December 2003

How Implementing PMTCT Services Expands
HIV Prevention and Care
Evaluation finds multiple benefits for facilities, clients

A couple and their baby wait to see the doctor at a district hospital. Higher levels of male involvement have been an important benefit of integrating PMTCT into existing reproductive health programs. Photo credit: Melissa May/Population Council

The benefits of services for prevention of mother-to-child HIV transmission (PMTCT) go far beyond providing antiretroviral drugs. Introducing PMTCT into existing maternal/child health services, including antenatal care, can contribute to a more effective response to HIV/AIDS by motivating health providers, improving HIV/AIDS knowledge in the community, getting male partners more involved in HIV prevention and the health of their families, and facilitating clients’ access to HIV/AIDS care and support.

In a recent evaluation of United Nations-sponsored pilot PMTCT projects in 11 countries, UNICEF and Horizons identified many of these benefits, as well as gaps in service delivery. The valuation employed a mix of qualitative and quantitative methodologies, including a review of progress reports from the country pilots; interviews with key informants; rapid assessments of pilot sites and their surrounding communities, site visits and face-to-face interviews with program managers in Rwanda, Zambia, Honduras, and India; and a collaborative analysis meeting with PMTCT experts from the United Nations and elsewhere. The evaluation also drew on the Horizons studies in Kenya and Zambia that are described in the cover story.

A nurse offers PMTCT counseling to women at Karatina District Hospital. Staff at Karatina and other study sites say their PMTCT training makes them feel more empowered to help their clients. Photo credit: Louis Apicella/Horizons

Motivating Staff

Health workers are key to making PMTCT services work. Until recently, most health workers did not have the training and skills to effectively provide counseling or other services to HIV-positive pregnant women, but new training programs have now reached thousands of health workers in Africa and elsewhere. Acquiring the tools to help clients and their infants avoid infection has given staff a sense of empowerment to do something about the disease and made them more supportive of HIV/AIDS-affected clients. The evaluation documented examples of newly trained staff who are now working to reduce stigma against HIV-positive clients and devoting extra effort to caring for and supporting women living with HIV.

The introduction of HIV/AIDS prevention and care into the antenatal care and maternal/child health setting has meant that health workers have been asked to greatly expand their responsibilities and tasks. Rarely has this been accompanied by financial and other types of compensation or the addition of new staff to share the work. Developing strategies for motivating health workers in these settings is thus also important for success. The evaluation team found that good management practices and strong leadership further encourage health staff to commit themselves to PMTCT goals. At the Kicukiro Health Center in Rwanda, for example, the director motivated her staff by personally promoting the PMTCT program. Her enthusiasm may well have contributed to the clinic’s extraordinary success in promoting service uptake. All women visiting the antenatal clinic in the first two years that PMTCT services were offered received HIV counseling, and a very high 86 percent opted to test for HIV.

Improving Knowledge

PMTCT programs have greatly expanded HIV/AIDS education, which has led to increased levels of knowledge about PMTCT among clients and within the community. For example, according to progress reports prepared on pilot PMTCT sites in India, the proportion of pregnant women who knew how to avoid HIV infection increased from 50 to 85 percent after they’d received counseling, and the proportion who knew how to avoid mother-to-child HIV transmission rose from 36 to 88 percent.

The evaluation found that PMTCT program staff are generally able to tailor the information and counseling they provide to the circumstances and concerns of their clients, taking into account individual levels of risk, the health of partners and children, and the quality of relationships with partners. Interviews with clients at pilot sites in Zambia and Rwanda revealed that their new knowledge helped overcome feelings of helplessness about HIV/AIDS:

“I now know even if I was HIV-positive I could still live a normal life, unlike when I only knew HIV is death.” (Zambian client)

“The morale of mothers involved in the program increases because they have hope that their children will be treated.” (Rwandan client)

Increasing Male Involvement

Involving male partners can make a real difference in improving women’s uptake of PMTCT services. When outreach efforts successfully engage men, they are far more likely to support women at critical turning points: deciding whether to take an HIV test, returning for test results, taking antiretroviral drugs, and practicing safer infant feeding methods.

One of the evaluation team’s most compelling findings is that attempts to involve male partners are most successful when they provide information about HIV and PMTCT directly to men outside of the antenatal or maternal/child health clinic setting, which many men perceive as the exclusive realm of women. For example, in rural Keemba and Monze, Zambia, program staff approached male leaders to promote PMTCT among the men in their communities, which has led to higher levels of male involvement in PMTCT decision-making and in uptake of VCT services. Providing men directly with information confirms their important role in such decisions and removes the onus of responsibility from women for bringing up PMTCT.

“Often it’s easiest to reach men in the more traditional and close-knit communities rather than in large urban areas,” said Dr. Chipepo Kankasa of the MTCT Working Group and a principal investigator for the Horizons PMTCT study in Zambia (see cover story). “There’s a recognizable leadership structure in place, usually headed by a man, through which programs can communicate health and prevention messages to men.”

Similarly, PMTCT program managers in Kenya developed strategies to inform male partners about PMTCT services such as providing community education on PMTCT in places where men congregate, organizing support groups for men, and directly inviting men to the clinic for HIV counseling and testing.

Springboard for Care and Support

The evaluation team found that while most communities lack a full array of care and support services, PMTCT programs are taking advantage of existing resources and referring clients for psychosocial and material support, as well as clinical and home-based care.

For example, in Kenya, one site is able to refer HIV-positive women to a clinic run by Médecins sans Frontières for antiretroviral treatment. In Zambia, the PMTCT site in Lusaka refers HIV-positive clients to the World Health Organization’s Pro-TEST program for prevention of tuberculosis and other opportunistic infections associated with HIV. Referrals are also made to the World Food Program for nutritional supplementation and to NGOs in the community that provide psychosocial and economic support and child care.

Botswana, with adult HIV prevalence above 35 percent, has the most advanced care and support network, with access to hospital resource centers staffed with nurses and social workers. These centers provide information and counseling to women and their partners, sponsor support groups for people living with HIV/AIDS, and offer home-based care, tuberculosis treatment, and antiretroviral therapy for HIV-infected mothers in the PMTCT programs.

PMTCT services are enhancing our response to HIV by providing HIV information tailored to women’s lives, empowering women and their partners to make decisions about HIV testing and other actions to reduce the probability of HIV transmission to their infants, and providing an entry point to HIV care.

For more information about this evaluation, contact Dr. Naomi Rutenberg at nrutenberg@popcouncil.org. The information in this article was based on the report, "Evaluation of United Nations-Supported Pilot Projects for the Prevention of Mother-to-Child Transmission of HIV: Overview of Findings,” published in August 2003 by UNICEF and Horizons. Also see "Integrating HIV Prevention and Care into Maternal and Child Health Care Settings: Lessons Learned from Horizons Studies.”

Carolyn Baek of Horizons/Population Council, a member of the evaluation team, wrote this article in collaboration with other members, including Naomi Rutenberg, Horizons/Population Council; and Sam Kalibala, International AIDS Vaccine Initiative (formerly of Horizons).

© 2003 The Population Council, Inc.

• Frontiers in Reproductive Health
• Population Council – HIV/AIDS
• Population Council – Safe Motherhood and Postpartum Care

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19 November 2007