**U.S. Agency for International Development**

**Highlights from the XIV International AIDS Conference**

### **July 31, 2002**

### **"Preventing Mother-to-Child Transmission of HIV"**

***Amanda Gibbons of USAID*** began by describing the three-pronged
approach to preventing mother-to-child transmission (MTCT) of HIV --
preventing HIV infection in women of reproductive age in the first
place, preventing unwanted pregnancies in women who have HIV infection,
and preventing vertical HIV transmission during pregnancy, delivery, and
infant feeding. USAID currently has programs in 11 countries serving
about 50,000 pregnant women annually and expects to dramatically
increase these efforts in the next few years. At Barcelona, many
strategies for reducing MTCT were discussed, including use of HIV rapid
testing methods for pregnant women, the effects of different infant
feeding options on MTCT, and new antiretroviral (ARV) prophylactic
regimens that can offer different, potentially more effective ways to
reduce MTCT. Perhaps the most important message from Barcelona was the
need to incorporate MTCT services into larger care and support services.
There was strong advocacy for comprehensive programming to provide care
for the pregnant woman, her newborn, and entire family unit affected by
HIV/AIDS, and for the integration of these services into the larger
antenatal health care infrastructure.

***Glaser Foundation Call to Action Project. Kate Carr of the Elizabeth
Glaser Pediatric AIDS Foundation*** began by noting the new cooperative
agreement between USAID and the Foundation for up to \$100 million to
expand MTCT prevention and related treatment activities over the next
five years. The agreement will allow MTCT programs in Africa and other
parts of the world to scale up. It will help new sites initiate MTCT
programs in a variety of settings, help countries scale up to national
programs, and move toward establishing MTCT prevention as an entry point
for larger care and treatment programs.

The Foundation's Call to Action project began in September 1999 with
eight sites in six countries. With private funding, the project has
expanded to 231 sites in 17 countries in sub-Saharan Africa, Asia,
Eastern Europe, Central America, and the Caribbean. The project provides
funds to local applicants for community mobilization and education;
training of health care workers; HIV counseling and testing; drug
interventions to prevent MTCT; HIV diagnosis in mothers, children, and
infants; infant feeding; and counseling and support. At Barcelona, the
project reported that about 110,000 women are currently attending
antenatal care at its sites. Of these, 90 percent received counseling
before receiving an HIV test, and almost 80 percent were tested for HIV
infection. Average HIV prevalence among those tested was 17 percent. Of
the HIV-positive women, 58 percent received ARV therapy with nevirapine
and 33 percent of their infants received the drug. The results show that
MTCT prevention is feasible in a variety of settings, ranging from urban
to rural and from university-based care to care provided by small
faith-based organizations.

Many more women must be reached, however. Innovations are needed to
increase the acceptance of testing and treatment and to reach women who
deliver at home. There is also a need for increased involvement of men
and communities, as well as a need to improve existing programs while
expanding them, instead of simply replicating them. MTCT prevention
programs are also a logical place to start care and treatment programs.
At most of the Call to Action project's MTCT sites, voluntary counseling
and testing is already in place and extending it beyond pregnant women
is very possible. Identifying other people who need care is very
possible, as is extending other interventions such as ARV treatment to
others who need it. Five project sites are instituting "MTCT Plus"
programs to demonstrate that additional care and treatment is viable and
cost-effective. As reported at Barcelona, reducing MTCT is feasible in
low-income countries. The time has come to scale up and establish MTCT
programs as the entry point for comprehensive care and treatment.

***Findings From Pilot Projects in Kenya and Zambia. Naomi Rutenberg of
Horizons*** began by noting that MTCT prevention has become a major
focus of Horizons' research agenda in recent years and then reported on
evaluations of MTCT pilot projects in Kenya and Zambia. The key finding
of these evaluations is that while the service coverage delivered by
MTCT programs is falling short of goals, these programs are making
significant (though perhaps unrecognized) contributions in helping women
and health care providers address HIV.

Supply-side constraints affecting delivery of MTCT services include
shortages of trained personnel and the lack of quality antenatal care
services in general. Constraints on the demand side include the
reluctance of women to learn their HIV status out of fear or anxiety
over a positive test result. The fear of being stigmatized contributes
to low demand, even though the actual stigma attached to attending MTCT
services appeared to be less than expected. Insufficient attention has
been paid to male partners and spousal concerns, which are critical for
getting women to test and return for test results. Finally, the
difficult questions about infant feeding options affect demand. There is
not enough training about infant feeding, and there are many
misconceptions about HIV infection through breastfeeding that are
difficult to correct. Formula may be unaffordable, and reluctance to use
replacement feeding may exclude a woman from other MTCT services.

On the positive side, the evaluations found that the projects were
providing information that is tailored to the client's context and
concerns about her own HIV risk, the health of her partner and children,
and her relationship with her partner. Even if information is confusing
or incomplete, it is nonetheless empowering for a woman to learn that
she is not helpless to respond to HIV. Also, a woman no longer has to
guess about her status but can choose to have a test. A negative result,
which is what most women receive, is an enormous relief. A positive
result is delivered in the context of services to help her have a
healthy baby as well as information about living positively with HIV.
The projects are also fostering partner communication and empowering
health workers. The way forward now is to continue with this progress on
these fronts while expanding services and offering them as an essential
entry point for HIV prevention and care for women. To do so, much more
provider training and support is needed.

***Questions and comments*** addressed breastfeeding; extending MTCT
programs beyond vertical transmission; maternal, infant, and pediatric
care; and nonclinic program settings.