Gender and HIV/AIDS: Prevention of Mother-to-Child-Transmission (PMTCT) and paediatric treatment
The risk of HIV transmission from a mother to her baby during pregnancy, delivery or breast feeding ranges between 25 and 45 percent, depending on the women’s health and her nutritional status. The transmission rate can be almost eliminated through a combination of interventions including voluntary counselling and testing, antiretroviral (ARV) prophylaxis for the mother and her baby, safe delivery and appropriate infant feeding.
Much progress has been made over the past years in providing HIV-positive pregnant women and their babies with access to such Prevention of Mother-to-Child Transmission (PMTCT) programmes, particularly in the Eastern and Southern Africa region (ESAR), which continues to be the epicentre of the pandemic.
However, huge disparities still exist between and within countries. Many women are excluded because they cannot reach the next health facility providing PMTCT programmes, because of the low quality of such services or because of stigma, discrimination and lack of support by their male partner, their family or their community. As a result, every day more than 1000 infants are born with HIV, the vast majority of them in sub-Saharan Africa.
Facts and figures
In ESA, around 50 percent of pregnant women were tested for HIV in 2009, up from 15 percent in 2005. On average, 68 percent of those tested HIV-positive received antiretroviral prophylaxis (19 percent in 2005). Paediatric treatment also increased significantly from 8 percent in 2005 to 32 percent. More than 250,000 children under 15 years were reached in 2009, 60,000 more than one year before.
Disparities: Such overall remarkable progress, however, masks enormous disparities between and within countries. In South Africa, for example, the country with the highest number of pregnant women living with HIV/AIDS, and in Zambia more than 95 percent of pregnant women were tested for HIV in 2009, while coverage in Ethiopia and Angola only reached 16 and 26 percent respectively.
Four countries (Botswana, Namibia, Swaziland and South Africa) already reached the Universal Access goal of 80 percent coverage or more of PMTCT services, which was established by the UN General Assembly Special Session on HIV/AIDS in 2001. In Burundi, on the other hand, only 12 percent of pregnant women living with HIV were enrolled in PMTCT services. In Botswana, Namibia and Swaziland more than 70 percent of infants and children in need of treatment received ARVs, compared to 14 percent in Mozambique.
Limited access to antenatal care: Geographical remoteness, limited infrastructure, and unaffordable transport costs all mean that a majority of women do not attend antenatal care (ANC) beyond the first visit, and they usually come late in the pregnancy to the health facility. Only about 40 percent of women deliver their babies with the assistance of a skilled attendant.
Thus, for many pregnant women and mothers living with HIV, PMTCT is an intensive, one-time event, taking place around the first ANC visit, or around the birth of their child. Later-on during the course of the PMTCT programme, many pregnant women with HIV and their babies are lost, and in many cases they only come back to a health facility when they become ill.
Disclosure and discrimination: Stigma and discrimination are important reasons why women drop out of PMTCT services. Pregnant women who test positive during their first ANC visit, often do not disclose their status to their male partner and family, because they fear violent reactions and being abandoned. A study by USAID in different countries in sub-Saharan Africa has shown that between 3 and 15 percent of women report being blamed, abandoned, treated with anger or beaten after they disclosed to their partner that they were HIV-positive.
In Tanzania, women accessing Voluntary Counselling and Testing (VCT) services reported fear of violence as a primary reason for not talking to their partners about their sero-status. An HIV-positive pregnant woman who has not disclosed her status to her family is generally less able to adhere to preventive drugs for fear of revealing that she is infected.
Disempowerment: Women throughout the region tend to have limited decision-making power on health expenditures and this directly affects their ability to access HIV prevention and treatment services. Studies have shown that in a poor household, more money will be spent on medical expenditures for a man living with HIV and AIDS than for a woman.
According to National Demographic and Health Surveys in 10 countries in ESAR, on average 40 percent of women say that their husbands alone make decisions on daily household expenditures. Without the ability to decide on expenditure, women cannot direct resources to their own or their children’s health. Many cannot even seek health care without their husband’s or another family member’s permission.
Limited male involvement: Men’s participation in PMTCT services is still limited in many countries. Men often perceive pregnancy and childbearing as the sole responsibility of women. Evidence shows that when male partners are supportive of women’s healthcare, stigma is reduced and uptake of HIV prevention and treatment services for women and children is increased.
UNICEF supports the UNAIDS call for a ‘virtual elimination of mother-to-child transmission of HIV by 2015’.
The Mother-Baby Pack contains the most efficacious ARV regimens for PMTCT, in line with the latest WHO recommendations.
Health workers in antenatal clinics and delivery care settings, including non-medical workers, distribute the packs to pregnant women living with HIV, who do not yet need ARV for their own health.
The Mother-Baby Pack is divided into three colour-coded sections and corresponding sub-packs, with one each for Pregnancy, Labour and Delivery and After Delivery. This makes it easy for women to take the medicines at home. The colour coding and pictograms help women including those with low literacy to take the correct dose.
During phase one (until June 2011) the Mother-Baby Pack is rolled out in Kenya, Lesotho, Zambia and Cameroon.
An important partner in PMTCT programmes is the non-governmental organisation mothers2mothers (m2m), which involves mothers living with HIV/AIDS who have successfully gone through a PMTCT programme themselves. These Mentor Mothers provide psychosocial support and counselling, help women adhere to their prevention programme and deal with issues of disclosure and stigma within families. The Mentor Mothers also encourage pregnant women to bring children who may be exposed to HIV to health facilities for testing. The programme runs in several countries, including Kenya, Lesotho, Malawi, Rwanda, South Africa and Swaziland.
UNICEF also addresses the social and cultural barriers that prevent women from making use of available PMTCT services. Strengthening the involvement of men is a key intervention in this regard. UNICEF supports the Male Champions Initiative in Malawi, Rwanda and Zambia, a community-based programme that uses positive messaging and male role models. In Rwanda, for example, male involvement in PMTCT increased from 16 percent in 2003 to 78 percent in 2008.
Another key component of the Maisha initiative is the Mother-Baby-Pack containing antiretroviral drugs and antibiotics, which women can easily administer at home. Pregnant women are supported by Mentor Mothers in using the Mother Baby Pack. Maisha means Life in Kiswahili.