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May 2010: Opening remarks by UNICEF Regional Director Elhadj As Sy at the Global Fund meeting

Madam Minister of Public Health, Representatives of Global Fund, PEPFAR, UN Agencies, PLHIV, Government Representatives, Civil Society, Facilitators, Invited Guests, Colleagues, 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 UNAIDS family working with the Global Fund to strengthen efforts to prevent mother to child transmission of the HIV virus. 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.

Ladies and Gentlemen, you are all aware Michel Sidibé, the head of UNAIDS has called for the virtual elimination of vertical HIV transmission by 2015.  Whether that aspiration is realistic or merely a mirage depends very directly on the people gathered in this room today- countries represented here contribute more than 90% of MTCT globally.

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 with the Global Fund, PEPFAR, UNITAID and other partners, and of- course, with national governments to achieve the lofty goal of an AIDS-free generation and the joint action for results - .UNAIDS Outcome Framework 2009-2011– saving mothers and saving babies.

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 still a death sentence.  The scale up 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, but we are all witnesses of the success of the ART programmes in transforming lives of people living with HIV.  At this time it was already well established that the HIV virus was transmitted from mother to infant before and during birth, and breastfeeding and there was nothing that could be done to protect the infant from HIV infection.   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 African countries’ trials, using short course ARV prophylaxis, including Nevirapine, and pressure and advocacy mounted to support wide implementation of the results of these studies.  However, there were many unanswered questions, which led both Governments and international partners 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, what to do about the health of the mother herself, given that there was no treatment available?

Critics of early efforts to the introduction of PMTCT said unkindly, but with some justification, that these efforts would simply create more orphans.

Thus, PMTCT efforts in Africa started as pilot programmes, on a limited scale, in just a few health centres inevitably, as a vertical programme, with separate staff, separate reporting systems, separate supply lines and so on. Expanding pilot programmes shined a spotlight on  many problems, 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, let alone the mother’s own HIV infection.

By 2003 there were many health facilities offering PMTCT services in most high HIV prevalence countries, and the percentage of HIV infected mothers actually benefiting from PMTCT was slowly increasing.

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.  The challenge now is to strengthen linkages and integration within existing structures to sustain the level of efforts towards virtual elimination of MTCT, given the weak health systems, particularly at the primary facility level.

While we acknowledge that many countries may not be on track to attain universal access by the end of 2010, now, the coverage rates are much higher and we are better equipped than ever before to tackle the impact of HIV on children, mothers, parents and families. 

On the flip side of the coin for the registered progress in PMTCT are the new and more complex challenges.  Geographical coverage is on the increase though rural areas are yet to catch up in a number of countries. Adaptation of provider initiated HIV testing and counselling using rapid test with same day results for all pregnant women has reduced lost opportunities to access PMTCT. Loss to follow up along the continuum of care for pregnant women, new mothers and their newborn babies remains a big challenge, even in relatively well performing programmes. I know I am preaching to the converted, but it makes no harm to remind each other of these challenges: weak referral systems for 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 closest to her home, to travel to another health facility for her to obtain a CD4 count, perhaps to yet another facility to obtain anti-retroviral drugs to treat her own infection, and then to travel to 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 their own health and the health of their infant.  

The PMTCT programme is one of the HIV interventions with enough evidence and strategies to achieve its goals and the question is not about research, though it is necessary to continue generating knowledge, but it is how do we use the knowledge and the successful scale up we already have to take the next giant leap, to bringing the rate of transmission from mother to child down to near zero?

Prevention of paediatric HIV infection is now receiving greater recognition at the global and national levels, and allow me to share with you some of the recent significant milestones in support of PMTCT

  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 WHO technical guidelines on PMTCT. 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 for the first 6 months of life but with the ‘cover’ of an appropriate anti-retroviral drug, given either to mother or infant as long as the infant is breastfeeding.   The new guidelines are also very clear on the relationship between PMTCT and ensuring that mothers get treatment to preserve their own health.  
  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 even for those mothers who do not deliver in a health facility- 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.  PMTCT programmes are now using mobile phone contacts to send reminders, and follow up patients, often using SMS text messages. 
  5. We have a very broad agreement that we must move away from vertical programmes.  In a number of countries with high HIV prevalence rates, PMTCT is probably the most important thing to do to reduce infant and child mortality as well as maternal mortality attributed to HIV. However, it is certainly not the only thing that needs to be done to achieve the Millennium Development Goals for maternal and child mortality.  The African Union is committed to implementing the Campaign for Accelerated Reduction of Maternal Mortality to address maternal mortality, and PMTCT must be fully integrated into ante-natal care and maternal and child health services, as one essential part of such services of the AU initiative. Strongly linked and integrated services also need to ensure that children are immunised, and that diarrhoea, pneumonia and malaria are treated. We also need to ensure that all of the four prongs of PMTCT - primary prevention of HIV infection, prevention of unintended pregnancies, prevention of maternal to child transmission and treating the mother and child and family are supported. 
  6. We have greater political support and leadership than ever before.  The enthusiastic support for scaling up PMTCT and moving towards the virtual elimination of pediatric HIV by many national governments is a key development and South African Government is one of the important examples.
  7. Finally, we have unprecedented support for PMTCT from funders. 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 for implementing sound programmes will be available.

As we focus our attention on the 20 high HIV burden countries in Africa, that are priority for accelerated PMTCT programming, let  me mention a milestone meeting, which took place here in Nairobi just one year ago now.  Participants from the Governments of the 9 countries in East and Southern Africa 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 in these countries by the end of 2010:-

  • 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

We believe that many of the countries present at the  Nairobi meeting have been keeping their commitments and are striving towards the achievement of the agreed targets, with strong support from partners.  Some progress is indeed reflected in the UNGASS reports submitted by these countries to UNAIDS at the end of March this year. The level of achievement of these three targets by the end of 2010 will undeniably vary in the 20 focus countries, but we hereby challenge ourselves with the bold vision that attainment of the goal of virtual elimination of mother to child transmission by 2015 is possible, with concerted efforts of all partners in the fight against AIDS. This meeting should be seen as a further boost to helping make those commitments a reality.
It is noteworthy that the Global Fund Round 10 and re-programming are two biggest funding channels to scale up the PMTCT efforts. It is important for the countries to develop sound and evidenced based proposals to be successful in reprogramming and Round 10, and it is critical for the UN and partners to jointly develop a concrete plan to support the Country Coordinating Mechanisms and Principal Recipients in making it happen.

Let me end by suggesting just two  remaining challenges, things 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.  But all too often, the entire burden of a newly diagnosed HIV infection is left for 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
  • 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 best way of prevention of the transmission of HIV from mother to child is to prevent mothers becoming infected in the first place.    We all know resources are diminishing and resources for treating HIV will sooner or later become exhausted, if prevention is not more effective.  There is much more to be done within PMTCT programming, beyond provision of ARVs to prevent transmission for example preventing HIV infection among adolescents, helping HIV negative pregnant women and /or couples stay negative. Perhaps there is also an opportunity to learn more precisely why young women who test HIV positive at an ante-natal clinic became infected in spite of current prevention efforts including condom promotion.   Perhaps there is an opportunity to discuss the importance of male circumcision in an ante-natal settings, both for infants, if male, as well as for male partners, if not circumcised.

As a veteran of the Global Fund, I know the significance of this re-programming opportunity.  I know also that it takes all of the partners working together, not just the Global Fund or the government or the Principal Recipient, to achieve the maximum result from the re-programming. Support for PMTCT is one of UNICEF’s four priorities in the field of HIV and AIDS, 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 keep mothers alive, improve health outcomes of children born to HIV infected mothers, and reduce the number of children who are orphaned.  The UN system is ready, willing and able to provide the technical support to achieve high-quality, universal PMTCT coverage.

Thanks to the Global Fund for calling this meeting and thank you  all of you for making an AIDS-free generation our common goal.

 

 
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