Integrating comprehensive HIV care into routine maternal health services

Background: Although programs to prevent mother-to-child-transmission of HIV (pMTCT) have been widely incorporated into comprehensive HIV programs, they have proven difficult to scale-up, do nothing for the health of mothers, and their efficacy is often partially or entirely undone where long-term breastfeeding is the norm. Basic pMTCT services, not including treatment, are only reaching about 11% of eligible women in Sub-saharan Africa. In areas where HAART is available, providing definitive treatment to eligible pregnant women has proven an even greater challenge. In most areas, pMTCT services were initially implemented separate from routine antenatal care and HIV triage and treatment services were not offered onsite.

Methods: In 2006, with the shift to an opt-out testing strategy for pMTCT programs, Manica and Sofala Provinces in Mozambique began integrating pMTCT services seamlessly into routine antenatal care. Innovative aspects of this model include: 1) one nurse providing the antenatal package including, syphilis testing, provision of preventive treatment for malaria, and HIV testing 2) combined HIV and syphilis testing 3) confidential pre-and post-test counseling in the routine visit 4) on-site CD4 testing and triage for HIV positive women and 5) decentralized HAART treatment in the same health centers where antenatal care is offered.

Results: Integrating HIV care of pregnant women and pMTCT into routine antenatal care reduces the burden on scarce human resources. This intervention also improves uptake of HIV testing. Since integrated opt-out testing was implemented, the percent of women accepting HIV tests rose to 90% (last 6 semester 2007) from 60% (first semester 2005). The number testing increased by 535 women/mo (p<.001) and the number of HIV positive women identified increased by 96/mo (p<.001). Where decentralized, on-site care was offered, A higher proportion of women referred from pMTCT programs to onsite clinics enrolled for care than those referred to off-site, nearby clinics (77.0% vs. 28.3%, OR 8.46, p<.001)

Conclusions: Protection of the right to health for HIV positive women requires new models of care which consider the social, economic and political context of women's lives. Comprehensive HIV care, including access to HAART treatment for eligible HIV positive pregnant women, must be integrated as an essential element of maternal care services.