatric AIDS have contributed to health systems strengthening

Inducing improved governance and policy changes Strong political leadership and commitment to ensure that health system goals of access, equity, efficiency and improvement in outcomes are achieved Promotion of innovative policies on: -Provider initiated HIV testing and counselling -access to treatment for women and children -Abolition of user fees for antenatal and delivery care in some countries Revision of the content of the basic package of antenatal and postnatal care to integrate HIV-related services Induction of changes in resource allocation including innovative approaches such as pe rformance-based financing

Strengthening programme management, coordination, and monitoring and evaluation Harmonization and alignment of programmes (SRH, Nutrition, MNCH, HIV) and partners through integrated coordination bodies and mechanisms Revision/adaptation of national indicators in line with global guidelines, development of M&E tools, and human capacity building for data management, analysis and use Setting up mechanisms for information sharing and referrals, including notification of HIV information on child and maternal health cards Growing support to impact evaluation and operational research

Addressing shortage in human resources and improving working conditions Innovative approaches to addressing insufficient skilled human resources to sustain expansion of services: - Task shifting and sharing - Engagement of PLWH 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 Engagement of civil society, PLWH, male partners and communities (lay counselors, peer support groups, Mother2Mother, post-test clubs)

Individual counselling Quality of antenatal and delivery care before and after the implementation of PMTCT; Cote d’Ivoire Therese Delvaux et al.

Impact of PMTCT on institutional deliveries in Rwanda – HIV-positive women Bangendanye, L; Price, J.E.; Micomyiza E.; Shumbusho F.; Wesson In the general population 45% of women delivered at HF (IDHS )

Proportion of married women age with unmet need for contraception, according to HIV serostatus, selected DHS surveys

The way forward

Closing the gaps toward virtual elimination of paediatric HIV infection 1.Closing the funding gaps through resource mobilization and allocation and more efficient use of available resources 2.Closing the gap in access to the best available science for all by scaling up more efficacious ARV regimens for PMTCT, early diagnosis and ART for infants and children 3.Closing the gap in access and equity for the majority of women and children in need through decentralisation and scaling up of innovation to service delivery

Closing the gaps toward virtual elimination of paediatric HIV infection 4.Closing the gap between health-based approach and communities through engagement of individuals, families and communities 5.Closing the gap with the future by building capacity and setting up appropriate fiscal policies and operational mechanisms to ensure sustainability 6.Closing the knowledge gap through promotion and support to impact evaluation and operational research to inform advocacy, policies and programming

Two Worlds, Two Realities One Hope

Before Rutobwe H.C. Maternity After