Not Vectors, But People: The Need to Move from PMTCT to Comprehensive Care for Women with HIV


On May 21, 2009, the United Nations Special Programme on AIDS (UNAIDS) issued a call for more effective actions to prevent transmission of HIV from mothers to children and for ongoing care and treatment for women, their partners and children. UNAIDS Director, Michel Sidibé, stated: "We can prevent mothers from dying and babies from becoming infected with HIV. That is why I am calling for a virtual elimination of mother-to-child transmission of HIV by 2015…This is one of the main priority areas for UNAIDS, UNICEF, WHO and UNFPA to act on."

Sidibé’s announcement was followed by a June 16 press release endorsing the 2009 theme for the World AIDS Campaign, "Universal access and human rights," in which Sidibé stated: "Achieving universal access to prevention, treatment, care and support is a human rights imperative. It is essential that the global response to the AIDS epidemic is grounded in human rights and that discrimination and punitive laws against those most affected by HIV are removed." The World AIDS Campaign also noted that "laws and regulations protecting people with HIV from discrimination and women from gender inequality and sexual violence are not fully implemented or enforced."

These public pronouncements draw attention to significant issues facing women living with HIV and we recognize advances over the past years in addressing issues of importance to HIV-positive women, such as increased attention to the intersections between HIV/AIDS and gender-based violence and measures that can greatly reduce the birth of HIV-positive babies. However, we feel that it is time to also publicly acknowledge that the focus on women in relation to the HIV/AIDS pandemic has mainly centered around only two of their social "roles": as vectors of (perinatal and sexual) HIV transmission and as of victims of violence.

One example of how this has played out is obvious. The emphasis on women as vectors of transmission led to the widespread implementation of "prevention of mother-to-child transmission" (PMTCT) programs in all countries. This push to prevent the birth of HIV-positive children replaced the original, and more gender-neutral, terminology of perinatal or vertical transmission with identification of women as the "agents" of transmission. PMTCT programs became a major focus of research, policy statements, and intervention planning by UN agencies, governments and some civil society groups. UNAIDS’ guidance on constructing core indicators for reporting to the 2010 UN General Assembly review of the Declaration of Commitment to HIV/AIDS (UNGASS review) includes an entire chapter on prevention of mother-to-child transmission, focusing on administration of antiretrovirals during antenatal care, delivery and the postnatal period.

PMTCT programming has primarily tended to center on the "unborn" and child rather than on the women and children to be born. In South Africa, most women only book for delivery after 20 weeks of pregnancy. If HAART is indicated for women, it is nevertheless not generally part of the package of care.  Instead treatment generally focuses on a drug regimen to stop transmission to the unborn prior to and during labor. Many women do not come for their post-natal six-week check up because services for them are limited. A more comprehensive approach would address treating women, preventing perinatal transmission and enabling positive pregnant women to be healthy mothers.

In a few cases, well-funded programs have become "PMTCT+" interventions, which also provide antiretroviral drugs to women and their children after the postnatal period. But even then, the concern has mainly been to ensure the survival of women so that they can continue to care for their children, i.e., in their role as mothers. Such ongoing antiretroviral therapy is not being offered to HIV-positive women who miscarry, have stillbirths or who choose to terminate unwanted pregnancies.

A truly gender-based approach to women and HIV/AIDS must approach women and girls (as well as men and boys, but our focus right now is mainly on women) both as persons independent of their societal roles and in relation to their multiple roles and needs. When considering HIV and reproductive health, we need to shift the focus from an emphasis on prevention of perinatal transmission to a more comprehensive consideration of HIV/AIDS in relation to women’s reproductive health.

On March 2, 2009, at the 53rd session of the UN Commission on the Status of Women, UNAIDS director Sidibé, stated:

 

The social revolution will require strong efforts on many fronts – some of which I have spoken about before….First, give women and girls the power to protect themselves from HIV. We are already facing a recession of care. We cannot allow HIV to contribute further to this burden. This requires investment in universal access to comprehensive sexual and reproductive health services. Now is the time to join forces to fully integrate delivery of antenatal, sexual and reproductive health and HIV services. Let us seize this moment. Second – we must respect and protect human rights. The social construction of gender will not be solved by services alone. The AIDS movement has used the power of human rights to transform society’s approach to the epidemic.


If UNAIDS and other actors honor Sidibé’s recommendations and commitment to a human-rights based approach, we must define what that integration of HIV and reproductive health will entail. Broadly speaking, it should – at very the least – include integration and/or linkages between HIV-related interventions and services that address the following elements of reproductive health:

  • Non-discriminatory and widely available access to reproductive health services – not limited to family planning and prevention of perinatal transmission – but also encompassing prevention (vaccines), screening and treatment of reproductive tract infections and cancers; multiple forms of prevention barrier methods, including female condoms; contraception in relation to antiretroviral therapy, emergency contraception and safe abortion care.
  • Comprehensive sexuality education and voluntary HIV testing for everyone, especially women outside the antenatal care setting.
  • Attention to the specific sexual and reproductive needs and desires of HIV-positive youth just entering puberty and women entering the post-menopausal period.
  • Neglected areas of programming, including risks and needs for lesbian and bisexual women related to HIV, substance abuse and depression issues for women affected by HIV/AIDS, ways to deal with unwanted pregnancies, options for parenting other than biological parenthood.

 

On July 10 and August 12, a group of 63 NGOs from both developing and industrialized countries asked UNAIDS to engage in a dialogue with them about how the agency can become a leader in promoting a comprehensive approach to HIV and reproductive health in which women and men stand central, apart from any specific roles they may have in their societies. Michel Sidibé has promised a response soon; we very much look forward to this since we believe that it is past time to define and plan for linking and integrating HIV/AIDS services with multiple areas of reproductive health, including those that have received little or no attention to date (e.g., reproductive tract cancer screening and treatment, HPV vaccination, abortion-related care). 

The 2010 UNGASS review will offer us an excellent opportunity to push for an HIV/AIDS-Reproductive Health Initiative that we can all endorse and support and we hope to work with UNAIDS on this in the months leading up to it.

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  • invalid-0

    A good article, Maria and Marion.

    In South Africa, PMTCT is often taken to only mean ARV treatment around delivery, whereas the WHO framework consists of four components:
    1. Prevention of HIV infection among young people and pregnant women;
    2. Prevention of unintended pregnancies among HIV-positive women;
    3. Prevention of HIV transmission from HIV-positive women to their infants;
    4. Provision of treatment, care and support to HIV-infected women and their families.
    Parts 1, 2 and 4 are often neglected.

    The “MTCT Plus” championed by ICAP at Columbia University (www.columbia-icap.org/whatwedo/mtctplus/index.html) is to be commended. Louise Kuhn presented it in the plenary of the recent IAS conference in Cape Town.