- Across the world more than 90% of the 2.1 million children under the age of 15 years living with HIV have acquired the infection through their mothers. The prevention of perinatal transmission during pregnancy and delivery, and through breastfeeding is an area where there are feasible interventions in resource-limited settings. Nevertheless, the coverage of prevention of perinatal transmission interventions is low: in 2009 an estimated 26% of pregnant women received an HIV test, and an estimated 53% of pregnant women living with HIV received antiretrovirals for preventing transmission to their infants (WHO/UNAIDS/ UNICEF, 2010). Much like with voluntary counselling and testing, stigma, discrimination and the fear of violence deter women seeking out and adhering to prevention of perinatal transmission interventions. (Also see WHO, 2009a. Integrating Gender into HIV/AIDS Programmes in the Health Sector: Tool to Improve Responsiveness to Women’s Needs. Geneva, Switzerland: WHO, Department of Gender, Women and Health).
- When integrating violence against women and girls into prevention of perinatal transmission interventions, key objectives should be to expand access to a comprehensive range of prevention of perinatal transmission interventions and to combat the stigma associated with HIV while encouraging and supporting disclosure (IGWG of USAID, 2009).
- Examples include:
- Develop or strengthen linkages among HIV programmes and services, with sexual and reproductive health services (e.g. family planning, sexually transmitted infections, screening for cervical cancer).
- Train family planning providers to routinely screen for violence during antenatal services and to offer voluntary counselling and testing for HIV.
- Train family planning providers to see women living with HIV as part of their regular clientele, offering them a full range of contraceptive options, and referring them appropriately for other health needs.
- Arrange for follow-up counselling for pregnant women who have tested positive for HIV. Health care providers can take this opportunity to provide women with information on prevention of perinatal transmission, the importance of taking ARV prophylaxis, and potential risks of disclosure (including partner violence). Using peer counsellors or community-based lay counsellors can be particularly effective as they may be able to share personal experiences and usually have more time available than clinic-based counsellors. For example, women living with HIV who have gone through prevention of perinatal transmission intervention scan act as peer counsellors and support to other women. Their role is especially important in that they can provide reassurance that prevention of perinatal transmission interventions can help to reduce the risk to unborn children. They can also act as role models for others, informing individual women, couples and communities through their own example that a programme is safe and effective (Excerpted from WHO, 2009a. Integrating Gender into HIV/AIDS Programmes in the Health Sector: Tool to Improve Responsiveness to Women’s Needs. Geneva, Switzerland: WHO, Department of Gender, Women and Health, pg. 35)
Example: The MOTHERS-TO-MOTHERS (M2M) programme in South Africa recruits HIV positive mothers who have recently given birth with a view to their educating, counselling and supporting HIV-positive pregnant women who attend antenatal clinics for prevention of mother to child transmission (PREVENTING MOTHER TO CHILD TRANSMISSION (PMTCT)). At every such visit, mentors engage pregnant women in conversation, share personal experiences, encourage adherence to anti-retroviral (ARV) prophylaxis, and help them during their hospital stay. The mentors also receive continued education and support, including a small stipend. The first M2M programme was started in a tertiary care hospital, with others scheduled to open over time in several primary care maternity centres. The peer support mentorship programme fits seamlessly into routine antenatal care. The programme helps to educate pregnant women and mothers and thus empowers them in their families and communities. Empowerment contributes to the destigmatization of HIV infection and to improved community health. Postpartum women who had two or more contacts with the programme were significantly more likely than non-participants to have disclosed their HIV status to someone (97% versus 85%; p<0.01). Participants were significantly more likely to have received ARV prophylaxis (95% versus 86%; p<0.05) and to report an exclusive method of infant feeding (i.e. either exclusive breastfeeding or exclusive replacement feeding). Moreover, they reported a significantly greater sense of well-being than their counterparts, feeling that they could do things to help themselves, cope with caring for infants and live positively.
Source: excerpted from WHO, 2009a. Integrating Gender into HIV/AIDS Programmes in the Health Sector: Tool to Improve Responsiveness to Women’s Needs. Geneva, Switzerland: WHO, Department of Gender, Women and Health, p. 36).
Example: The Twubakane Decentralization and Health Program is a five-year program in Rwanda built on fostering strong decentralized local government that is responsive to local needs and promotes sustainable use of community health services. The Twubakane Program’s overall goal is to increase access to and the quality and utilization of family health services in health facilities and communities by strengthening the capacity of local governments and communities to ensure improved health service delivery at decentralized levels. Between 2002 and 2004, IntraHealth tested an approach to assess the readiness of the health, policy and community systems to respond to gender-based violence in the context of two obstetrical-gynaecological services in Armenia.
In response to a request for assistance by USAID/Kigali, Twubakane conducted a similar qualitative and quantitative assessment to prepare for an initiative to integrate response to gender-based violence in antenatal care and prevention of mother-to-child transmission of HIV services. After consultation with a steering committee made up of the national partners involved in the prevention of both GBV and HIV transmission in Rwanda, and taking the lessons learned from Armenia, Twubakane adapted and tested their readiness assessment approach and tools in anticipation of preparing and implementing a multi-level, multisectoral intervention to integrate response to GBV in five sites in the districts of Nyarugenge, Kicukiro and Gasabo in Kigali Ville.
For additional information and tools, see the Twubakane website.
Illustrative Tools:
For guidelines and technical documents on preventing mother to child transmission of HIV, see dedicated section of the World Health Organization website in English.
Twubakane Gender-based Violence/ Preventing Mother to Child Transmission Readiness Assessment Tools (IntraHealth International, 2008). Twubakane Project. The tools are all available in English and French and include:
- Clinic Record Review Form to Assess Providers’ GBV Practice
- Interview Guide for Focus Group with antenatal care/ preventing mother to child transmission (PMTCT) Clients: Integrating Response to Violence in care/ preventing mother to child transmission (PMTCT) Services
- Interview Guide for Focus Group with Community Members
- Interview Guide for Focus Group with preventing mother to child transmission (PMTCT) Service Providers: Integrating Response to Violence in preventing mother to child transmission (PMTCT) Services
- Interviews Guide with Policy and Legal Stakeholders and Document Review Form
- Inventory to Assess Facility Readiness to Manage Gender-Based Violence
- Provider’s Questionnaire on Knowledge and Beliefs Related to Gender-Based Violence
- GBV Resource Scanning Guide
Integrating Gender into HIV/AIDS Programmes in the Health Sector: Tool to Improve Responsiveness to Women’s Needs (World Health Organization, 2009a). Available in English.
Additional Resources:
Prevention of Mother-to-Child Transmission Services as a Gateway to Family-Based Human Immunodeficiency Virus Care and Treatment in Resource-Limited Settings: Rationale and International Experiences (Abrams, E.J., Myer, L., Rosenfield, A. and El-Sadr, W.M., 2007). American Journal of Obstetrics and Gynecology, Vol. 197, No. 3 Suppl., S101-S106. Journal available in English.
Gender-based Violence, Relationship Power, and Risk of HIV Infection in Women Attending Antenatal Clinics in South Africa (Dunkle, K.L., Jewkes, R., Brown, G.E., McIntryre, J.A., Harlow, S.D., 2004). The Lancet, Vol. 363, No. 9419 (May), 1415-1421. Journal available in English.
Partner Notification in Pregnant Women with HIV: Findings from Three Inner-city Clinics (Forbes, K. M., Lomax, N., Cunningham, L., Hardie, J., Noble, H., Sarner, L. et al., 2008). HIV Medicine, Vol. 9, No. 6, 433-435. Journal available in English.