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Opening remarks by UNICEF Regional Director Elhadj As Sy at the Global Fund PMTCT meeting

Courtesies and recognitions…., ladies and gentlemen

Good morning.

It is an honour and a privilege to be asked to make introductory remarks on behalf of the United Nations bodies which are particularly engaged with the work that we have before us – working with the Global Fund to strengthen efforts to prevent mother to child transmission of the HIV virus and helping us get to the situation that we all want to be in in a few years time, with very few infants and young children becoming infected with HIV in the entire Continent of Africa. I speak to you therefore on behalf of the Secretariat of UNAIDS and the UNAIDS Co-sponsors, particularly those most closely associated with support for PMTCT, the World Health Organisation, UNFPA and, the organisation that I now have the honour to work for, the United Nations Children’s Fund.

WHO, UNFPA and UNICEF with UNAIDS have been working closely together in the past with shared objectives and priorities and I want to assure you that we are committed to working even more closely together with each other in the immediate future, and even more
closely with the Global Fund, with other partners and of course with the national government to achieve the lofty goals which have been set.

Allow me to take a minute or two to sketch out where I think we have come from, because we have already travelled on a long journey together – some would say a journey that has taken too long, with too many casualties on the way, but remembering where we started from might help us understand where we have now to go.

Twelve years ago, in 1998 an HIV infection in Africa was a death sentence. There was virtually no treatment available anywhere. Indeed, the thought of treatment in Africa was seen by many to be an illusion, and we heard critics say that providing treatment for HIV in Africa would simply not be practical or affordable, and that even if it was, people did not have watches to take their pills at regular times. At this time it was also well established that the HIV virus was transmitted from mother to infant before and during birth, and that the virus was also transmitted through breastfeeding, but there was nothing that could be done to reduce those risks. Then we got the results from the first study of the impact of anti-retroviral treatment given in late pregnancy from Thailand in 1998 and, a year later the even more exciting results from the Uganda trial of Nevirapine. Following the publication and review of these research studies, pressure and advocacy mounted to support wide implementation of the results of these studies. But there were many unanswered questions, which led both Governments and the agencies that supported them, to proceed cautiously. Questions included:

  • What to do about infant feeding?
  • Who would pay for the cost of the then very expensive drugs needed?
  • And, disconcertingly, what to do about the health of the mother herself, given that there were no treatment programmes available?

Critics of early efforts to introduce PMTCT said unkindly, but with some justification, that these efforts were simply creating more orphans and adding to what was then seen to be the enormous burden of AIDS orphans that no state would be able to cope with.

Partly for these reasons, proceeding into the unknown with caution and wanting to closely monitor programmes, PMTCT efforts in Africa started as pilot programmes, on a limited scale, sometimes in just one part of a country, or in just a few health centres, or in one major hospital. PMTCT also started, perhaps inevitably, as a vertical programme, sometimes with separate staff, separate reporting systems, separate supply lines and so on. This ‘pilot’ situation continued for rather too many years, although there was increasing demand for the pilot programmes to be expanded, the vertical support structure often remained. The expanding pilot programmes continued to experience many problems, the most important being the continued dilemma about what infant feeding method was best, and what to do to preserve the health of the mother. There was also the dilemma of very weak existing health systems, and all too frequently we saw the anomaly of a health facility having anti-retroviral drugs for PMTCT, but no antibiotics to treat pneumonia, or medicines to treat malaria.

By 2003 there were many health facilities offering PMTCT services in most high HIV prevalence countries, and we might estimate that, with one or two exceptions, the percentage of HIV infected mothers actually benefiting from PMTCT was around 20 percent. On World Aids Day 2003, WHO and UNAIDS released a concrete plan to provide 3 million people with antiretroviral treatment by 2005, and enormous efforts were made to scale up anti-retroviral treatment in Africa from an extremely low baseline. The Global Fund, which made its first grants in 2002, and PEPFAR also supported scaling up HIV treatment programmes, and access to treatment expanded rapidly.

The legacy of this history is that we now have rather good access to both PMTCT and HIV treatment programmes in many of our countries, but vertical programmes and separate systems for delivering the benefits often remain. The challenge now is to move towards true integration.

There is ample data to show that referral of patients from one part of the health system to another, particularly referral from a rural health centre to an urban hospital, does not work very well in most parts of Africa, with very high drop out rates. Given this, I wonder how many of our current programmes require a mother who has just been diagnosed with an HIV infection at an ante-natal clinic, to travel to another health facility for her to obtain a CD4 count, and then perhaps to yet another facility to obtain anti-retroviral drugs to treat her own infection, and then to travel to yet another facility to obtain an ‘early infant diagnosis’ test for her infant. Little wonder then that relatively few mothers complete all of the steps required to maximise her own health and the health of her infant.

Enough of history. Many things have now changed for the better. Now, in May 2010, we are better equipped than ever before to tackle the impact of HIV on children, mothers, parents and families. Let me just touch upon seven recent developments, many of which you will hear more detail about during the course of the next two days. …

  1. Prevention of mother to child transmission is one of the ten priority areas and strategies of the UNAIDS Outcome Framework 2009- 2011 supported by all of the UNAIDS co-sponsors.
  2. We now have radical new technical guidelines on how to ‘do’ PMTCT, developed in record time by WHO and published in late 2009. For the first time, these guidelines give a very clear answer to the old and difficult problem of infant feeding – the answer is very clear – continue with exclusive breastfeeding, but with the ‘cover’ of an appropriate anti-retroviral drug, given either to mother or infant. The new guidelines are also very clear on the relationship between PMTCT and ensuring that mothers get treatment to preserve their own health as soon as they need it, preferably guided by determination of their CD4 count. Full implementation of this approach should of course dramatically reduce the future number of maternal orphans due to AIDS, with enormous cost and other savings to the State.
  3. We have the ‘mother baby pack’, – a kit of PMTCT medicines for the mother and the infant all packed together to facilitate the implementation of the new WHO Guidelines - now ready for phased implementation in four countries in Africa, Kenya, Lesotho, Zambia and Cameroun…
  4. We have the capacity to dramatically reduce ‘drop outs’ from PMTCT efforts, to remind mothers to return for critical appointments and to follow up families who do not return on time. Although we do not have accurate surveys, I think it is true to say that in virtually all high HIV prevalence countries, more than half of all mothers enrolled in PMTCT programmes either have their own mobile phone, or access to the phone of another family member or friend. Increasingly, PMTCT programmes are using mobile phone contacts to send reminders, and follow up patients, often using sms text messages. There are very simple systems in use, and more sophisticated options under development. We must make full use of this opportunity, and devise ways that mothers who have no access to a mobile phone can gain access.
  5. We have a very broad agreement that we must finally and completely move away from the legacy of vertical programmes. PMTCT is important, in some high prevalence countries it is indeed probably the most important thing to do to reduce infant and child mortality rates and maternal mortality, but is certainly not the only thing that needs to be done if the lofty Millenium Development Goals are to be achieved. PMTCT must be fully integrated into ante-natal care and maternal and child health services, as one essential part of such services. But strong integrated services also need to ensure that children are immunised, that diarrhoea, pneumonia and malaria are well treated, that family planning services are available and that all steps are taken to reduce maternal mortality – to give just some examples of other ‘essential’ services. We also need to ensure that all of the four prongs of PMTCT, agreed to in Abuja back in 2005 are supported, primary prevention of HIV infection, prevention of unintended pregnancies, prevention of maternal to child transmission and treating the mother and child and family. Strengthening these services will also make a major contribution to other shared goals, including the reduction of maternal mortality.
  6. We have greater political support and leadership than ever before. The enthusiasticsupport for scaling up PMTCT and moving towards the virtual elimination of pediatric HIV by the Government of South Africa is important not just within South Africa, but within the entire SADC region and beyond.
  7. We have unprecedented support for PMTCT from funding agencies. Much of our recent progress can be attributed to PEPFAR and Global Fund support. Now we have the opportunity of this meeting, following a decision of the Global Fund Board, of support and flexibility to help ensure that the funds required to implement sound programmes will be available. Michel Sidibe, the Executive Director of UNAIDS, has provided his own strong leadership to help make PMTCT a priority and I know he is personally very excited about this new opportunity to work with the Global Fund to achieve the virtual elimination of pediatric AIDS.

Let me mention a milestone meeting which took place here in Nairobi just over one year ago now. Participants from the Governments of the 14 countries in Africa which contribute most of the new cases of pediatric HIV in the entire world came together, with staff of UN and partner agencies to review progress and future direction of PMTCT. They unanimously agreed to a conclusion that three specific things could be achieved by the end of 2010 :-

The achievement of these three targets would put countries in a good position to reach the goal of virtual elimination of mother to child transmission by 2015.

By the time you get back home from this meeting, there will be just seven months left to the end of 2010 and the declared goal of ‘Universal Access’. We believe that many of the countries present at that Nairobi meeting have been keeping their commitments and are
striving towards the achievement of those targets that they agreed to, with strong support from partners. Some progress is indeed reflected in the preliminary reports on progress towards Universal Access submitted by countries to UNAIDS at the end of last March.

This meeting should be seen as a further boost to helping make those commitments a reality.

Let me end by suggesting just two remaining challenges, things that it might be useful for you to think about as you work to strengthen your own PMTCT approaches and as you develop proposals for consideration by the Global Fund

First male partner involvement. Up until now I have talked only of mothers, but children have fathers as well! There has been a lot of debate and discussion about how to involve men more, but so far relatively few results. There are a few success stories, and I hope you will hear more about them during the course of this meeting. But all too often, the entire burden of a newly diagnosed HIV infection is left for:

  • Reaching at least 80% coverage for ART prophylaxis for PMTCT for the mother.
  • Reducing the gap between maternal and infant ARV coverage by half

  • Doubling the number of children on HIV treatment and care

the woman herself to manage, fearing victimisation or violence and stigma and discrimination, fearing that she will be blamed, sent away from the family home. I suggest that we should not just be talking about male involvement in PMTCT, but further involvement of men in the entire decision making process around reproductive health – for HIV negative couples as well as for couples living with HIV. I suggest that in many countries the starting point for male involvement should be discussions about a couple’s future prior to marriage, with encouragement for the couple to know their HIV status, and disclose the results to each other, prior to becoming married. In this way, the first HIV test at an ante-natal clinic should be seen as a confirmatory test, not a first time surprise. I understand that the leaders of many of the major religions in Africa already encourage an approach along these lines, perhaps we should think of what Governments and agencies could do to strengthen this approach all the time guarding confidentiality and avoiding stigma and discrimination.

Which brings me to my final point. Prevention. How can we better link ante-natal care, PMTCT, mother and child health programmes to effective HIV prevention?
We must never forget that the very best way of prevention the transmission of HIV from mother to child is to prevent mothers becoming infected in the first place. I do not have time to go into details, but I think you all know we are making painfully slow progress with prevention. Whether the journalist who recently wrote the article in the New York Times entitled “At the front lines, AIDS war is falling apart” was right or wrong, that article reminded the world again that for every 100 people starting treatment there are 250 new infections, and that sooner or later treatment budgets are going to be exhausted if prevention is not more effective. I think there is much much more that could be done, linked to PMTCT programmes, to help ensure that HIV negative couples stay negative. And we should remember as well, that we know that discordant couples are much more common that we once thought – are we doing enough to keep HIV negative male partners of women diagnosed in ante-natal clinics HIV negative? Perhaps there is also an opportunity to learn more precisely why young women who are discovered to have an HIV infection at an ante-natal clinic became infected, in spite of efforts to provide education and awareness, condoms etc etc – what went wrong? Perhaps there is an opportunity to discuss the importance of male circumcision with mothers in an ante-natal setting, both for their infants, if male, as well as for their male partners, if not circumcised. I think it would be good if you can make the time in your detailed discussions about programme strengthening to consider some of these things.

Let me end then by saying that the situation is now right for all countries in Africa with a medium and high prevalence of HIV to make major progress – during the rest of this year towards reaching the goal of Universal Access and during the following five years to reaching the Millenium Development Goals and the virtual elimination of pediatric HIV. We should make maximum use of this window of opportunity and ensure that we use PMTCT as an entry point to re-vamp integration and comprehensive health systems strengthening. This will not be easy, and it will require the extraordinary commitment from all of us. You will get the details of the commitment of the Global Fund to making this happen here in this meeting. Support for PMTCT is one of UNICEFs four priorities in the field of HIV and AIDS, as part of what has become known as the ‘Four Ps’, together with primary prevention, pediatric HIV treatment and protection, care and support of orphans and vulnerable children. And effective PMTCT programmes, which include timely treatment for mothers, will of course do much to reduce the number of children who are orphaned. I believe you will also hear some details of what the other UN agencies are planning to do to support your work, but let me say in summary that the entire organisations of UNAIDS, WHO and UNICEF are giving this work, including providing countries with support to effectively re-programme past grants or apply for new grants to the Global Fund for PMTCT the highest priority, and that we pledge to provide you with the support that you may require, working together as part of the UN family wherever this makes sense.

Thank you very much.

 

 
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