1 BRIEF FOR PARLIAMENTARIANS ON HIV AND AIDS Towards an HIV-free generation: Ending the vertical transmission of HIV
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3 3 Towards an HIV-free generation: Ending the vertical transmission of HIV HIV infection transmitted from an HIV-positive mother to her child during pregnancy, labour, delivery or breast-feeding is known as vertical transmission or mother-to-child transmission. More than 90 per cent of new HIV infections among infants and young children globally occur through vertical transmission. The elimination of vertical transmission is possible by This is because the prevention of vertical transmission can be ensured through relatively simple health interventions and inexpensive drugs if they are accessible to the women and infants that need them. In 2009, over half the women who needed antiretroviral drugs (ARVs) to prevent transmission to their unborn child in low- and middle-income countries received them, up from 15 per cent in The elimination of vertical transmission has already been achieved in most high-income countries, and it can be achieved in low-income countries. Much more needs to be done to prevent mothers from dying and babies from becoming infected with HIV. Without intervention, about one in three children born to HIV-positive mothers will become HIV positive. Additionally, HIV is the leading cause of mortality in women of reproductive age worldwide, and is a determining factor in poor maternal and child health outcomes. For these reasons, the UNAIDS Strategy Getting to Zero, , has set the elimination of vertical transmission of HIV and reduction by half of AIDS-related maternal mortality as goals for Furthermore, at the 2011 UN High Level Meeting on AIDS, UNAIDS with partners launched the Global Plan towards the Elimination of New HIV Infections among Children by 2015 and Keeping Their Mothers Alive 1. This plan lays the foundations for country-led initiatives towards the elimination of new HIV infections among children and rights-based approaches to protecting the health and lives of mothers, including mothers living with HIV. Achieving the goal of eliminating new HIV infections among children and ensuring that their mothers are alive and healthy will require the provision of appropriate HIV treatment to women in need of treatment for their own health and HIV medicines to prevent transmission during pregnancy, delivery and breast-feeding for HIV-infected women not yet in need of treatment. The World Health Organization (WHO) and UNAIDS promote a comprehensive approach to preventing vertical transmission of HIV, which includes the following four components: 2 Preventing HIV infection among women of childbearing age; Preventing unplanned pregnancies among women living with HIV; Preventing HIV transmission from a woman living with HIV to her infant by providing ARV prophylaxis or treatment; and Providing appropriate treatment, care and support to mothers living with HIV and their children and families. Factors that impede progress towards an AIDS-free generation Weak health systems and financing Limited human resource capacity, insufficient health financing, and lack of medicines and medical facilities all limit efforts to prevent the vertical transmission of HIV. Interventions that can prevent transmission have been shown to be cost-effective, even in some of the most resource-poor parts of the world. To achieve the widest possible coverage, rights-based programmes to prevent vertical transmission should be integrated into maternal, newborn and child and reproductive health programmes. Stigma and discrimination Even though more and more women are using PMTCT services today, HIV-related stigma and discrimination 1 Global Plan towards the Elimination of New HIV Infections among Children by 2015 and Keeping Their Mothers Alive: en/media/unaids/contentassets/documents/unaidspublication/2011/ _jc2137_global-plan-elimination-hiv-children_en.pdf. See also guidelines issued by the World Health Organization: Antiretroviral drugs for treating pregnant women and preventing HIV infection in infants: Recommendations for a public health approach (2010 version) (http://whqlibdoc.who.int/publications/2010/ _ eng.pdf) 2 World Health Organization: PMTCT Strategic Vision : Preventing mother-to-child transmission of HIV, p. 14.
4 4 Impact of HIV-related stigma on programmes to prevent the vertical transmission of HIV Discourages women from accessing essential health services, including antenatal care services; Prevents people from receiving HIV testing and counselling, or returning for their test result, and, consequently, they do not access the services they need; Discourages women from discussing their HIV test result with their spouse or partner; and Dissuades women from participating in programmes to prevent vertical transmission for fear of their status becoming known and/or raising questions about the status of their child/children. pose distinct challenges to the delivery of services to prevent the vertical transmission of HIV. Some women report they are reluctant to attend clinics that provide HIV and other health services, for fear that they will receive a positive diagnosis, that their HIV-positive status becomes known to others, and they might face ostracism, rejection and even violence from their families and communities. Mothers who participate in programmes to prevent vertical transmission to their children also risk stigmatization of their children on the basis of their presumed HIV status if their participation in the programme is known or suspected. In addition to the concerns of pregnant women over HIV-related stigma and discrimination in the community, HIV-positive pregnant women report experiencing stigma and discrimination in health care settings, where health care workers judge them as irresponsible for wanting to have children. In several countries, women Blood test at a roadside HIV testing table in Langa, a suburb of Cape Town, during World AIDS Day on 1 December living with HIV have reported forced or coerced abortions and sterilizations on account of their HIV status. All of these factors can deter pregnant women from seeking health services, including HIV testing and programmes to prevent the vertical transmission of HIV and to protect their own health. Criminalization of HIV transmission In many countries, criminal law has been used to prosecute HIV transmission or exposure. The United Nations, the IPU and other organizations have spoken out against excessively broad laws criminalizing HIV transmission or exposure as well as the inappropriate application of existing criminal laws. 3 Such laws feed HIV-related stigma and can discourage women from accessing antenatal and HIV-testing services for fear of criminal investigation or prosecution. Avoiding the health care system altogether in the hope of protecting one s family is a regrettable situation, and carries devastating health consequences for both mother and child. Low uptake of HIV testing and counselling HIV testing and counselling for pregnant women provides a key entry point for accessing services to prevent vertical transmission. In most high-income countries, voluntary HIV testing has been either routinely offered as part of antenatal care, or offered to pregnant women thought to be at high risk of exposure to HIV. While access to services is expanding in lowand middle-income countries, the majority of pregnant women are still not being offered HIV testing and counselling and, therefore, do not know whether or not they are HIV-positive. In 2009, an estimated 26 per cent of the estimated 125 million pregnant women in low- and middle-income countries took an HIV test, up from 21 per cent in 2008, and 7 per cent in Unfortunately, HIV testing is often accompanied by inadequate counselling, fears of confidentiality being breached, and lack of clear and accurate information on the steps that women can take to reduce the likelihood of vertical transmission. These factors dissuade women from 3 UNAIDS/UNDP Policy Brief: Criminalization of HIV transmission (2008)
5 5 Contribution of the 25 countries with the largest number of women needing antiretrovirals for preventing mother-to-child transmission of HIV to the global gap in reaching 80% of those in need, Countries (among the 25) estimated to contibute each less than 2% to the global gap a (10%) Other low-and middle-income countries (6%) United Republic of Tanzania (2%) Mozambique (3%) Angola (3%) Burundi (3%) Sudan (3%) Zimbabwe (3%) Chad (3%) Malawi (3%) Nigeria (32%) Cameroon (5%) Ethiopia (5%) India (6%) Uganda (6%) Democratic Republic of the Congo(7%) Source: UNAIDS. a These countries include Botswana, Burkina Faso, Côte d Ivoire, Ghana, Kenya, Lesotho, Namibia, Rwanda, South Africa, Swaziland and Zambia. Countries (among the 25) estimated to contibute each less than 2% to the global gap a (10%) Other low-and middle-income countries (6%) Mozambique (3%) Angola (3%) Burundi (3%) Sudan (3%) Zimbabwe (3%) Chad (3%) Malawi (3%) Nigeria (32%) Cameroon (5%) Ethiopia (5%) India (6%) Uganda (6%) Democratic Republic of the Congo(7%) HIV-positive demonstrators take part in a protest outside the Indian Health Ministry in New Delhi, demanding that the HIV/AIDS bill be presented in parliament.
6 6 seeking and accepting HIV testing services and other health services that may be available. Gender-based violence Gender-based violence and inequality further discourage women from seeking information and services, and accessing HIV treatment and care. Many women who test positive for HIV, including pregnant women, are afraid to disclose their status to their partners for fear of violence or abandonment. These fears can be significant obstacles to participation in programmes to prevent vertical transmission and protect women s health. Strengthened protection of women s rights, including protection from violence, is essential to reducing women s vulnerability to HIV, eliminating vertical transmission and keeping mothers alive. Couples counselling and other ways of involving male partners can help ensure that men learn their HIV status, and support uptake and compliance with treatment. Although pilot initiatives have shown benefits related to the expanded involvement of men, too few programmes to engage men are taken to scale. Poverty, exclusion and other barriers to accessing care Antenatal care services remain out of the reach of too many women, and in many cases, the services that are available are of poor quality and involve long waiting times. Women report that the inability to pay for transportation to health centres prevents them from attending all the recommended antenatal visits and delivering their child in a health facility. Where comprehensive antenatal care is out of reach, so too are the services that will prevent the vertical transmission of HIV. Community-based health workers including women living with HIV can play an important role in reaching out to those women who are most vulnerable and marginalized. They can encourage women to access HIV testing and counselling in the early stages of pregnancy, and make sure that women who test positive for HIV understand what will help reduce the risk of vertical transmission and protect their own health, and be supported to access services. Women queue up with their babies to be tested for HIV at a hospital in Bududa, Uganda.
7 7 Percentage of pregnant women living with HIV and infants born to them who received antiretrovirals for preventing mother-to-child transmission, % % % % 32 % 35 % % 15 % 12 % 18 % 20 % 0 6 % Pregnant women living with HIV receiving antiretrovirals for preventing mother-to-child transmission. Infants born to pregnant women living with HIV receiving antiretrovirals for preventing mother-to-child transmission. Source: UNAIDS What can parliaments and their members do to support the virtual elimination of vertical HIV transmission by 2015? Meet with organizations of women living with HIV to find out from them: What they think it will take to reach the goal of elimination of vertical transmission; How you can lend support to their advocacy and outreach efforts; and How you can help them identify funding for their work. Develop laws and policies that support efforts to prevent the vertical transmission of HIV by: Ensuring that all pregnant women are offered HIV testing and counselling, but are not tested mandatorily or without their informed consent; Ensuring that all pregnant women and adolescent girls living with HIV have access to the full range of methods for reducing the risk of transmitting HIV to their infants, in accordance with the most up-todate WHO guidelines; Ensuring that programmes to prevent vertical transmission are linked to other maternal health and reproductive health programmes; Protecting the human rights of women living with HIV, including the right to have children, access health care services without discrimination, stigma or violence, and the right to provide full and informed consent for all medical procedures/treatment; Repealing HIV-specific criminal laws, laws on the compulsory disclosure of HIV status, and other laws which are counterproductive to HIV prevention, treatment, care and support efforts; and Holding the executive to its international commitments on HIV and AIDS, and the prevention of mother-to-child transmission of HIV. Provide strong political leadership for programmes to prevent vertical transmission by: Increasing community awareness about programmes to prevent vertical transmission, and helping men and women recognize their roles and responsibilities in protecting themselves and their families against HIV infection; Speaking out against HIV-related stigma and discrimination, and gender-based violence and inequality; Speaking out for the right of people living with HIV to start a family and have children; Promoting know your HIV status campaigns, and sexual and reproductive health education programmes to increase awareness about HIV; Visiting clinics to see how programmes to prevent mother-to-child transmission work, and raise awareness of them among colleagues in parliament, as well as the media; and
8 8 Encourage programmes to include men, and not focus on women alone; lead by example, by championing men s engagement and requesting programmes to report on indicators assessing the extent of couple counselling and testing, not just women alone. Press for the rapid expansion of programmes to prevent vertical transmission by: Advocating for higher budget allocations and expenditures; Calling for monitoring of budgets and programmes to ensure that government departments and agencies spend allocations as per approved budgets; and Advocating for an increase in official development assistance for programmes to prevent the vertical transmission of HIV. Global commitments on the prevention of mother-to-child transmission (PMTCT) of HIV A number of global commitments have been made in recent years to improve the health of women and children, including by reducing the vertical transmission of HIV. Some of them include: Millennium Development Goals (MDGs) 4, 5 and 6 (agreed by UN Member States in 2000) are concrete, time-bound commitments to reduce child mortality, improve maternal health, and combat HIV/AIDS, malaria and other diseases by MDG 6 specifically calls for universal access to HIV services, including services to prevent the transmission of HIV from mother to child. Political Declaration on HIV/AIDS: Intensifying our Efforts to Eliminate HIV/AIDS 4, adopted by the UN General Assembly in June 2011, under which world leaders pledged to work towards eliminating new HIV infections among children in the next five years. Elvira, an HIVpositive woman, takes part in a workshop about the stigma and discrimination experienced by HIV-positive people in Lima, Peru. 4 Political Declaration on HIV/AIDS: Intensifying our Efforts to Eliminate HIV/AIDS. This brief for parliamentarians on HIV and AIDS introduces priority issues requiring action by parliamentarians, towards a world with zero new HIV infections, zero discrimination, and zero AIDS-related deaths. It accompanies the IPU-UNAIDS-UNDP Handbook for Parliamentarians, Taking action against HIV and AIDS. The Handbook is a call to action for bold parliamentary leadership, and serves as a comprehensive reference volume that legislators and their staff can consult for information and guidance on a wide range of issues relating to the epidemic. Aleksandra Blagojevic, HIV/AIDS Project Officer at the IPU, researched material for this brief. Contributions and editorial comments were received from Susan Timberlake, Senior Human Rights and Law Adviser, UNAIDS; Jason Sigurdson, Human Rights and Law Programme Officer, UNAIDS; Mandeep Dhaliwal, UNDP Cluster Leader, HIV, Health, Human Rights, and Governance; and Brianna Harrison, UNDP, HIV, Health, Human Rights and Governance cluster. Copyright Inter-Parliamentary Union (2011) Photos: AFP / Layout: Le Cadratin, Plagne (France) / Printed in France by Courand et Associés
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