| HIV/AIDS is a critical development issue
in sub-Saharan Africa, where a disproportionate number
of all HIV/AIDS infections occur. HIV prevalence is now
as high as 40% among antenatal care attenders in some
parts of Africa. At the same time, in many sub-Saharan
African nations, maternal deaths from direct obstetric
causes are also extraordinarily high compared to other
regions. Almost half of all maternal deaths that occur
each year take place in Africa. AIDS-related maternal
deaths have increased dramatically and have begun to outpace
the number of deaths from obstetric causes. The high prevalence
of both obstetric-related maternal mortality and HIV among
pregnant women in most African nations shows the need
for programs that simultaneously address both problems.
In 2001, the number of infants who become HIV+ through
maternal transmission of the HIV virus during pregnancy,
birth, and during breastfeeding was estimated at 800,000.
Almost 90% of them lived in sub-Saharan Africa. At the
country level, this translates to an estimated 40,000
AIDS-related infant deaths in Uganda, and 56,000 in
Kenya each year.
Interventions to prevent mother-to-child transmission
of the HIV virus (PMTCT) are now an important part of
HIV/AIDS reduction programs worldwide. During the past
several years, researchers have learned valuable lessons
about reducing Mother-to-Child Transmission (MTCT) of
HIV in resource-poor settings. One of the greatest challenges
is the need to translate lessons learned from short-term
clinical trials into effective, actionable, large-scale
program interventions.
Both PMTCT and Safe Motherhood (SM) program planners
may not always prioritize behavior change interventions
(BCI)... Common behavioral objectives of PMTCT and SM
programs - emphasis behaviors - and logical ways to
integrate promotion of joint objectives are proposed.
Some innovative behavior change methodologies used
by the CHANGE Project and other safe motherhood programs
could be applied to PMTCT behavior change programs.
Behavior change methodologies could help increase acceptability
and utilization of PMTCT services and treatment regimens;
identify key areas where a strategic multi-level approach
to behavior change could enhance current PMTCT program
results; and help in developing a set of standardized
tools that can accelerate scaling-up of strategic, integrated
behavior change interventions that support SM, PMTCT
and newborn survival programs.
Barriers to Preventing Mother-to-Child HIV
Transmission
Three mechanisms are essential for effective reduction
of MTCT:
- reduce maternal viral load with ART
- prevent avoidable exposure to maternal virus at
birth through improved obstetric practice
- reduce exposure to HIV through breastfeeding
Currently, improved obstetric practice is not receiving
equal emphasis. All three mechanisms should be addressed
in PMTCT programs especially in the behavior change
program component.
Despite impressive achievements in a short timeframe,
the current level of success of PMTCT programs in reaching
pregnant women and their newborns with ART and other
program components demonstrates the need for rapid action
to refine and strengthen PMTCT behavior change strategies.
Barriers which can be addressed with behavior change
interventions, include:
- missed opportunities to offer, or low uptake of,
VCT during routine ANC
- low levels of acceptance of HIV testing where it
is available, by both pregnant women and partners
- failure to return for HIV test results where rapid
testing is not available
- inadequate acceptance of ART offered to HIV+ women
at ANC
- insufficient use of facility-based delivery where
improved obstetric practices can be used and ART for
mother and newborn can be supervised
- poor adherence to "take-home" ART for
mother and newborn when given to HIV+ women at ANC
- low coverage of newborns with ART even when delivered
in facility
- low uptake of recommended infant feeding behaviors
to minimize MTCT
Integrating Behavior Change to Promote PMTCT
and SM
Several key interventions to improve both maternal and
newborn survival are common among safe motherhood, PMTCT
and Saving Newborn Lives (SNL) programs. Many take place
around the time of labor, delivery, and early postpartum.
One of the most important potential linkages between
PMTCT, SM and SNL programs is collaboration to identify,
strengthen and integrate overlapping program emphases
and to access the substantial expertise and experience
in the safe motherhood community. Vertical PMTCT programs
with emphasis solely on PMTCT may miss valuable opportunities
to help avert common obstetric and newborn emergencies.
This could result in successfully preventing mother-to-child
transmission of HIV, only to have the new mother or
newborn die from an avoidable obstetric-related cause.
Key points:
- The most significant overlap between behavior change
objectives of PMTCT and SM programs occurs in the
area of improved obstetric practices.
- Most perinatal transmission of HIV occurs during
delivery so this period should be the target of the
most intensive PMTCT program efforts.
- Much more emphasis should be placed on accumulating
an evidence base for the contribution of improved
obstetric practices to reducing MTCT.
- A suggested point of entry to begin integrating
SM/PMTCT behavior change interventions is to focus
on reducing delays in obstetric careseeking to reduce
prolonged labor and rupture of membranes (ROM) longer
than four hours. Both are important contributing factors
to MTCT of HIV.
- It is estimated that every year more than a million
women infected with HIV deliver babies at home without
professional help. One of the most important PMTCT
behavior change interventions may be to inform communities
and professional and traditional birth attendants
that whether a birth takes place at home or in a health
facility, there are improvements in childbirth related
behaviors that can help to reduce HIV transmission
not only to newborns, but also to birth attendants
and others who may be present during and immediately
after birth.
- In addition to improving obstetric practices in
maternity facilities, a set of simple, realistic obstetric
behaviors to reduce MTCT during home births should
be a component of all PMTCT programs in settings where
home births predominate.
- Timely use of skilled obstetric care and reducing
delays in seeking, reaching and receiving skilled
childbirth care should be part of behavior change
objectives of PMTCT programs.
- Behaviors that potentially reduce prolonged exposure
to ruptured membranes should be emphasized to both
skilled and traditional birth attendants, families
and communities.
- "Nesting" recommended PMTCT behaviors
in already established SM programs may help to minimize
stigma and "normalize" PMTCT interventions
as part of routine maternity care.
- PMTCT program emphasis on ART and infant feeding
without addressing obstetric practices may result
in deterioration rather than improvement in obstetric
practices.
Behavior Change Approach
Behavior change methodologies and approaches that could
be more widely utilized in integrated
PMTCT/SM programs include:
- Reinforce need for strategic, multi-level, research-based
behavior change (BC) interventions.
- Develop and promote a set of EMPHASIS BEHAVIORS
that contribute to the common goals of PMTCT, SM,
and SNL programs.
- Develop setting-specific approaches that are tailored
to the needs of PMTCT/SM programs, for example in
areas with low use of facility-based childbirth; high
use of facility-based childbirth, "mixed"
use of facility birth.
- Add innovative methods such as concept testing,
trials of improved practices (TIPS), and positive
deviance (doer/non-doer) to research methods used.
- Use "generic" PMTCT/SM behavior framework
as a broad guide; validate locally and adapt.
- Integrate separate frameworks for stigma, PMTCT,
BCC that are now in use to create one comprehensive
BCI approach.
Next Steps
There are many steps that must be taken to speed both
the integration of PMTCT and safe motherhood programs.
Some activities to support this at the global/donor
level include:
- Plan a meeting of representatives of key organizations
working in PMTCT and SM behavior change to accelerate
development of PMTCT BC support materials for country
programs.
- Collaboratively outline next steps for implementing
PMTCT behavior change program components.
- Develop strategies and activities to help PMTCT
and SM programs rapidly integrate program objectives,
behavior change objectives and delivery of integrated
services
- Develop plans for operations research to provide
information on the potential effectiveness of improved
obstetric practice in facilities and in communities,
even in settings where NVP treatment is not yet offered;
and on the effectiveness of various PMTCT BC approaches.
- Develop a "diagnostic" tool to assess
local capacity to adapt and implement comprehensive
PMTCT behavior change interventions. This BC-specific
tool would complement the country assessment tools
now being used in several countries.
- Develop a simple, standardized set of qualitative
research instruments that all PMTCT programs could
use. Results would be comparable and more easily compiled
to determine trends.
- Develop and pretest PMTCT BC materials, including
a set of facility-based and community-based "PMTCT
Counseling Cards" and a Users Guide, that contain
simple information on the full set of PMTCT behaviors.
The two sets of cards should be appropriate for health
facility use by providers, or community health workers
in homes and communities, and should contain the basic
information required for families to make informed
choices about options for the many PMTCT behaviors.
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