What Works for Women and Girls

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health facilities have traditionally excluded men even though fatherhood is important in almostall societies and women often want the support of their male partners during pregnancy, labor,delivery and the postpartum period. Good maternal health can also be highly dependent onaccess to HIV prevention, treatment and care for men, as focusing on men in addition towomen protects the health of women and, by extension, their children.Involving men in PMTCT programs—with the permission of women—is an importantcomponent in increasing women’s uptake of HIV testing, prevention, treatment and care(Ghanotakis, 2010). Yet in 2007, only 5% of the male partners of women attending antenatalcare were tested for HIV (UNAIDS, 2009e). Involving men in PMTCT programs can also helpaddress the gender issues that impact women’s acquisition of HIV, as well as access to prevention,testing, treatment and care. [See also Chapter 11. Strengthening the Enabling Environment]Recent work has focused on men and fatherhood (Barker et al., 2010). Programs such asWomen Fighting AIDS in Kenya is successfully working to increase male involvement inPMTCT services (Ovaro and Kaduwa, 2008). A number of programs, such as EngenderHealth’sMen as Partners or Catholic Medical Mission Board’s Men Taking Action in Zambia are workingto increase the positive involvement of men in maternal health care in general, but few evaluatedstudies were found for PMTCT programs. PMTCT programs may learn from involvingmen in safe motherhood programs. Interventions related to this pillar are included in Chapter7. Treatment, Chapter 10. Preventing, Detecting and Treating Critical Co-Infections, and Chapter 12.Care and Support.Most PMTCT Programs Focus On Pillar 3Despite the importance of pillars one and two in preventing vertical transmission, “for mostprograms in the field, PMTCT is in fact focused on the program’s third and fourth components”(Msellati, 2009:808). While this chapter touches on pillar two, additional information onpreventing unintended pregnancies is in Chapter 8. Meeting the Sexual and Reproductive HealthNeeds of Women Living With HIV. The majority of this chapter focuses on pillar three—safemotherhood and prevention of vertical transmission. The other pillars are covered, however, inadditional chapters as noted above.What Works in Safe Motherhood and Preventing VerticalTransmissionA number of proven strategies work to reduce the risk of HIV transmission from mother tochild. Confidential HIV testing with counseling during antenatal care that includes women,and with their permission, their partners, is a critical foundation for reducing vertical trans-208 CHAPTER 9 SAFE MOTHERHOOD AND PREVENTION OF VERTICAL TRANSMISSION
mission of HIV. HIV testing and counseling allows women to know their serostatus and makeappropriate decisions to prevent vertical transmission. Maternal use of ARV therapy for herown health saves the lives of both mother and child and reduces orphan death in the long term.ARV prophylaxis during pregnancy drastically reduces perinatal transmission. Initiating ARVtherapy or prophylaxis in a timely fashion and adherence are also important. [See Chapter 7.Treatment] A 2008 review on child survival and PMTCT reported that child survival dependslargely upon the mother’s health and survival. HAART for pregnant women dramaticallyreduces perinatal transmission; reduces the risk of resistance to antiretroviral drugs relatedto monotherapy or duo therapy; and the risk of virological failure of HAART for HIV-positivechildren (Russo et al., 2009). In November 2009, WHO released new rapid advice recommendingARV use for treatment or prophylaxis for pregnant women: http://www.who.int/hiv/pub/mtct/rapid_advice_mtct.pdf.Improvement of maternal health services globally will be necessary to reach all womenand infants who need services, ensuring safe motherhood and prevention of vertical transmission.Provision of contraception to women who wish to avoid pregnancy is the first stepin preventing vertical transmission. In order to best advise a woman living with HIV abouther options for safe motherhood and prevention of HIV transmission to her future child, it isoptimal to reach her prior to pregnancy. However, most women become aware of their positiveserostatus once they are pregnant, via HIV testing during antenatal care. Strengtheningaccess to early antenatal care, services for labor and delivery and postpartum is essential toproviding adequate PMTCT services. During antenatal care, HIV testing, treatment options,syphilis screening malaria prophylaxis and other essential antenatal care must be fundamentalservices for pregnant women living with HIV. Access to basic emergency obstetric care andemergency obstetric care is also essential for pregnant women living with HIV. All the interventionsnoted in “What Works, Safe Motherhood” (Gay et al., 2003) take on additional importancefor HIV-positive women [www.policyproject.com/pubs/generalreport/SM_WhatWorksps2.pdf]. For recent evidence and information on maternal health, see also WHO, 2010a; WHO,2009g; WHO, 2006c and the website of the Maternal Health Taskforce: www.maternalhealthtaskforce.org.The evidence for what works in preventing perinatal transmission in this chapter is organizedaccording to the way women access health services, particularly maternal health services:prevention of unintended pregnancies, preconception planning; antenatal care (testing andcounseling, treatment); delivery; and postpartum.Not All of the Science Related to PMTCT Is ResolvedIn many respects, programming for PMTCT is quite advanced and yet for some aspects ofPMTCT, current research provides incomplete and complex guidance, adding to the ongoingchallenge of programming to meet the needs of women and to reduce vertical transmission.Many unknowns remain about HIV in pregnancy and how best to provide appropriate andWHAT WORKS FOR WOMEN AND GIRLS209
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WHAT WORKSFOR WOMEN AND GIRLSEviden
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Authors:Jill Gay, MAKaren Hardee, P
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Jose Esparza, MD, Ph.D.Senior Advis
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Shyam Kottilil, MD, Ph.D.Staff Clin
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Larry Slutsker, MD, MPHChief, Malar
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Table of ContentsList of Abbreviati
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List of Abbreviations3TCACTAHIANCAP
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PEPPHAPHRPIDPLHAPMTCTPPEPPTPRPTPRBP
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MethodologyMeasuring “what works
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2. Hormonal contraception is safe f
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outcomes has been more difficult to
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2. Promoting contraceptives and fam
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International Political Commitments
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established national action plans o
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Organization of the DocumentThis do
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Table 1.1Countries included in What
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understanding the epidemic in any g
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girls in school, for example. The c
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Within each intervention, studies a
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Chapter 3.Prevention for WomenA. Ma
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Special Risks for WomenStill, despi
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AIDS cases reported from 1982 to 20
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experience observed in clinical tri
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Female Condoms Are the Only Female-
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condom if it gives them more pleasu
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Correct use of the female condom ha
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A two month prospective study from
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A study of trends from Demographic
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8. Peer education for women can inc
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3B. Prevention for Women: Partner R
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matic focus on partner reduction, y
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of HIV acquisition, but were either
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four visits, each participant was i
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What Works—Prevention for Women:
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vention immediately following the b
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Chapter 4.Prevention for Key Affect
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2010). Transgender men and women al
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confidentiality—violate human rig
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there were major socio-demographic
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and post-intervention were used to
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tent condom use and 1.5 times more
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to their peers, distribute condoms
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Gaps in Programming—Female Sex Wo
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of a sexual relationship with a pri
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than were naltrexone or placebo. HI
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attributed to …swift introduction
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Promising Strategies:5. Sex-segrega
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9. Programming to prevent initiatio
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D’Ivoire, Cuba, Estonia, Indonesi
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Gaps in Programming—Women Prisone
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EVIDENCEPromising Strategies:1. Vol
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In fact, as of September 2008, 66 o
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Transgender women and men are often
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2009). “The invisibility and marg
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especially young women, have their
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negotiation skills and other critic
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to be reached with sex and HIV educ
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What Works—Prevention for Young P
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44% and 100% of participants (Kirby
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tudes, self-efficacy, intentions, a
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as young people in this area had li
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ical validity of the findings that
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study reported having received info
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nancy. Almost 87% of men and 89% of
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last sex, having ever used a condom
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Gap noted, for example, in South Af
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Disaggregated Data Is NeededEffecti
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were also effective in increasing u
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Chapter 6.HIV Testing and Counselin
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Equitable Access to Testing and Cou
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they would come for HIV testing, re
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their jobs (Human Rights Watch, 200
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What Works—HIV Testing and Counse
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women. Of all married HIV-positive
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A study in Ethiopia found that inco
Page 159 and 160: At a provincial hospital in Mombasa
Page 161 and 162: Between June and December 2007, mob
Page 163 and 164: Promising Strategies:6. Encouraging
Page 165 and 166: 10. Counseling may reduce risk beha
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Page 169 and 170: Chapter 7.TreatmentA. Provision and
Page 171 and 172: Treatment Has Been Successfully Adm
Page 173 and 174: HIV Prevention Is Needed as well as
Page 175 and 176: Gaps in Programming—Provision and
Page 177 and 178: These practices and tools are usefu
Page 179 and 180: Non-judgmental, non-stigmatizing in
Page 181 and 182: percent among ART-experienced patie
Page 183: (Donnell et al., 2010). (Abstract)
Page 186 and 187: The sexual health of women is an im
Page 188 and 189: [ for women living with HIV]: impro
Page 190 and 191: Available GuidelinesA number of sex
Page 192 and 193: advantages of dual method use, alon
Page 194 and 195: contraception: 57% used hormonal co
Page 196 and 197: different; and progression to WHO c
Page 198 and 199: HIV-related behavioral or biologic
Page 200 and 201: use was positively associated with
Page 202 and 203: Gaps in Programming—Meeting the S
Page 204 and 205: Interactions between ARVs and oral
Page 207 and 208: Chapter 9.Safe Motherhood and Preve
Page 209: Pillar 1: Preventing Primary HIV In
Page 213 and 214: EVIDENCE1. Preventing unintended pr
Page 215 and 216: Gaps in Programming—Reducing Unin
Page 217 and 218: 9B. Safe Motherhood and Preventiono
Page 219 and 220: EVIDENCEPromising Strategies:1. Dis
Page 221 and 222: Gaps in Programming—Pre-Conceptio
Page 223 and 224: 9C-1. Safe Motherhood and Preventio
Page 225 and 226: tion (Kershaw et al., 2006). “…
Page 227 and 228: outine tests. Fifty percent of the
Page 229 and 230: An evaluation of UNICEF-funded PMTC
Page 231 and 232: and syphilis (by rapid plasma regai
Page 233 and 234: 2. Additional efforts are needed to
Page 235 and 236: for their own disease” (ITPC, 200
Page 237 and 238: own health needs has never been eva
Page 239 and 240: dine and lamivudine during pregnanc
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Page 243 and 244: their current pregnancy or a past p
Page 245 and 246: Promising Strategies:5. Integrating
Page 247 and 248: Gaps in Programming—Treatment1. I
Page 249 and 250: cesarean, and 221 were non-elective
Page 251 and 252: 3. Efforts are needed to ensure tha
Page 253 and 254: “There is no doubt that there are
Page 255 and 256: formula feeding increases the risk
Page 257 and 258: of age. For breastfed infants, the
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A study in Côte d’Ivoire with 54
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during breastfeeding compared with
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3 times higher for infants who were
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counseling tools are needed. Studie
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Chapter 10.Preventing, Detecting an
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latent infection. Some immunocompro
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concurrent active TB and HIV infect
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mortality of HIV-positive people re
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in a 65% decline in mortality and t
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1. Efforts are needed to reduce TB-
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al., 2004 cited in Slutsker and Mar
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stillbirths by 33%. Three cluster-r
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Gaps in Programming—Malaria1. Fur
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dose global coverage was just 27% i
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Chapter 11.Strengthening the Enabli
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combining microfinance and training
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pants meeting once per week for thr
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the men believed that they should n
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in the intervention village were si
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positive impacts. The quasi-experim
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Samoa, Serbia and Montenegro, Thail
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factor associated with sexual assau
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What Works—Strengthening the Enab
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worked with women’s groups, radio
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of school in addressing gender-base
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11C. Strengthening the Enabling Env
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also widely used worldwide and part
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ecognize women’s property rights
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Promising Strategies:2. Community o
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11D. Strengthening the Enabling Env
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more likely to report having used a
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likely than illiterate women to kno
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of the women surveyed were HIV-posi
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countries extending the fee aboliti
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families and separated from their c
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used the resource “Understanding
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6. Support groups for people living
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11G. Strengthening the Enabling Env
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EVIDENCEPromising Strategies:1. Inv
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Chapter 12.Care and SupportA. Women
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ical care provided by family member
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dealing with their sorrow, grief, a
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What Works—Care and Support: Wome
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2. Peer support groups can be highl
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discriminated unjustly against them
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6. Home-based antiretroviral therap
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12B. Care and Support: Orphans and
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(Thurman et al., 2007). As of 2008,
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care and services were provided, wh
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for treatment can be safely monitor
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A study done in Kenya (year not giv
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ather than a narrowly defined HIV/A
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7. Further interventions to provide
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ning providers, antenatal care and
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What Works—Structuring Health Ser
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counts available at primary health
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Pregnant women reported feeling out
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Before implementation of the PMTCT
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accessing PMTCT. An evaluation of 3
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A mathematical model based on TB tr
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1. Improved integration is needed b
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15. Additional efforts are needed t
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Community-based Care is holistic ca
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Microfinance is often defined as fi
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Sexuality is a central aspect of be
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