Rene Ekpini E

1. Virtual elimination of mother-to-chilfd transmission of HIV: progress, remaining challenges, opportunities and way forward Rene Ekpini E Senior Adviser UNICEF, New York

2. Expenditure in HIV care and treatment, prevention and PMTCT in selected countries Source: UNAIDS 2008 Global Report

3. Remaining challenges-1 • Lack of translation of political commitment into catalytic • actions with accountability mechanisms at the country • level between central and sub-national authorities and • health management structures • Donor-driven programmes with limited national • ownership, parallel funding, M&E and PSM systems with • concentration in limited urban settings • Weak health systems with low access to and uptake of • services, the use of less efficacious interventions (e.g. Sd- • NVP) and poor continuum of care for mothers and children

4. The gap between antenatal care coverage and HIV testing and counseling in the context of PMTCT in selected countries – 2007

5. Coverage of antenatal care and skilled attendant at birth Coverage of PMTCT services Sources: 1- ANC coverage: Antenatal care in developing countries-Promise, achievements and missed opportunities – An analysis of trends, level and differentials, 1990-2001 updates 2- Skilled attendant at birth 2006 Building up PMTCT on weak health systems in resource-limited settings

6. Current system performance (KZN province) Attend ANC clinic 92% Counseled and tested for HIV, CD4 75% Get ARVs (pre- and perinatal) 50% Adapted from Pierre Baker & Nigel Rollins

7. 95% efficiency of the system (KZN province) Attend ANC clinic 92% Counseled and tested for HIV, CD4 95% Get ARVs (pre- and perinatal) 95%

8. Quality of antenatal and delivery care before and after the implementation of PMTCT; Cote d’Ivoire Therese Delvaux et al. Individual counselling

9. Impact of PMTCT on institutional deliveries in Rwanda – HIV-positive women In the general population 45% of women delivered at HF (IDHS 2007-08) Bangendanye, L; Price, J.E.; Micomyiza E.; Shumbusho F.; Wesson

10. Remaining challenges - 2 • Insufficient integration and linkages within maternal, • newborn and child health services, and other sexual and • reproductive health services, including family planning • Limited resources and operational guidance for effective • implementation of primary prevention and prevention of • unintended pregnancies among women living with HIV in • the specific context of PMTCT

11. PMTCT as an opportunity to operationalize combination prevention Preventing HIV infection in women Preventing HIV infection in pregnant women(and their partners) Preventing HIV infection in all women(and their partners) Within national multi-sectoral prevention strategies Specific interventions targeting pregnant women

12. Prevention of unintended pregnancies among women living with HIV • Provide HIV testing and counselling at family planning clinics (on-site or through referrals) • Provide FP services with focus on condom-based dual protection at PMTCT sites, STIs clinics and ART centers • Provide access to emergency contraception services and post-abortion care services • Capacity-building of service providers in addressing SRH needs and rights of women living with HIV

13. Remaining challenges-3 • Lack of operationalisation of community-based • interventions (lay counselors, peer support • groups, Mother2Mother) as integral components of • national scale-up strategies • Poor data collection, reporting, analysis and use, and • limited capacity for operation research to inform • policy formulation, advocacy and programming

14. Opportunities Current momentum for health systems strengthening (IHP+, H4, etc) Current momentum for virtual elimination of mother-to-child transmission of HIV UNAIDS joint programme: focus of all the UNAIDS cosponsors on PMTCT as a priority area by making the resources of the UN work for results at the country level The Global Fund has declared PMTCT a priority: reprogramming existing grants to accelerate scale-up in 10 countries (Ethiopia, Kenya, Malawi, Mozambique, Nigeria, South Africa, Tanzania, Uganda, Zambia, and Zimbabwe) PEPFAR’s second five-year authorization includes as target PMTCT coverage of 80%

15. Global strategic vision for virtual elimination of mother-to-child transmission of HIV - 1 • Strategic shift from HIV infection averted and HIV-free survival focus towards the overall goal of improved maternal and child health and survival for an HIV-free and AIDS-free generation • Increasing access and coverage by bringing services closer to those in need through decentralization and devolution to subnational authorities and subnational health management structures

16. Global strategic vision for virtual elimination of mother-to-child transmission of HIV - 2 • Using implementation of PMTCT as an opportunity to strengthen health systems with special attention to MNCH services • Operationalising integration and linkages within MNCH services, other SRH services including FP and HIV care and treatment services to ensure better continuum of care for women and children

17. Way forward -1 • Alignment and harmonization among national programmes (HIV/PMTCT, MNCH, Nutrition, SRH, …) and partners around population-based national scale up plans and sub-national operational plans to address programme fragmentation and parallel funding • Promoting and supporting decentralisation and devolution: operationalizing planning, financing and implementation of decentralised delivery of services using sub-national level as unit of planning, implementation and M&E and making resources available • Scaling up innovations as integral components of continuum of care for children and mothers (Point of care CD4; Mother-Baby-Packs; Rapid SMS) to accelerate expansion of services

18. Way forward - 2 Making resources available and fostering sustainability through induction of changes in resource allocation including innovative approaches such as performance-based financing Improvement of infrastructure and equipment, optimizing working conditions, and improve efficient delivery of services: Rehabilitation and equipment of ANC, delivery care, laboratory and pharmacy facilities Reorganization of service delivery mechanisms

19. Way forward - 3 Closing the gap between health facility-based approach and communities through partnering with individuals, families and communities, including PLWH and male partners in service provision, curbing stigma and discrimination and demand creation Closing the knowledge gap through promotion of and support to impact evaluation and operational research to inform policies, advocacy, and programming

20. Ways forward - 4 • Promoting and supporting access to the best available science for all in need by: • Scaling up more efficacious ARV regimens for PMTCT • Early diagnosis and ART for infants and children • Redoubling our efforts for optimal and safe infant and young child feeding practices • Building national capacity in M&E (data collection, analysis and use), progress tracking, and operational research (including impact assessment) to inform advocacy, programming and scale up

21. Two Worlds, Two Realities, One Hope: addressing inequity for social justice