Lisa Bohmer Former HIV/AIDS Director, UNICEF/Ethiopia November 23, 2004

1. Prevention of Mother to Child
Transmission of HIV/AIDS in
Africa: Challenges and
Opportunities
Lisa Bohmer,
Former HIV/AIDS Director
UNICEF/Ethiopia

2. Presentation Summary
• Role of the Program Manager
• HIV/AIDS epidemic and MTCT
• PMTCT Summary and program components
• Key issues and progress in Sub-Saharan Africa
with a focus on Ethiopia
• Challenges
• Opportunities
• Selected photos

3. My background
• Domestic social work – homelessness and
domestic violence during the later 1980s
• International focus on reproductive and sexual
health for past 12 years: adolescents, abortion,
HIV/AIDS, empowerment of girls and women
• Work throughout East and West Africa: research
and program management
• Spent the past two years with UNICEF in Ethiopia
(five years resident in Ethiopia total)
• MPH from UCLA in 1994

4. UNICEF’s HIV/AIDS Program in
Ethiopia
• Prevention of HIV/AIDS among young people
(10-24 yrs)
• Care and support for people infected and affected
by HIV/AIDS– including orphans
• Prevention of mother-to-child transmission of
HIV/AIDS (PMTCT)
• HIV/AIDS annual budget for Ethiopia was 3
million – total annual country budget was 45
million USD (rose to over 60 million in 2003
drought)

5. PMTCT Program Manager Roles
• Utilize experts: Ob/Gyn and Pediatricians
and research
• Launch and sustain programs at large scale
• Incorporate training, follow-up technical
assistance and provision of equipment,
drugs and supplies – lots of logistics
• ADVOCACY – all levels
• Building partnerships with government,
NGOs, donors, clinical experts etc.

6. HIV/AIDS Epidemic
• 38 million infected worldwide over past 20 years –
young people 15-24 years now account for nearly
half of all new infections worldwide
• In 2000, an estimated 800,000 children were
newly infected and over 90% live in Sub-Saharan
Africa
• Most infection (95%) in children occur as a result
of mother-to-child transmission
• HIV is reversing past gains against infant
mortality in many countries

7. HIV/AIDS in Sub-Saharan
Africa• SSA has just over 10% of the world’s population
but 2/3 of all those living with HIV
• New infections continue to increase – lots of
country/regional variation
• Women account for 57% of all people living with
HIV/AIDS in SSA
• Young women most disproportionately infected:
ratio of young women to men is 4 to 1 in Kenya
and Mali (we have data to same effect in Ethiopia)

8. HIV/AIDS in Ethiopia
• Infection rates are believed to be increasing – 2nd
most populated
country in Africa: 71 million people
• 1993: 3.2% adults infected – 6.6% in 2002 – ages 15-24 most infected
• Urban areas most affected but spreading to rural areas (85% rural)
• By 2001, 2.2 million people living with HIV/AIDS – 200,000 children
under 5
• 1.2 million children under 15 orphaned by HIV/AIDS
• Female Face of HIV/AIDS: More women than men are HIV infected
• Ethiopia is one of the poorest countries in the world and less than 50%
of the population has access to modern health services, 1/3 of the
population lives on less than $1/day
• TFR is 6.75%, MMR 1,800 per 100,000

9. Timing of Mother-to-Child HIV Transmission
with Breastfeeding and No ARV
Pregnancy
Late Postpartum
(6-24 months)
Early Postpartum
(0-6 months)
Adapted from N Shaffer, CDC
5-10% 10-20% 10-20%
Labor and Delivery Breastfeeding (24mos)

10. Of 100 HIV+ pregnant women, what
percent of babies will be infected?
0
20
40
60
80
100 # uninfected
# infected during
BF for 2 yrs
# infected during
delivery
#infants infected
during pregnancy
63 babies
will not
become
infected
15
15
7
# Babies
Piwoz & Ross, 2002
63%63%
37%37%

11. 3. Prevention of
Mother to Child
Transmission
• in late pregnancy
• during labor
• through breast-
• feeding
2. Prevent
unintended
pregnancies
in HIV+women
Program Strategies-
4 Prongs
1. Primary
HIV prevention in
parents to be
4. Care
and
support

12. Prevention of transmission from an
HIV-infected pregnant woman
to her infant
• Antiretroviral therapy - various regimens recommended;
selection mainly based on cost and operational practicalities
• Replacement feeding - when affordable, feasible, acceptable,
safe and sustainable
• Elective caesarian section - In European randomized trial
transmission dropped from 10.7% to 1.7%
• Making vaginal deliveries safer- Limiting episiotomies,
avoidance of traumatic deliveries, delaying rupture of membranes
• Screening and treatment of STD and malaria

13. PMTCT Services include
• Education, Voluntary Counseling and
Testing for all women as part of Ante-natal
care within hospitals and health centers
• Counseling on breastfeeding choices
• Referrals to community-based care and
support
• Continued care and support after delivery

14. Anti-Retroviral Treatment
• A drug called nevirapine is given to the mother at the onset of labor
(self-administered by most Ethiopian women)
• Neviripine is given to the newborn baby in the first 3 days of life – this
may decrease the risk of infection to the baby by half! (now only
available in health facilities despite concern that many infants will not
be brought on time)
• It is not a treatment or cure for the mother
• On-going anti-retroviral treatment for the mother is currently being
planned for (PMTCT+) – a number of SSA countries currently
initiating
• Free donation program exists to Ministries of Health
• Other regimens are also used (AZT and nevirpine), but current
neviripine only most commonly used in low resource settings

15. Counseling on infant feeding
• Breastfeeding is best but can lead to the baby getting HIV. The risk of
not breastfeeding must be balanced with the risk of breastfeeding
• Breastfeeding provides protection from death due to diarrhoeas and
respiratory infections – during the first two months of life a child
receiving replacement feeding is nearly 6 times more likely to die from
infectious diseases compared to a breastfed infant
• Women are counseled to assess their situation and make their own
choice
• If breastfeeding is chosen, they are instructed to give ONLY breast
milk without other food or liquids for six months and then to wean –
mixed feeding is very common and a real concern
• Formula is a safe option for infant feeding only when it is affordable,
safe (clean water) and acceptable to the mother and others in her
household

16. Care and Support
• HIV positive women and their families need care and support to live
well with HIV. Care includes:
• Treatment of infections
• Good nutrition
• Social support: counseling, acceptance from family and community
members
• ARVs when available
• Plan for care of children when the mother or fathers becomes sick and
dies: including memory books
• Home-based care when family member is bed-ridden with AIDS (in
SSA 4.3 million need HBC, but only 12% are receiving it)
• Currently this area is not well addressed – particularly the area of
social support

17. 11 UN-Supported Pilot PMTCT
Programs Initiated 1999-2000
Honduras
Ivory Coast
Botswana
Uganda
Zimbabwe
Zambia
Kenya
Rwanda
Burundi
Tanzania
India

18. What have the outcomes been so far?
Cascade of interventions and challenges
Pregnant
Results given
HIV positive
ARV initiated
ARV completed
Safer infant feeding
Infections averted
Test accepted
Pre-test counselling
ANC
Communication can contribute
to improving this cascade
0
20 ,000
40 ,000
60 ,000
80 ,000
100,000
120,000
140,000
160,000
ANC
137,575
Counselled
(62%)
85,980 HIV tested
(70%)
59,985
HIV infected
(16%)
9,842
Mothers on
AZT/NVP
(40%)
3,941
Numberofpregnantwomen
Source: UNICEF Oct 2001

19. PMTCT in Ethiopia:
• UNICEF and MOH began in four sites during June – October 2003 (it
took nearly 3 years to launch following development of guidelines and
an ARV policy). As of mid-2004:
• 2,272 pregnant women counseled
• 1,203 tested, 122 tested positive
• 42 women received NVP, 25 delivered
• 22 infants received NVP (RESULT)
• These sites are now expanding to 20 satellite sites – mainly health
centers
• Generally – update has been slow due to various factors
• An additional 23 sites started in 2004 funded by the USG – rapid
expansion is taking place given these funds and Global Funds

20. Challenges: Stigma
• Fear of disclosure and stigma means low uptake of VCT
and ART
• Without availability of ARVs – many don’t want to know
their status
• Beliefs may include idea that first person to be tested will
be blamed for bringing HIV into relationship
• Male partners may react with violence if a woman
discloses that she is HIV+
• Stigma associated with not breast feeding and with not
exclusively breastfeeding also a concern
• Community-level activities, work with the media, etc. key
for addressing stigma

21. Challenge: Safer Labor and Birthing
Practices
• Ideally pregnant women with HIV deliver in a
hospital or health center
• The doctor, nurse or midwife can use practices in
labor and delivery which will reduce the risk of
MTCT
• Need to work with community-based health
workers such as TBAs in places where most
deliveries are at home such as Ethiopia
• Opportunity to link with safe motherhood efforts

22. Counseling on infant feeding
• This area is still confusing – need clear messages, good
counseling and the research is still in progress
• Not all health workers make good counselors despite
training efforts
• Most pregnant HIV positive Ethiopian women chose to
continue breastfeeding as replacement feeding was not
feasible
• Lots of education and advocacy necessary so that policy
makers and program managers understand the appropriate
use of formula within PMTCT programs
• Opportunity to increase exclusive breastfeeding in
resource poor settings such as Ethiopia

23. Some key challenges
• Keep focus on women and children as programs shift from
PMTCT to ARVs for all
• Ensure that ARV efforts adequately address nutrition
• Coordination of programs by different actors at the
national level
• Avoid erosion of the national health care systems as NGOs
establish parallel systems
• Reaching women and children in rural communities
• Addressing gender discrimination that puts girls and
women at risk
• Increasing low rates of antenatal care attendance
• Limited ability of some governments to utilize HIV funds

24. Key challenges continued
• Ensuring that newborns receive a dose of ARV
within 72 hrs after birth
• Addressing stigma, gender and promoting care
and support so that PMTCT programs don’t
increase the burden on women
• Unrealistic targets imposed from Washington for
the Pepfar initiative of the US Government
(Ethiopia is very different from Botswana)
• Ensuring a steady supply of key supplies and
equipment such as test kits and drugs

25. Opportunities
• Increased funding now available
• Use PMTCT funds to improve antenatal care services
• Integrate PMTCT as part of other efforts such as safe
motherhood, malaria control, integrated management of
childhood illness, voluntary counseling and testing in the
broader community
• Integrate family planning and HIV/AIDS prevention
efforts
• Improve care and support for positive women and their
families
• Integrate within existing youth-driven prevention
activities, Anti-AIDS clubs etc.

26. Opportunities continued
• Use the fact that more women and girls are HIV+
to direct attention to the role that gender
discrimination and gender-based violence in
increasing risk
• Provide PLWAs with opportunities to gain skills
in counseling and other care and support activities
(move from victims to key actors)
• Prioritize pregnant positive women for free ARVs

27. Roles for communities
• Strong community participation component beneficial
although not very common: community dialogue approach
showing good results in Southern Ethiopia
• Outreach education should target men as well as women
• Engage People Living with HIV and AIDS to promote
positive living and reduce stigma
• Encourage all pregnant women to receive antenatal care
• Encourage voluntary counseling and testing for all
• Encourage short-term exclusive breastfeeding

28. Conclusion
• Much is happening to increase access to ARVs –
soon HIV/AIDS will not mean a death sentence!
• PMTCT is a challenging, complex program that
can make a difference and improve MCH overall –
needs to be part and parcel of other prevention and
care efforts
• Despite the devastation caused by HIV/AIDS in
African countries- there is much to be hopeful
about – many talented and committed Africans are
leading innovative efforts that could be scaled…..