HIV in maternal and child heath: concurrent crises demand cooperation

Integration of HIV and maternal healthcare in a high HIV-prevalence setting: analysis of client flow data over time in Swaziland

OBJECTIVE

Maternal and child health (MCH) care may provide an entry point for HIV services in high HIV-prevalence settings. Our objective was to assess integration of HIV with MCH services in public sector facilities in Swaziland.

DESIGN

In 2009, 2010 and 2012, client flow assessments (CFAs) were conducted over 5 days in the MCH units of eight government facilities, purposively selected as intervention or comparison sites.

PARTICIPANTS

8263 MCH visits with female clients were tracked: 3261 in 2009, 2086 in 2010 and 2916 in 2012.

INTERVENTION

Activities and resources to strengthen integration of HIV services into postnatal care (PNC), 2009-2010.

MAIN OUTCOME MEASURES

The proportion of all visits in which an HIV/sexually transmitted infection (STI) testing, counselling or treatment was received together with an MCH service; the proportion of all visits in which a client receives HIV counselling.

RESULTS

Across facilities, the proportion of visits in which HIV/STI and MCH services were received varied considerably, for example, from 9% to 49% in 2009. HIV/STI services were integrated most frequently with child health (CH), antenatal care (ANC) and family planning (FP)-the most common reasons for women's attendance-and least often with PNC and cervical screening (CS). There was no meaningful difference in integration over time by design group and considerable heterogeneity across facilities. Receipt of integrated services increased in one intervention and two comparison facilities, where HIV counselling also rose, and fell in one intervention and two comparison facilities.

CONCLUSIONS

Provision of HIV/STI services with MCH care occurred at all facilities, yet relatively few women receive integrated services. Increases in integration were driven by increases in HIV counselling, while sharp declines in some facilities indicate that integration is difficult to sustain. Opportunities for intensifying HIV integration lie with ANC, CH and FP, while HIV-PNC integration will remain limited until more women attend PNC.

TRIAL REGISTRATION NUMBER

Current Controlled Trials NCT01694862.

A new approach to maternal mortality: the role of HIV in pregnancy

As 2015 quickly approaches, we have been made increasingly aware of our progress toward Millennium Development Goals (MDGs). However, one MDG has been particularly recalcitrant to progress: MDG 5, namely, improving maternal health. Few countries are on track to achieve the first part of MDG 5’s goals, reducing maternal mortality by 75%. This article addresses the key priority issues of maternal health as part of sexual and reproductive health issues and maternal health and communicable diseases. It argues that only an integrative approach to the twin challenges of HIV and maternal mortality can help reduce devastatingly high rates of maternal deaths worldwide, especially in sub-Saharan Africa. The article reenvisions the MDGs not as separate, independent tasks, but as related, cohesive issues for which a holistic approach is needed. New causes of the relationship between HIV and maternal mortality are considered, and possible solutions are broached.

Leveraging progress in prevention of mother-to-child transmission of HIV for improved maternal, neonatal, and child health services

Finding ways to leverage the substantial investment in prevention of mother-to-child transmission of HIV to address other maternal, neonatal, and child health threats is a priority. With increased emphasis on health systems strengthening and the integration of disease-specific initiatives within primary care, we propose three areas for consideration: 1) increased integration of service delivery; 2) adaptation of successful implementation models; and 3) a reconceptualization of the care continuums for prevention of mother-to-child HIV transmission and maternal, neonatal, and child health.