HIV Update: Integrating Maternal, Newborn and Child Health into Community Based HIV

Supporting community action on AIDS in developing countries

HIV UPDATE Integrating maternal, newborn and child health into community-based HIV programmes

No. 11 August 2011

1. Introduction

2. Summary

This HIV update provides an introduction to reproductive, maternal, newborn and child health (RMNCH) and its linkages to HIV. Based on international evidence and the experience of the International HIV/AIDS Alliance (the Alliance), it provides an overview of the different components within RMNCH, the importance of linking RMNCH and HIV, and looks at key interventions that link HIV with RMNCH. It also highlights the current policy and funding opportunities for HIV/RMNCH work through the Round 11 call for applications from the Global Fund to fight AIDS, TB and Malaria.

n Progress against the Millennium Development Goals (MDGs) which focus on reducing child mortality (MDG 4), reducing maternal mortality and improving access to reproductive health (MDG 5) has been limited, with both maternal and child mortality remaining persistently high in many countries. n Linking RMNCH and HIV as part of sexual and reproductive health and rights (SRHR)/HIV integration is practical, necessary and can make a real impact on responding to the wider health needs of women and children leading to improved health outcomes for both. n While there is increased attention to linking RMNCH and HIV programmes, many community groups have linked the two approaches with excellent outcomes for both HIV prevention and treatment and care of women and children. n Strategies to reduce maternal and child mortality must use key windows of opportunity such as the Global Fund Round 11 to scale up coordinated and integrated RMNCH services within HIV responses.

Figure 1: Countries with the highest number of MDG 4, 5, 6 deaths and PMTCT needs

Afghanistan

Pakistan

China

India

Bangladesh

Ethiopia Côte d’Ivoire Burkina Faso

Nigeria D.R. Congo

Uganda Kenya Tanzania

Angola

Mozambique Zimbabwe

South Africa

Countries with the highest numbers of: s Maternal deaths (2008)1: India (63,000), Nigeria (50,000), D.R. Congo (19,000), Afghanistan (18,000), Pakistan (14,000), Tanzania (14,000), Ethiopia (14,000) s Child deaths (2009)2: India (1,726,000), Nigeria (754,000). D.R. Congo (558,000), Pakistan (460,000), China (347,000) s TB deaths (2009)2: India (280,000), China (160,000), Nigeria (100,000), Bangladesh (83,000), Pakistan (68,000) s AIDS deaths (2009)1: South Africa (310,000), Nigeria (220,000), India (170,000), Tanzania (36,000), Zimbabwe (83,000) n Malaria deaths (2009)3: D.R. Congo (21,168), Côte d’Ivoire (18,156), Angola (10,530), Burkina Faso (7,982), Nigeria (7,552) n HIV-positive pregnant women’s PMTCT needs (2008)3: Nigeria (210,000), South Africa (200,000), Mozambique (110,000), Kenya (110,000), Uganda (82,000) In each category the categories the countries are listed in descending order of deaths (or PMTCT needs).

Data sources: 1Childinfo www.childinfo.org. 2Global Health Facts www.globalhealthfacts.org. 3WHO PMTCT Strategic Vision 2010–2015.

1. ‘The Millennium Development Goals Report 2010’. 2010, UN: New York.

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3. Background deaths in Sub-Saharan Africa.5 Although HIV is not one of the direct causes of maternal mortality, HIV infection in pregnancy increases the risk of miscarriages, anaemia, post partum haemorrhage, puerperal sepsis and post surgical complications as well as risk of TB and malaria infection.

Through these mechanisms, HIV is a key contributor to the indirect causes of maternal deaths which account for 18% of overall maternal mortalities globally.6

Reducing child mortality by two-thirds (MDG 4), reducing maternal mortality by three-quarters and improving access to reproductive health (MDG 5), and combating HIV, malaria and other diseases (MDG 6) are strongly interlinked. Although significant progress has been made against HIV, TB and malaria (MDG 6), child and maternal mortality persists at unacceptable levels in many countries with much more concerted efforts needed.1 Amid these positive signs, weak health systems, scarce financial resources and stigma and discrimination, continue to be a real threat towards achieving the health MDG targets in many countries. In addition, the realisation that HIV is key to progress on SRH and MNCH has opened up opportunities to scale up integrated and comprehensive approaches to HIV, to ensure that the gains made in HIV are sustained while moving forward to close the implementation gap on RMNCH.

Understanding the impact of HIV is based on the fact that most HIV infections occur in regions where there are both high fertility and HIV prevalence rates amongst women, especially in sub-Saharan Africa. Thus, due to the compounding effect of HIV on maternal mortality, in many poor countries with high HIV prevalence, ‘pregnant women are confronted not only with the risk of death associated with advancing HIV disease, but also with an increased risk of pregnancy related death’.7 There is a thus a clear direct and indirect relationship between maternal mortality levels and HIV which needs to be taken in to account in achieving the MDG 5. Specifically, it has been estimated that unless renewed commitment to reducing the impact of HIV on maternal mortality is demonstrated by all stakeholders, women in high burden countries such as Malawi and Zimbabwe will continue to be up to eight times more likely to die either during pregnancy or following childbirth.8 Female sex workers, women who use drugs and female partners of men who have sex with men or men who use drugs often have poor access to mainstream RMNCH services due to stigmatising attitudes of health care providers who are critical of key populations having children. In addition, criminalisation of key populations such as sex workers prevents these populations from disclosing their health needs and avoiding

Main causes of maternal and child deaths Every year around eight million young children die of preventable causes, and more than 350,000 women die from preventable complications related to pregnancy and childbirth. The leading causes of maternal mortality are haemorrhage (35%) and hypertension (18%).2 This does not include maternal morbidity which causes suffering to millions of women from debilitating disability such as obstetric fistula and the resulting pain and marginalisation.

HIV and complications related to pregnancy and childbearing are the two most important causes of death in women of reproductive age. HIV alone accounts for more than 61,000 maternal deaths annually3,4 with recent estimates reporting that HIV accounts for 9% of maternal

Figure 2: Causes of maternal deaths (350,000/year)

Embolism 1% Sepsis 8% Haemorrhage 35%

Abortion 9% Other direct 11% Indirect 18%

Hypertension 18%

2. Figures adapted from ‘Countdown to 2015, decade report’. 2010.

3. Hogan, M.C. et al., ‘Maternal mortality for 181 countries, 1980–2008: a systematic analysis of progress towards Millennium Development Goal 5’. Lancet. 2010;375(9726):1609-23. Epub 2010 Apr 9.

4. Abdool-Karim et al., ‘HIV and maternal mortality: turning the tide’. Lancet 375:1948-49.

5. ‘Inter-agency estimates: trends in maternal mortality’. 2010, WHO. 6. Hogan, C. et al., ‘Maternal mortality for 181 countries, 1980–2008: a systematic analysis of progress towards Millennium Development Goal 5’. Lancet. 2010;375:1610-23.

7. Abdool-Karim et al., ‘HIV and maternal mortality: turning the tide’. Lancet 375:1948-49.

8. Bicego, G., Boerma, J.T., Ronsmans, C. ‘The effect of AIDS on maternal mortality in Malawi and Zimbabwe’. AIDS 2002;16: 1078–1081.

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healthcare providers. Pregnant women and mothers who use drugs often do not access safe motherhood or underfives services for fear of disclosure of drug use and arrest as well as fear that their children may be being removed due to child protection policies. Worryingly, a lack of legal protection of these groups sometimes leads to coercive practices such as forced sterilisations.

to environmental, social and health risks10 and risk of death, especially if the child is living with HIV. Analysis from Africa has documented that when a mother’s CD4 count is below 200 cell/ml, her children are three and half times more likely to die, which then increases to 4.2 times when a mother dies.11 Therefore, there is an urgent need to ensure that mothers and their children are provided comprehensive PMTCT, primary health care, and social and community support. More investment is required to ensure that fewer infections occur in children as a result of mother-to-child transmission of HIV. Once this prevention effort fails, it becomes an immediate liability on MDG 4 because HIV infected children are at a much higher risk of death compared with their HIV negative counterparts12 and this will effectively prevent the achievement of MDG 4 targets.

Of the eight million deaths occurring on a yearly basis amongst children under five years, the major causes are preventable. Presently, HIV accounts for 2–10% of global childhood mortality translating to more than 200,000 deaths per year, and this proportion is as high as 27–42% in countries with high HIV prevalence, such as Swaziland.9 HIV infection can affect a mother’s ability to care for her family which thereby increases her children’s susceptibility

Figure 3: Causes of deaths in children under five years (over million/year)

Newborns 12%

Children 59% Diarrhoea 14%

Pre-term 12%

Pneumonia 14% Asphyxia 9% Other infections 9% Sepsis 6%

Malaria 8%

Other neonatal 5% Pneumonia neonatal 4% Congenital 3% Tetanus 1% Non-communicable diseases 4%

Diarrhoea neonatal 1%

Injury 3% AIDS 2% Pertussis 2% Meningitis 2% Measles 1% Figures adapted from ‘Countdown to 2015, Decade report.’ 2010

9. Black, R.E. et al., ‘Where and why are 10 million children dying every year?’ Lancet. 2003;361(9376):222634.

10. Hecht, R. et al,. ‘Putting it together: AIDS and the Millennium Development Goals’. PLoS Med 2006; 3(11): e455. doi:10.1371.

11. Newell, M.L. et al., ‘Mortality of infected and uninfected infants born to HIV-infected mothers in Africa: a pooled analysis’. Lancet 2004; 364:1236-43.

12. Brahmbhatt, H. et al., ‘Mortality in HIV-infected and uninfected children of HIV-infected and uninfected mothers in rural Uganda’. Acquir Immune Defic Syndr. 2006 Apr 1;41(4):504-8.

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4. Key interventions and opportunities for MNCH and HIV integration The MNCH continuum of care, also called the life cycle continuum of care refers to integrated service delivery for mothers and children across the dimension of time from adolescence/pre-pregnancy through to pregnancy, birth, the postnatal period, infancy and childhood (see Figure 4.)

There are many opportunities for integration and linkages for RMNCH interventions in HIV service settings and vice versa provided within families and communities and by the health system through outpatient, outreach, clinical and other health facilities. Entry points include primary and secondary care, health facility and community settings for SRH services, antenatal clinics, obstetric care, post-natal and immunisation clinics, post-partum care services as well as outreach services for HIV prevention, care and support.

Timing is critical for delivery of care during pregnancy, birth and postpartum periods. However, women often have limited access to resources – transport, money, food, time, and childcare – for different visits to clinics for different services.

ONG JAMRA School, Dakar, Senegal © Nell Freeman for the Alliance.

Figure 4: The life cycle continuum of care

Adolescence and pre-pregnancy

Pregnancy

Birth

Postpartum

Maternal health

LINKING ACROSS THE TIMES OF CARE GIVING Neonatal Postnatal

Infancy

Secondly, RMNCH care-giving is carried out in households, communities and health facilities. Linking interventions across time and location can achieve greater efficiency, reduce costs and increase uptake. For example, if a woman accesses child health, family planning, pregnancy services, HIV and TB testing and treatment all within the same location and during the same visits, she saves considerable time and expense and may be less likely to miss followup appointments. If the facility is also supportive of men’s involvement with pregnancy and child health, involvement of fathers in support to women and children becomes easier, also supporting disease prevention. (Please refer to key interventions 8, 9 and 10 from the Alliance’s Integration of HIV and sexual and reproductive health and rights good practice guide and good practice programming standard 6. (Available at: www.aidsalliance.org/includes/Publication/ SRHGPG2.pdf)

Childhood

Integrated HIV/RMNCH interventions include: n Comprehensive SRHR services for HIV-positive women including family planning n Antenatal care services that provide testing for HIV and sexually transmitted infections (STIs) n Direct provision or referral of HIV treatment and care for HIV-positive women from antenatal care (ANC) services (antiretroviral therapy, treatment of opportunistic infections, nutritional, psychosocial and peer support) n Prevention of mother-to-child transmission (PMTCT) services.

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The four prongs of PMTCT demonstrate how RMNCH and HIV interventions can be integrated.13

1 The prevention of HIV infection in young men and women as they are growing up and before they conceive.

2 The prevention of unintended pregnancies in all girls and women, whatever their status.

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4

HIV testing and counselling for all pregnant women, with fast referral to antiretroviral therapy (ART), care and support; ART prophylaxis; safer delivery; use of co-trimoxazole for HIV exposed infants and safer infant feeding.

Testing of partners and safer sex promotion as risk of HIV transmission is very high if partner is recently infected.

Long term ART for mothers and children living with HIV. Ensure that mother and child get longterm support with nutrition, prevention of infections, treatment and care.

The uptake of PMTCT has been hampered by many barriers, including low community acceptance of voluntary counselling and testing (VCT), even in settings where PMTCT services are widely available.14,15 Community mobilisation is key to overcome these barriers16 by creating demand and uptake for PMTCT services and enhance the delivery of cost effective interventions throughout the continuum of care, such as community health workers referring mothers to appropriate facilities accompanying women through multiple health visits, providing community HIV testing, and providing support for treatment adherence, adherence for HIV exposed infants on co-trimoxazole, safer infant feeding and post-natal care. The successes of these community-based initiatives critically depend on an enabling policy environment to be advocated for and monitored at international and country level.17

A mother at Mukono Health Centre, Uganda © Nell Freeman for the Alliance.

13. Cohen, S.A. (2008), ‘Hiding in plain sight: the role of contraception in preventing HIV’, Guttmacher Policy Review, 11(1); Druce, N. and Nolan, A. (2007), ‘Seizing the big missed opportunity: linking HIV and maternity care services in sub-Saharan Africa’, Reproductive Health Matters, 15(30): 190–201.

14. Temerman et al., ‘Mother to child transmission in resource poor setting: how to improve coverage?’ AIDS. 2003;17:1239-1242.

15. Van’t Hoog et al., ‘Preventing mother-to-child transmission of HIV in western Kenya: operational issues’. J AIDS.2005;40:344-349.

16. ‘Place of voluntary counselling and testing’. Am J Public Health. 2002;92:347-351.

17. Countdown coverage writing group. ‘Countdown to 2015 for maternal, newborn and child survival: the 2008 report on tracking coverage of interventions’. Lancet. 2008; 371:1247-1258.

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5. Alliance’s integrated approach to tackle MDG 4, 5 and 6 The Alliance approach comprises of working with communities to reach those populations that are key to the HIV epidemic, while creating a series of entry points to the continuum of RMNCH services. These include community-based organisations: n providing counselling and health information and education on SRH/RMNCH n distributing contraceptives, lubricants and condoms n accompanying people to access HIV and SRH/RMNCH services such as PMTCT n doing community mobilisation and peer education to increase demand for HIV and RMNCH services n training healthcare workers on the SRH/RMNCH needs of people living with HIV and key populations n Advocacy for policies, supportive laws and appropriate health spending that promote access to integrated SRH/HIV services, including RMNCH.

COUNTRY

GLOBAL FUND ROUND

NO. OF SUBRECIPIENTS

AMOUNT USD

PERFORMANCE RATING

RMNCH INTERVENTIONS

Table 1: Alliance HIV programmes supported by the Global Fund which integrate RMNCH

India

6

8

14 M

A1

Project summary Now completed, this project provided educational, nutritional and psychological support as a minimum package of care and support services to children affected by HIV (CABA). It used PMTCT as an entry point to reaching pregnant women Key outputs related to RMNCH n 18,450

CABA within 13,344 households were provided with a minimum package of care and support services

n 841

children were referred to paediatric ART to a healthcare institution

n 7,626

CABA received nutritional demonstration.

n 2,883 CABA have been provided with educational support and/or vocational training n 1,859

Senegal

6

15

4.4 M A1

households provided with income generation support

Project summary The objective of the project is to accelerate the implementation of PMTCT programme and support health infrastructure. The project is now in its third year of implementation Key outputs related to RMNCH n 58,929

female condoms distributed so far

n 286,993

pregnant women received awareness-raising messages on PMTCT and safe delivery at community level

n 569

orphans and vulnerable children received care and psychosocial support though ANCS

n 369

orphans and vulnerable children received nutritional support, including counselling, nutritional commodities and follow up

n 4

Ukraine

1

94

67 M

N/A

VCT centres renovated

Project summary In its seventh year, this project has implemented a comprehensive community-based HIV care and treatment programme Key outputs related to RMNCH In 2008, 80% pregnant women living with HIV had received antiretroviral treatment to prevent motherto-child transmission (up from 35% in 2003), translating to some 9,875 pregnant women and 9,748 newborns

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A good example of the Alliance approach is the Network Support Agents programme in Uganda which supported networks of people living with HIV to increase community access to HIV and wrap-around services such as VCT, ANC, PMTCT and ART. Over 1,300 Network Support Agents (NSAs) were providing community- and health facility-based support by linking people to a range of services including reproductive health, PMTCT and support for children affected by HIV, such as infant immunisation, and testing.

This helped increase uptake of PMTCT services in the mideastern districts of Uganda from 1,264 in 2008 to 15,892 in 2009, with NSAs still delivering essential community based services even after project funding ended.

In Nigeria, the Alliance, working with the Linking Organisation, NELA, runs a short-stay centre which provides basic primary healthcare services, including rapid malaria testing, treatment of opportunistic infections, referral systems for pregnant mothers to PMTCT services, supporting 52 households and 3,502 adults and children with nutritional counselling and commodities, implements counselling on breastfeeding, immunisation and links HIV-positive women to government hospitals for PMTCT services.

In the Democratic Republic of Congo, the Alliance addresses nutrition, and performs referrals for vitamin A supplementation, promotes paediatric provider-initiated testing and counselling in government health centres and distributes bed nets within a wider CABA care and support package. In addition, the Alliance is involved in a provincial project with an objective of strengthening HIV counselling and testing/PMTCT services through referral for ART, capacity building and training in PMTCT as well as provision of condom provision as part of home-based care kits.

Access to RMNCH services is very low for female sex workers, women who use drugs and female partners of men who have sex with men and of men who use drugs.

The Alliance partner SASO is an non-governmental organisation (NGO) working with people who use drugs and their families in Manipur, India. SASO’s work highlights the impact of injecting drug use on women in Manipur due to marginalisation, drug use, sex work, gender inequality, human rights violations by law enforcement agencies and HIV. Services for women who use drugs is very limited and access to basic health services including RMNCH services is very poor due to criminalisation, exclusion and stigma. A recent SASO baseline study reported a 56% unmet need for contraception and poor health seeking behaviour amongst women who use drugs and a limited capacity and skills of service providers to respond to the RMNCH needs of female drug users. This has led to the late identification of pregnancies, particularly amongst young female drug users who delay visiting ANC clinics due to fear of harassment and incarceration.

Case study: Action for Rights, Relief and Development (ARRD), South Sudan ARRD, is a community-based organisation in the Pageri Payam district of Eastern Equatoria State in South Sudan. It works in an area of around 23,000 inhabitants and a radius of over 100 miles.

There are around eight clinics in the area, but only one provides PMTCT services. The closest hospital, in Nimule, is around 40 miles away. There are two main issues that affect the provision of safe maternal health care in the area, which ARRD responds to as a sub grantee of the DFID-supported MNCH project: 1. Uptake of health services by women Many women in the area were unaware of the risks of delivering at home. Most relied on traditional birth attendants; others who wanted to deliver in a clinic or hospital could not afford to pay for the maternity kit (which includes gloves, containers, medication, razors and other utensils). As it is obligatory for pregnant women to undergo an HIV test in hospital and for their husband to accompany them, many men and women do not attend clinics.

Through peer educators and community dialogues every month, ARRD sensitises families about the importance of the uptake of maternal health services, including HIV testing for women and men and the need to prioritise it.

The Alliance also supports national level advocacy on RMNCH/HIV integration through supporting programmes such as the DFID-funded Alliance project, ‘Reducing HIVRelated Maternal and Child Mortality’, in Kenya, South Sudan, Uganda and Zambia. This project is generating evidence from communities with a high burden of maternal mortality and HIV, and is using this evidence to raise awareness and build political momentum to shape relevant policies relating to RMNCH and HIV at the national level, such as policies which support greater access to effective health services for HIV-positive women of child bearing age. In each of these four countries, the Alliance is supporting civil society engagement through specific advocacy platforms (known as National Partnership Platforms) to identify weaknesses in country responses to the health MDGs and advocate for better response to HIV-related maternal mortality. In Uganda, this has led to the Alliance Linking Organisation joining other activists in taking a landmark case against the Government of Uganda for unacceptable number of maternal deaths in the country. The Alliance also implements a wide range MNCH/HIV services including water chlorination, malaria screening, and distribution of insecticide treated nets, nutritional intervention, referrals to ART and PMTCT, vitamin A supplementation, contraception, post-natal care, and support with breastfeeding.

2. Referrals and transportation Unless pregnant women go to the clinic of their own will, without ARRD, pregnant women and their families would not be able to access essential services to assess their situation and refer them to the clinic or the hospital in case of need. Once at the clinic these women are asked to return for checkups (especially for PMTCT in the case of HIV-positive women) but there would be no follow up to ensure that women return for ongoing services and that they adhered to the protocol. The same applies for referrals from the clinic to the hospital. The transportation provided for the pregnant women by ARRD is also essential. Without that, most women, for lack of financial means or for not finding vehicles, would not deliver in the clinic or hospital.

Since the beginning of the year, ARRD has done and followed up on 164 referrals.

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6. Policy and funding opportunities for integrated RMNCH/HIV programmes This opportunity under the Global Fund Round 11, calls for a renewed approach of strategically positioning, using and strengthening HIV as a key entry point to maternal and child services. PMTCT, for instance, provides an effective and unique point of contact with a pregnant woman, a post-natal mother and a newborn child and provides an opportunity to deliver specific interventions that have been shown to reduce maternal and child mortality.

Acknowledging the important role that community mobilisation can play, the Alliance plans to provide technical support to applicants who wish to integrate RMNCH into their HIV and health systems strengthening Round 11 proposals.

The Global Fund’s current mandate focuses on HIV, TB and malaria and health systems strengthening and since 2010, supports the efforts of countries to integrate RMNCH within their HIV, TB and malaria programmes, strongly encouraging Country Coordinating Mechanisms to look at opportunities to scale up an integrated health response that includes RMNCH in their applications in Round 11.

Round 11 was launched on August 15th, 2011, for which the Global Fund and WHO have prepared a number of resources in order to support countries to maximise the impact of their HIV, TB, malaria and health systems strengthening proposals in order to achieve positive outcomes for the health of women and children. The final guidance notes are available at www.theglobalfund.org.

Figure 5, below, provides an overview of the PMNCH/ Global Fund’s guidance on how HIV, TB and malaria interventions can fit into the RMNCH continuum of care.

Figure 5: HIV, TB and malaria interventions and the RMNCH continuum of care Adolescence and pre-pregnancy

Pregnancy

Birth

Post-natal (mother) Post-natal (newborn)

HIV

Motherhood

Infancy

Childhood

Sexual and reproductive health services, including counselling and prevention and treatment of sexually transmitted infections

Infant feeding support

Nutrition and psychosocial support for orphans and vulnerable children

Antiretroviral therapy

PMTCT four prongs

Social care and support

TB

TB screening, diagnosis and treatment

Malaria

Insecticide treated nets (ITNs) Intermittent preventive treatment in pregnancy Diagnosis and treatment

Cross-cutting strategies

Strengthen health systems and community systems Ensure a continuum of care for women, children and families Emphasise additionality and value for money Realise human rights and prevent discrimination Promote accountability for results

ITNs

Adapted from: The Global Fund (2010). ‘Scaling up investments in women and children to accelerate progress towards MDGs 4,5 and 6’.

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Women wait at the Mukono Health Centre clinic, Uganda, which has a programme for the prevention of mother-to-child transmission of HIV. Supported by Alliance Linking Organisation, ACHI. © Nell Freeman for the Alliance.

In 2011, at the United Nations High Level Meeting on AIDS, global leaders launched a Global Plan that will make significant strides towards eliminating new HIV infections among children by 2015 and keeping their mothers alive.

Called the ‘Global Plan towards the elimination of new HIV infections among children by 2015 and keeping their mothers alive’, its key elements include ensuring that:

The unacceptable deaths of women and children have catalysed a global response from the international community, national governments, academia and civil society to ensure that all women and children get affordable package of life-saving health interventions, such as the Partnership for Maternal, Newborn and Child Health (PMNCH). These include the UN Global Strategy for Women’s and Children’s Health, launched in September 2010 which clearly outlines the key areas where action is required including:

n All women, especially pregnant women, have access to quality life-saving HIV prevention and treatment services – for themselves and their children.

n country led health plans

n The rights of women living with HIV are respected and women, families and communities are empowered to fully engage in ensuring their own health and, especially, the health of their children.

n comprehensive package of essential interventions (that include greater access to family planning, ante-natal, newborn and post-natal care, emergency obstetric care, as well as prevention of and treatment for HIV and AIDS, and other STIs)

n Adequate human and financial resources are available from national and international sources in a timely and predictable manner.

n integrated care: stronger links with HIV intervention and services targeting women and children

n HIV, MNCH and family planning programmes work together, deliver quality results and lead to improved health outcomes.

n health systems strengthening n coordinated research and innovation.

n Communities, in particular women living with HIV, are enabled and empowered to support women and their families to access HIV prevention, treatment and care. n National and global leaders act in concert to support country-driven efforts and are held accountable for delivering results.

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7. Conclusions and recommendations Although there is considerable progress in HIV treatment, HIV continues to have tremendous impacts on maternal, newborn and child deaths as identified in MDGs 4 and 5.

It is now clear that better health for women and children and less women and children dying may not be achieved by 2015 unless increased commitment from donors, governments and civil society is demonstrated. More effective and integrated approaches are needed to build on recent successes and accelerate responses to all the health MDGs. This requires systematic, effective and strategic approaches that maximise the investment made in one and achieve cost effectiveness by reaching more beneficiaries and delivering more interventions for every cent spent on health programs. A greater financial investment in HIV not only serves to scale up HIV prevention, care and treatment, but to also to deliver key RMNCH interventions that support the health and well-being of women and children.

PMTCT interventions, such as those implemented by the Alliance, are a key intervention for integrating MNCH and HIV and is critical in preventing HIV amongst women of reproductive age, and if HIV-positive to help them plan for intended pregnancies through family planning, and to access treatment, care and support for themselves, their spouses and children. Strategies to reduce maternal and child mortality and achieve universal access to reproductive health must use key windows of opportunity such as the Global Fund Round 11 to scale up coordinated and integrated services within HIV responses. This will have a positive impact on reducing the number of women who die from preventable complications related to pregnancy and the more than eight million children deaths that occur annually.

Mothers undergoing prevention-of-mother-to child transmission treatment at The Blue House, a clinic for people living with HIV run by MÊdecins Sans Frontières, Nariobi, Kenya Š Nell Freeman for the Alliance.

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Established in 1993, the International HIV/AIDS Alliance (the Alliance) is a global alliance of nationally-based organisations working to support community action on AIDS in developing countries. To date we have provided support to organisations from more than 40 developing countries for over 3,000 projects, reaching some of the poorest and most vulnerable communities with HIV prevention, care and support, and improved access to HIV treatment.

The Alliance’s national members help local community groups and other NGOs to take action on HIV, and are supported by technical expertise, policy work, knowledge sharing and fundraising carried out across the Alliance. In addition, the Alliance has extensive regional programmes, representative offices in the USA and Brussels, and works on a range of international activities such as support for SouthSouth cooperation, operations research, training and good practice programme development, as well as policy analysis and advocacy.

For further information please contact: Divya Bajpai Senior Advisor: Sexual and reproductive health dbajpai@aidsalliance.org Telephone: +44(0)1273 718729 International HIV/AIDS Alliance (International secretariat) Preece House 91–101 Davigdor Road Hove, BN3 1RE UK Telephone: +44(0)1273 718900 Fax: +44(0)1273 718901 mail@aidsalliance.org www.aidsalliance.org Cover image: Betty with her niece at home, Nyokuon, South Sudan © Nell Freeman for the Alliance.

This publication has been printed with the support of UKAid through the Department for International Development (DFID).

The contents of this publication are the sole responsibility of the International HIV/AIDS Alliance and can in no way be taken to reflect the views of DFID.

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