Treatment for Women and Prevention for Infants: Can't We Do Both?
The rate of new infections among women is growing at alarming rates. Although women make up about half of those living with HIV in the world, in Sub-Saharan Africa, the proportion of people living with HIV who are women is nearly 60% of adults and an astonishing 75% of young people between the ages of 15 and 24.1 The numbers are reflective of gender inequality and the particular vulnerability of women in all societies. Women have less access to education and economic opportunity, which makes them more dependent on their families and on male partners. As a result of these power differentials, women and are less able to negotiate the terms of sex and safer sex practices, like condom use with their male partners. In many cases, women resort to engaging in survival sex for food and material support for themselves and their children.
In addition to a high burden of infection, women bear the brunt of the epidemic in other ways. Biologically, women are twice as likely as men to contract HIV from an episode of unprotected intercourse, and in discordant couples men are more likely to have introduced HIV into the relationship.2 Socially and culturally, women are caregivers for the infirm and orphans and they suffer great financial hardships when their partners become sick or die. Despite the disproportionate burden of HIV on women in Africa, care and treatment programs have largely failed to respond to their specific needs or consider the special challenges women face when accessing care.
Nowhere is this phenomenon more evident than in the conception and implementation of "Prevention-of-Mother-to-Child-Transmission" (PMTCT) programs in the developing world. The PMTCT concept has its roots in a 1994 study, which showed that taking AZT during pregnancy dramatically reduced the chances of an HIV positive mother passing on the virus to her newborn.3 While a short course was shown to be effective, AZT was then still prohibitively expensive for residents of poor countries. The AZT regimen quickly became standard for HIV positive pregnant women in wealthier countries. Since then, the PMTCT regimens for HIV-positive pregnant women in rich and poor countries have continued to sharply diverge. If women are provided with a complete package of care and treatment during pregnancy, the chances that they will pass the virus on to their children can be decreased to less than 2%. Without these interventions, about 20-45% of HIV-exposed infants will contract the virus.4
About 4 years after the 1994 AZT study, another study showed that a single dose of Nevirapine given during labor reduced intra-uterine and peri-partum transmission rates by 50%.5 Because of its ease of delivery and relatively low cost, single-dose Nevirapine was quickly promoted as the prime PMTCT strategy in low-income, high-HIV-prevalence countries and was at the center of the World Health Organization's (WHO) first PMTCT recommendations in 2000.
Somewhere in this myopic focus on transmission rates, we lost sight of one simple fact: the survival of infants depends heavily on the well-being of their mothers. In 1999, Berer noted, "Short course AZT treatment is an intervention that uses women's bodies to deliver preventive treatment to infants. Although the anti-HIV benefit to infants is clear, there is no benefit to the women."6 Nevirapine proved even worse. Studies subsequently demonstrated that mothers face an increased risk of developing resistance when they eventually must take antiretrovirals for their own treatment if they had previously taken Nevirapine during pregnancy to protect their infants.7
Following the WHO guidelines, PMTCT programs were implemented in a number of pilot sites in Africa starting as early as 1999. For the most part, the PMTCT programs were instituted by international organizations, not primarily by public sector health services, so they tended to be fragmented and rely on intensive international support. Implementation was also "vertical" in nature. PMTCT clinics were often stand alone sites -- separated from prenatal care and disconnected from treatment programs. One could find heavily-funded PMTCT programs in the same places where there was poor access to prenatal care and no c-sections, where institutional delivery rates were less than 50%, and where referral for treatment for pregnant women was a low priority.
As early as 2001, advocates argued for a reemphasis on care and treatment for women in PMTCT programs, but only recently did their arguments have a significant impact on implementation strategies.8 The shift came largely due to widespread acknowledgement that PMTCT is not working as a vertically implemented, stand-alone program. The results of the 2007 PMTCT report card were damning. Over 500,000 children were infected with HIV in 2006, nearly all through mother-to-child transmission -- a number that has not budged since the late 1990s. Only 16% of women in middle and low income countries were even tested for HIV during their prenatal visits, and only 27% of prenatal clinics in sub-Saharan African offered PMTCT services. Finally, of the estimated total number of pregnant women with HIV in countries with generalized epidemics, only about 20% received antiretrovirals as prophylaxis to prevent transmission of the virus to their children. The vast majority of those received only single dose Nevirapine. Although more effective regimens have now been tested and proven, regimens which also have less risk of inducing resistance for the mother, they are more complicated, requiring longer courses, and have been difficult to implement. There is no mention of how many women were able to access antiretroviral treatment (ART), but only two years after the widespread initiation of pediatric treatment, the report estimates that nearly a quarter of children who need ART received it in 2006.9
This contrasts starkly to the estimated number of pregnant women able to access treatment for themselves. At least 20% of pregnant women with HIV in Africa would be eligible for ART, but in a recent review of PMTCT programs implemented in Africa by a major US-based organization, only about 1% of women who tested HIV positive during pregnancy received treatment.10
Protection of the right to health for HIV positive women in Africa clearly requires a new framework for services which include integrating PMTCT programs into routine prenatal care for women and finding innovative ways to deliver ART treatment to HIV positive pregnant women before labor and delivery. The new models must consider the social, economic and political context of women's lives.
In Mozambique, the Ministry of Health shifted to an opt-out testing strategy for PMTCT programs in 2006. This shift in pre-test counseling meant that the test would be presented as a routine part of the prenatal care labs, much as it is in the U.S., giving women the opportunity to "opt out" instead of requiring them to "opt-in" and affirmatively request the test. With this change, Manica and Sofala Provinces in central Mozambique began to integrate PMTCT services seamlessly into routine prenatal care. Innovative aspects of this model include: 1) one nurse taking care of the entire prenatal visit including routing prenatal care, syphilis testing, provision of preventive treatment for malaria, and HIV testing 2) combined HIV and syphilis testing 3) pre-and post-test counseling delivered in a confidential setting as part of the routine visit 4) on-site CD4 testing and triage for HIV positive women and 5) decentralized treatment programs with HAART available in the same health centers where prenatal care is offered.
Integrating HIV care of pregnant women and PMTCT into routine prenatal care reduces the burden on scarce human resources by streamlining the patient visit. This intervention also improves uptake of HIV testing. Since integrated opt-out testing was implemented, the percent of women accepting HIV tests rose to 90% from the pre-integration acceptance rate of 60%. Perhaps most importantly, integrating both PMTCT services and treatment as closely as possible into prenatal care means that more pregnant women get treatment for themselves; which is ultimately the best strategy to prevent HIV transmission to their children and also ensures that children will have a mother to care for them into the future.
Where decentralized, on-site care and HIV treatment was offered, a higher proportion of HIV positive women referred from prenatal care enrolled for care than those referred to off-site, nearby clinics. In places where women could get both prenatal care and HIV treatment at the same health clinic, 77% enrolled for care, versus only 28% who enrolled when they had to be referred to another site for their HIV treatment -- even if the HIV clinic was nearby in the same town.11 Mozambique now integrates even more services into the prenatal care visit itself. In many places, pregnant women can get their CD4 test done in the prenatal visit, the same day they receive their positive HIV test. A few sites now train prenatal care nurses to assess the HIV disease stage of patients using clinical guidelines combined with CD4 results and, if they are eligible under treatment guidelines, to prescribe the initial month of antiretroviral treatment until women can become enrolled in the HIV clinic. As result of these innovations, the percent of pregnant women receiving treatment has gone up from about 2% to around 10% in just a couple of years.12
While these results are encouraging, more must be done to shift the focus back onto the well-being of both mothers and children. In light of the great gains in HIV treatment access in Africa celebrated over the past several years, the lack of attention for pregnant women is all the more appalling. A new paradigm would focus not just on the infections prevented in children but equally importantly on the numbers of HIV positive mothers and children receiving treatment. By ignoring the mothers, we risk defining success by lowering infection rates in children, but increasing the number of HIV orphans.
Wendy Johnson, M.D., M.P.H. is a Clinical Assistant Professor in the Department of Global Health at the University of Washington. From 2004 to 2006, she was the Mozambique Program Director for Health Alliance International, scaling-up HIV treatment and prevention programs in central Mozambique.
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