DONOR AND POLICY PERSPECTIVE Integrating HIV/AIDS and Maternal Health Services

Outline Background Recent PEPFAR Results Integration of HIV and maternal health services Highlights of current integrated approaches PEPFAR Moving Forward

Background HIV and maternal conditions are the two leading causes of mortality in women age in low income countries and worldwide* million women and girls living with HIV worldwide Girls between the ages of 15 and 19 may have three to six times higher HIV prevalence than boys their age Over 530,000 women die in pregnancy or childbirth yearly An estimated 200 million women in the developing world want to space or limit childbearing but are not using family planning, which contributes to 25% of maternal and child deaths Women who are HIV-infected have rates of maternal mortality up to 5- times that of uninfected women *Women and health: today's evidence tomorrow's agenda, WHO, 2009

PEPFAR Results as of Sept.2009 Through its partnerships with more than 30 countries PEPFAR directly supported life-saving ARV treatment for over 2.4 million men, women and children  They represent more than half of the estimated four million individuals in low and middle- income countries on treatment PEPFAR partnerships have directly supported care for nearly 11 million people affected by HIV/AIDS, including 3.6 million orphans and vulnerable children In FY 2009, PEPFAR directly supported HIV counseling and testing for nearly 29 million people, providing a critical entry point to prevention, treatment, and care In FY 2009, PEPFAR directly supported prevention of mother-to-child transmission programs that allowed nearly 100,000 babies of HIV-positive mothers to be born HIV-free, adding to the nearly 240,000 babies born without HIV due to direct PEPFAR support during FYs

PEPFAR’s Focus on Women & Girls As of September 2008: Women represent 63 percent of people receiving PEPFAR- supported antiretroviral treatment Women represent 64 percent of people who received PEPFAR-supported counseling and testing services Girls represent 51 percent of children who received care services The United States Government has supplied more than 2.2. billion condoms worldwide from 2004 to 2008; more than 25 million were female condoms

Progress Toward Meeting PMTCT goals, Percentage of pregnant women receiving HIV counseling and testing, 2006 and 2008 Percentage of HIV-infected pregnant women receiving PMTCT ARV, 2006 and 2008

Integration of HIV and women’s health services

Obama Administration’s Global Health Initiative In May 2009, President Obama announced a six-year, $63 billion commitment to global health. The Initiative maintains robust funding and strong commitments to fighting HIV/AIDS, TB and malaria; also focuses increased resources on MCH, FP, NTDs. The Initiative also seeks to improve coordination and integration, expand country ownership, increase capacity and strengthen health systems, increase multilateral engagement, and increase women’s access to care.

Why is Integration of Family Planning Into HIV Prevention and Care Important? Women with HIV, like all women, have a right to determine the number and spacing of their children Many women with HIV express an unmet need for contraception. Opportunity to expand access to contraception and improve quality of life for those living with HIV and prevent unintended pregnancy

FY2010 Guidance to PEPFAR Country Programs on PMTCT/MCH/FP Integration Where feasible and appropriate to the epidemic support should be provided for: Integrating PMTCT with MCH services as an entry point to other HIV services. Linkages and wrap around with family planning services  e.g., co-locating and linking PMTCT and family planning services, training FP clinical providers on PMTCT, counseling HIV+ women in PMTCT Safe Motherhood and child survival interventions :  Emergency Obstetric Care and neonatal resuscitation could be integrated into PMTCT training where feasible. Linkages should be strengthened between key initiatives such as PEPFAR and PMI, which focus on pregnant women and children

Accelerating PEPFAR’s PMTCT Response PEPFAR will devote specific additional financing to PMTCT in FY2010 to expand PMTCT coverage With this funding, PEPFAR will target low-performing countries and support them to expand testing, prophylaxis, treatment and care for women and their families This increased investment in improving access to PMTCT services will be closely linked with efforts to MCH, family planning, nutrition and will provide a platform for wider efforts to support comprehensive services for women, children and their families

Bolstering Primary Prevention Pregnant women are at an approximately 2-fold increased biological risk of acquiring HIV. Given the very high total fertility rate in sub-Saharan Africa, a high proportion of new infections in women occur in pregnancy. Partner discordance rates have been documented to be high (up to 30-50%) in PMTCT settings. Involving male partners in the antenatal period is a an emerging strategic approach to reduce risk through counseling both partners on the importance of mutual fidelity and partner testing, condoms for discordant couples, and other prevention with positives (PWP) interventions

Screening for Cervical Cancer Cervical cancer is the most common cancer among women in many developing countries It is now well-established that HIV positive women have a high burden of precancerous lesions and cancer of the cervix, compared to HIV negative women Detection and treatment of precancerous lesions can prevent progression to cervical cancer; detection and treatment is feasible in low resource settings PEPFAR supports screening/treatment to prevent cervical cancer in HIV positive women, in sites where HIV positive women seen for care PEPFAR supports approaches which are feasible and effective in resource-limited settings, such as a “screen and treat” approach using visual exam and cryotherapy, which can be performed in a single visit, and has been shown to be cost-effective

PEPFAR: Integrating Gender into Programming Five cross-cutting strategies 1. Increasing gender equity in HIV/AIDS activities and services 2. Reducing violence and coercion 3. Addressing male norms and behaviors 4. Increasing women’s legal rights and protection 5. Increasing women’s access to income and productive resources Addressing gender issues unique to prevention, care, and treatment interventions Programming best practices that are responsive to each unique country context

Shisana O, Rehle T, Simbayi LC, Zuma K, Jooste S, Pillay-van-Wyk V, Mbelle N, Van Zyl J, Parker W, Zungu NP, Pezi S & the SABSSM III Implementation Team (2009) South African national HIV prevalence, incidence, behaviour and communication survey 2008: A turning tide among teenagers? Cape Town: HSRC Press Comparison of HIV incidence in the 15–20 age group, South Africa 2002, 2005, and 2008

Responding to Gender-Based Violence PEPFAR supports GBV activities in all its country programs GBV prevention and response  strengthen and expand access HIV post exposure prophylaxis (PEP) as part of a comprehensive package of services for rape victims  raise health workers’ awareness of and skills to address violence, and to establish links with community and social services  work with men and boys through community mobilization and group education to address root causes for enhancing prevention of violence  strengthen policy and legal frameworks that outlaw GBV PEPFAR SGBV Initiative: Aims to expand the evidence base on sexual violence programming in Africa, by strengthening health services for victims, referrals to other support services, and linkages between communities and health services. The initiative is being implemented in South Africa, Uganda, and Rwanda. Scaling-up and tracking GBV activities is a priority for PEPFAR

Highlights of current integrated approaches

Highlights of PEPFAR supported linkages: South Africa Government has a strong family planning program and the country has an overall high contraceptive prevalence rate, around 56%, HIV programs can be added to the existing family planning services.  PEPFAR supports the provision of provider initiated HIV counseling and testing within several family planning clinics.  These programs offer work to improve the use of dual protection/dual method, as condoms are the only contraceptives that provide protection against both unintended pregnancy and HIV/STIs.  The integration approaches have also helped to an early entry point for PMTCT services for the family planning client’s who test HIV-positive.

Highlights of PEPFAR supported linkages: Kenya Provincial level AIDS, Population and Health Integrated Assistance (APHIA) projects have achieved rapid and impressive results by combining funds from PEPFAR and other funding for maximum effectiveness at facility level. With wrap-around Population funding, the APHIA projects have achieved a 90 percent increase in couple years of protection (from 98,000 in 2006 to 186,338 in 2007) and a nine-fold increase in family planning service delivery points during the first full year of scale-up.

Cervical Cancer Screening in Zambia Cervical cancer screening program established in Zambia in January 2006, through Center for Infectious Disease Research in Zambia (CIDRZ) Integrated into government-operated public health clinics, CIDRZ care and treatment program and University Hospital; utilized nurses to perform screening, with physician back-up if necessary Low-tech approach based on visual inspection with acetic acid, including magnified digital photo of cervix (digital cervicography), and cryotherapy Close attention to several critical elements – specific protocols, careful supervision and follow-up, quality assurance, excellent training As of Sept 2008, over 20,000 women screened; overall 19% underwent cryotherapy for amenable lesions; 8% underwent further testing, and overall 5% found to have high-grade lesions or cancer Training now provided for several countries interested in replicating model In FY08, nine countries proposed cervical cancer programs (Botswana, Guyana, Kenya, Mozambique, Namibia, South Africa, Tanzania, Uganda, Zambia) and additional countries are now involved in screening activities

PEPFAR Moving Forward

Key Concepts for Next Phase of the Global HIV Response Transition from an emergency response to promotion of sustainable country programs. Strengthen partner government capacity to lead the response to this epidemic and other health demands. Expand prevention, care, and treatment in both concentrated and generalized epidemics. Integrate and coordinate HIV/AIDS programs with broader global health and development programs to maximize impact on health systems. Invest in innovation and operations research to evaluate impact, improve service delivery and maximize outcomes.

New Strategic Directions for PEPFAR Increasing investment in prevention of mother-to-child transmission to meet 80% coverage levels in HIV testing and counseling of pregnant women and 85% coverage levels of ARV prophylaxis for those women who test positive Increasing proportion of HIV-infected infants & children who receive treatment commensurate to their representation in a country’s overall epidemic, helping countries to meet national coverage levels of 65% for early infant diagnosis, and doubling the number of at-risk babies born HIV-free Expanding integration of HIV prevention, care and support, and treatment services with family planning and reproductive health services, so that women living with HIV can access necessary care, and so that all women know how to protect themselves from HIV infection

New Strategic Directions for PEPFAR Strengthening the ability of families and communities to provide supportive services, such as food, nutrition, education, livelihood and vocational training, to orphans and vulnerable children Expanding PEPFAR’s commitment to cross-cutting integration of gender equity in its programs and policies, with a new focus on addressing and reducing gender-based violence.

Challenges Limited research on optimal methods of integration Determining the best platforms off of which to expand integrated services Limited data on the costs Overcoming challenges inherent in different funding streams and varying policies (although hopefully this will be changing) Under-developed indicators for measuring successful service integration

but, huge opportunities…. Building on PEPFAR’s platform to advance general MCH and reproductive health goals Location of US Government and Non-US Government supported Prevention of Mother-to-Child Transmission sites over the estimated number of HIV+ Pregnant women in Tanzania, 2008

In Conclusion PEPFAR has made great progress in increasing access to PMTCT services and taken important steps toward building more integrated programs Through the Global Health Initiative, PEPFAR will help drive much greater integration of PMTCT, MCH, FP and other RH services over the next several years Truly integrated approaches will consider not only the clinical needs of women but will also address underlying societal inequities and structures that will improve the wellbeing of women

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