World AIDS Day 2008: Lead. Empower. Deliver
Dr Isabelle de Zoysa: Let's speak up for women and children affected by HIV and AIDS
Millions of women and children are living with HIV and AIDS in developing countries, and they are at most risk in heavy burden regions. Some 15.5 million women and 2 million children live with HIV in developing countries. In sub-Saharan Africa,the region with the highest prevalence, more than 60% of new infections are occurring among women.
On this World AIDS Day, 1 December 2008, we speak with Dr Isabelle de Zoysa, Senior HIV/AIDS Adviser to the WHO Assistant Director-General (ADG) for Family and Community Health, about the opportunities and challenges faced in reducing the spread of the infection and suffering related to AIDS among women and children.
Dr de Zoysa is a medical epidemiologist who has worked in child, sexual, reproductive health and HIV prevention programmes in developing countries over the past 20 years. In her current role as the Senior HIV/AIDS Adviser to the WHO ADG she works to make the best use of research results in the development of evidence-based policies and programmes.
The global community has substantially scaled up efforts and resources in the field of HIV/AIDS in recent years. The major goal is to achieve universal access to HIV services by 2010. On a parallel track, partners are working towards MDGs by 2015. While the MDGs 4 & 5 focus on child and maternal survival, the MDG 6 is a target for HIV and other infectious diseases. Where are we in our pursuit to achieve these global goals?
Progress in the response to HIV/AIDS towards MDG 6 should play an important role in the attainment of the MDGs 4 and 5 for child and maternal survival. Indeed these goals are interlinked, especially in high burden countries. There is evidence that HIV/AIDS contributes to poor progress, and in some cases, reversal of progress in reducing maternal and child mortality in African countries with large generalized HIV epidemics. In some countries in the region, 60% of child deaths in the hospitals and 30% of child deaths in the community are caused by AIDS. Studies from these countries indicate that more than half of non-obstetric maternal deaths may be related to AIDS. So while the contribution of HIV as a direct cause of maternal and child mortality may not be so visible globally when averaged across all countries and regions, it represents a significant constraint in attaining MDGs 4 and 5 in a number of high burden countries.
Millions of women, mothers and children are now living with HIV. And the fact that most HIV transmission to children takes place during pregnancy, childbirth and breastfeeding shows a great need for integration between maternal, child health and HIV services. Are services delivered in such an integrated manner?
They should be. The health of the mother and the child are inextricably linked. This is most obvious for mothers who are living with the virus. There is evidence that when a mother living with HIV becomes ill, her children, irrespective of their own HIV status, are more than three times more likely to die. And if the mother dies, her children are more than four times more likely to die. So it's critical that services for the prevention of mother-to-child transmission (PMTCT) include services to improve the health of both mother and child and be fully integrated into the maternal and child health services through which they are delivered.
All the same, huge numbers of children - some 420 000 in 2007 alone - are getting newly infected with HIV. Why is that?
We need to make sure that HIV is not transmitted to children by ensuring mothers have access to PMTCT. We see many challenges to integration between HIV and maternal, newborn and child health services, due to the ways the services are organized. PMTCT services are quite complex. They should include: primary prevention to ensure that mothers and women do not get infected with HIV in the first place, provision of family planning services for women living with HIV to prevent unintended pregnancies, the offer of HIV testing and counselling to all pregnant women so that they can learn their HIV status, and then for women who test positive, the provision of antiretroviral drugs as treatment if she needs it for her own health or as prophylaxis to avoid transmission to the infant, and infant feeding counselling and support. Only if these services are fully integrated into antenatal care, delivery and postnatal care will they reach sufficient number of women and children to make a difference.
What is the current rate of global coverage of PMTCT services?
In 2007, it was estimated that around 33% of HIV positive pregnant women were receiving antiretroviral prophylaxis to prevent the transmission of HIV to their babies. This is a significant improvement on the situation in earlier years. However, two thirds of pregnant women who need essential HIV services are not getting them and there is still a long way for us to go.
This shows rapid improvement from 2005 when only 11% of women in need of PMTCT had access. So success is indeed possible: what are the key lessons?
Indeed a number of countries have achieved their PMTCT targets. Countries that are doing well tend to be characterized by strong political commitment and good basic health services, particularly in relation to antenatal care and skilled birth attendance. In that sense, the improvements in health systems that are required to achieve the MDGs 4 and 5 are also key to reaching this component of MDG 6 in terms of preventing HIV infections in children and mothers. However, we do not need to wait for significant improvements in health systems to make a difference. In high burden countries, even if coverage with antenatal or delivery care is low, pregnant women who do seek such care should be offered HIV services, for their own health and that of their children. Too often, such women are not given the chance to learn their HIV status and, if needed, access antiretroviral treatment or prophylaxis.
What do you think we should do to make the best of our efforts to achieve the goals for universal access and MDGs 4, 5 and 6?
I believe that we should position the scale up of PMTCT services as an integral part of efforts to improve maternal, newborn and child health. This would enable us to draw on the energy, commitment and resources that are available for the response to HIV/AIDS. It can give us traction to deal with some of the despair or complacency that we face in countries that are having difficulties in making progress in reaching their child health and especially maternal health goals. This is not a time for competition between the maternal, newborn and child health and the HIV/AIDS communities. Overall, now is the time for us to come together and focus efforts on addressing the challenge of HIV/AIDS among women and children. And I see PMTCT as a rallying call for all of us.
Today is 1 December 2008, do you have a special message on this World AIDS Day?
Yes, I do. I think we should acknowledge the tremendous role played by activists, community leaders and representatives of people living with HIV in the rapid increase in access to antiretroviral treatment in recent years. They demanded what seemed impossible at the time for those living in resource-constrained settings and spurred global action which has led us to where we are now. I wish for the same level of activism for demanding PMTCT services linked to care and treatment for mothers, and children living with HIV, which we don't see yet. I think, if every mother, father, community member, and leader could stand up for the right of all mothers to have access to HIV services, for their own health and to protect their babies from HIV, and the right of all children exposed to HIV to access proper care and treatment, we would see much more rapid progress in stopping the spread of HIV and suffering among women and children.