2. 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

3. 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

4. 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)

5. 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.

6. HIV/AIDS Epidemic
38 million infected worldwide over past 20 years – young people 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

7. 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)

8. 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 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 11 UN-Supported Pilot PMTCT Programs Initiated 1999-2000
Honduras
Ivory Coast
Botswana
Uganda
Zimbabwe
Zambia
Kenya
Rwanda
Burundi
Tanzania
India

18. What have the outcomes been so far?

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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

25. 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.

26. 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

27. 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

28. 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…..