accelerating progress on aids and maternal and child health

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Accelerating Progress on AIDS and Maternal and Child Health

ICASO Discussion Paper (September 2010)

Accelerating Progress on AIDS and Maternal andChild Health

International Council of AIDS Service Organizations



About the International Council of AIDS Service Organizations (ICASO): Founded in 1991, the

mission of ICASO is to mobilize and support diverse community organizations to build an effective

global response to HIV and AIDS. As the world’s leading network of AIDS organizations, ICASO’s

network of secretariats operates globally, regionally and locally, and reaches over 100 countries.ICASO’s International Secretariat based in works with its Regional Secretariats based on ve

continents: AfriCASO, AAE, APCASO, LACCASO, and NACASO. In reaching over 100 countries, we

actively communicate with thousands of people, community organizations and networks across the

world through our global network of civil society organizations.

ICASO Discussion Papers: ICASO discussion papers are intended to stimulate debate, foster

consultations, and to facilitate policy dialogue amongst various stakeholders involved in developing

and deciding policy on HIV and AIDS globally. ICASO is seeking direct feedback and discussion on

the content of discussion papers (email: [email protected]).

ICASO Discussion Paper (Sept 2010) Accelerating Progress on AIDS and Maternal and Child Health,

was prepared by Rodney Kort (Kort Consulting), edited by Kieran Daly and Robert Carr (ICASO), in

collaboration with the Interagency Coalition on AIDS and Development (ICAD).

We are grateful for the nancial support provided by the Ford Foundation, GTZ BackUp Initiative, and

the Canadian International Development Agency of the Government of Canada (CIDA). The views

expressed within this publication do not necessarily represent the views of the Ford Foundation, GTZ,

or CIDA.

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Copyright © 2010 by the International Council of AIDS Service Organizations (ICASO).

Information contained within this publication may be freely reproduced, published or otherwise used

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source of the information.




Health-related Millennium Development Goals

MDG 4: Child Health Target: Reduce under-ve mortality rate by two thirds,

between 1990 and 2015

MDG 5: Maternal Health Target 1: Reduce by three quarters the maternal mortality ratio

Target 2: Achieve universal access to reproductive health

MDG 6: Combat HIV/AIDS, malaria and other disease Target 1: Have halted by 2015 and begun to reverse the spread of HIV/A

Target 2: Achieve, by 2010, universal access to treatment for HIV/AIDS

all those who need it

Target 3: Have halted by 2015 and begun to reverse the incidence of m

and other major diseases

(Source: United Nations)

ICASO Discussion Paper (September 2010)


1.0Context: Day-to-day realities of women and children

“Andaiye’s” family is deeply ashamed of what has happened to her brother, so shehad no help in caring for him when he became sick. He was weak and had fevers and

sometimes could not get out of bed to go to the bathroom, so she had to stay with himmost of the day. Before her husband left her, she would bring in the crop from theirfarm, and he would take what they didn’t need to market. But he was angry when hecame back from the clinic and told him about the AIDS test and the new baby coming,and told her she had brought sickness and death into his home. He has been gonethree months, and between taking care of her little girl and her brother and the long tripfor water every day, she does not have time to harvest and sell what little they have.Her neighbours are afraid and stay away, and she has little money left to buy food.

The doctor at the clinic says she has medicine that will help her and her unborn baby,but it is a long way and she has to walk because she has no moneyfor the bus that comes to the next village. And she is afraidof what will happen to her brother if she leaves him. Heis very weak now, and has no one else to care forhim.

The above is a composite case study,elements of which were taken froma number of interviews, examplesand case studies of womenliving in Africa and acrossthe Commonwealth for aforthcoming study onwomen’s unpaid work inthe HIV care economy.1

Maternal, newbornand child health(MCH) and progresson MillenniumDevelopmentGoals (MDGs)4 and 5 havebecome aprominent focus



ICASO Discussion Paper

in global health and development discussions. Lost sometimes in the intense globalpolicy debate surrounding the status and nancing for MCH are the daily realitiesfaced by women and children in the developing world. Lost is the need for a holistic

approach to address the many factors contributing to under-ve morbidity and mortalityand poor maternal health outcomes, which range from food insufciency and access tohealth services for rural populations, to gender inequality and HIV-related social stigma.

While the focus of this brief is on the important contributions that nancing for AIDSare having in improving maternal and child health, particularly in Africa, the challengesfaced by women and children in the developing world will not be solved by any one – oreven a set – of interventions. It will be achieved by ensuring that nancing for all healthMDGs is adequate, effectively coordinated with other development efforts, and meetsthe day to day realities of women struggling to maintain their own health and those of their families.

1.1Policy and Programmatic Context: MCH in 2010

This brief provides an overview of the current policy and nancing context related toaccelerating progress on MDGs 4 and 5, focusing on evidence of the impact thatprogress on MDG 6 has had on MCH to date, and demonstrates the urgent need forleadership from the international community to accelerate progress on all health MDGsduring a benchmark year in global health. Below is a list of key milestones:

• In 2000, eight international development goals are established that all 192 UnitedNations Member States agree to achieve by the year 2015 (see sidebar on health-

related MDGs)

2

• In 2005, the G8 and all UN Member States set 2010 as the deadline for achievinguniversal access to HIV prevention, care, treatment and support

• In June 2010, the G8 announces the Muskoka Initiative, which commits toproviding an additional $5 billion in funding for MCH over the next ve years

• In September 2010, the MDG Review Summit assesses progress on all MDGs

• In October 2010, donors conrm contributions to the Global Fund to Fight AIDS, Tuberculosis and Malaria at the Second (Pledging) Meeting of the Third VoluntaryReplenishment

While the 2010 global health calendar might ordinarily presage increased political

attention and nancial commitment to MCH and the three diseases (AIDS, tuberculosisand malaria) which continue to contribute signicantly to maternal and child morbidityand mortality, there are concerning signals that both domestic and overseasdevelopment assistance (ODA) for global health commitments – particularly as itrelates to AIDS - may be weakening. While the 2010 G8 Communiqué reafrmed theircommitment to universal access, no additional funding was announced, despite ampleevidence that substantial increases in resources are required to meet that commitment.

The global economic crisis continues to place signicant scal pressures on publicsector budgets in both the developed and developing world. Recent reports indicate




that the resulting cuts to health and ODA budgets are already having an impact:progress in expanding access to antiretroviral therapy (ART) in several high-burdencountries has stalled; ART coverage goals in Swaziland, Botswana and Tanzania

have been downscaled, requiring many programmes to stop enrolling new patients: ARV stock-outs and clinically dangerous treatment interruptions (1). Médecins SansFrontières (MSF) released a report in May 2010, based on research conducted in eight

African countries, conrming both caps and reductions in donor nancing for AIDS andthe implications of the ODA and domestic nancing context in rising rates of morbidityand mortality for those waiting to access ART (2), the majority of whom are women.Progress on MDG 6, particularly AIDS, remains fragile, and the recent MSF reportshighlights what is at stake if the international community fails to full its obligations.

If nancing is scaled up to meet the collective commitments of the G8 and other UNMember States in the global response to AIDS, mounting scientic evidence indicates itwill have a signicant impact in accelerating progress not only on MDG 6, but on a widerange of health and development goals. Given progress to date, it is more important

than ever to identify the impact that the outcomes from these events will have on thewomen and children whose lives hang in the balance.

2.0 AIDS Financing: Evidence of Impact on MCH

There is substantial scientic evidence that HIV plays a major role in maternal and childhealth status, and of the impact that HIV investments can have in reducing illness and

death among women and children:

• AIDS is the leading global killer of women of reproductive age; in sub-Saharan Africa over 60% of people living with HIV are women, the majority of whom areeligible but do not have access to ART (3)

• A South African study found that 38% of maternal deaths were not related topregnancy and were primarily due to HIV, TB and pneumonia (4)

• A ve-year audit of maternal mortality in South Africa showed that maternal deathswere six times higher among women living with HIV (5)

• AIDS is the leading cause of under-ve mortality in the six highest HIV prevalencecountries, accounting for over 40% of under-ve deaths in these countries (6)

• An estimated 430,000 children under 15 years of age were infected with HIV in 2008, primarily due to vertical transmission (3); UNAIDS estimates that ARV prophylaxis to prevent vertical transmission has averted 200,000 infections amonginfants (7)

• Almost 80% of malaria deaths occur in children (6)

• Over 700,000 women die every year of TB, with children under 15 years of agecomprising 10% – 15% of the global TB burden (8)




These data highlight not only how interrelated the threehealth-related MDGs are, but also on how substantialprogress in improving maternal and child health isconditional on increased nancing to combat AIDS,

TB and malaria. Interventions for these diseases arenot limited to HIV-specic interventions, but alsoinclude sexual and reproductive health services(including treatment for sexually transmittedinfections), pre, intra and post-partum care(including expanded access to trained birthattendants), and implementation of updated WorldHealth Organization (WHO) ART guidelines forpregnant and lactating women. The followingsection of this paper summarizes the key ndingsof recently-published scientic literature on currentprogress and outstanding challenges in improving

MCH.

2.1 Progress and Challenges in ReducingMaternal and Child Mortality

Progress in reducing childhood mortality has varied fromcountry to country and region to region, with countries in

sub-Saharan Africa making the least progress. A 2008 reporttracking coverage of MCH interventions indicated that only 16

out of 68 priority countries (comprising 97% of maternal and child

deaths worldwide) were on track to meet MDG 4, and that most of thecountries which reported increases in child mortality were countries with

high HIV prevalence (9). Contraception, skilled attendance at birth and clinicalcase management of newborn and child illnesses were priority health interventions

agged by the report as the most signicant gaps in the continuum of care. Allthree are included in WHO’s package of priority HIV prevention, care and treatmentinterventions for the health sector (10).

Increased nancing for these interventions would help close gaps in coverage that arecontributing to child mortality. The report indicates that WHO’s Integrated Managementof Childhood Illness Strategy – estimated at only 1% coverage in the progress report– could signicantly reduce under-ve mortality, including complications due to HIV infection (9). The report also notes the signicant impact of the HIV epidemic inhampering improvements in maternal mortality (particularly in Africa) (9).

While progress to date has been disappointing, there is also reason for optimism; aMay 2009 analysis published in the Lancet indicated that under-ve mortality droppedfrom 11.5 million deaths in 1990 to 7.7 million deaths in 2010. Although insufcientto meet the 2015 goal of reducing under-ve mortality by two-thirds, it demonstratesthat if sufcient political attention and resources are devoted to common globalhealth goals, signicant progress can be achieved (11). The report also notes that, ‘...

AIDS financingis clearly having

a significant impact on MCH andbeyond, and can now be

measured in population-level vital statistics; life

expectancy has begun rising in countries with large, generalizedepidemics .




uctuations in post-1990 under-5 mortality in southern sub-Saharan Africa show theeffect of HIV in the region’ (11).

Recent increases in access to HIV interventions affecting child and maternal health will

hopefully be reected in accelerated progress on MDGs 4 and 5 in the next CountdownWorking Group report. For example, ART coverage for children (under 15 years of age)increased 39% between 2007 and 2008 alone, with 45% of children in need accessing

ART at the end of 2008 (12).3 An estimated 65% of women who need it are accessing ART; ARV prophylaxis to prevent vertical transmission increased from 35% of women inneed in 2007 to 45% in 2008 (including fewer women on suboptimal ARV prophylaxisinterventions). However, an important cautionary note on this progress is that estimatesof need are expected to increase signicantly as a result of revised WHO guidance onearlier initiation of ART, released in December 2009. The guidelines, based on scienticevidence indicating earlier ART initiation will reduce HIV-related illness and death, greatlyexpands the number of people eligible for ART.

AIDS nancing is clearly having a signicant impact on MCH and beyond, and cannow be measured in population-level vital statistics; life expectancy has begun risingin countries with large, generalized epidemics . Average life expectancy in Botswanahad dropped dramatically in less than a generation, from 64 years of age to 35 years of age (29 years) by 2004 due to AIDS (13). In 2006, however, Botswana reported gainsin overall life expectancy and reduced infant mortality in over a decade, following theexpansion of HIV prevention and treatment services (14). Recent scientic literatureprovides additional evidence of how expanded access to HIV treatment and preventionare improving MCH:

• A study in Eastern Ugandan found an 81% reduction in infant mortality amonginfants uninfected with HIV following scale-up of ART in the area, likely a resultof the 93% reduction in orphanhood that ART access had in reducing parental

mortality (15)• A study in KwaZulu-Natal reported that deaths in under-twos declined by 49%

between 2001 and 2006, with researchers estimating that 31% of the 2005 declinein mortality was due to the availability of ART and PMTCT programmes (16)

• A study in western Kenya found that the use of ART reduced the probability of anHIV-infected child being diagnosed with incident TB by 85% (17)

• A joint South Africa/Zimbabwe study found mortality rates were cut in half within 12weeks of ART initiation

• Treatment sites in Rwanda improved their tracking of services to women at risk of infection , enabling them to rollout information programmes on HIV prevention,transmission and ART; the percentage of women receiving appropriate ARV prophylaxis to prevent vertical transmission increased from 60% to 90%

HIV investments are having a dramatic impact on reducing maternal and child morbidityand mortality, including a signicant impact on other endemic diseases, such astuberculosis. However, one of the constraints noted in the abovementioned progressreports on MDGs 4 and 5 are the health systems in low and middle-income countries,which are responsible for delivering many of these interventions. The question of how vertical (disease-specic) investments should be balanced and coordinated with




horizontal (health systems) investments is an important one for every organizationworking in global health.

3.0Health Systems Strengthening: Impact on MCH

A 2008 progress report focused on how well-functioning health systems – includingadequate levels of health human resources – are key to reducing maternal and childmortality: of the 68 countries included in the review, 54 had health workforce densitiesbelow the critical threshold identied by WHO (2.5 health care professionals per 1000population) (18). It is clear that strengthening fragile health systems is key to increasing

both the quality of services and expanding access to MCH interventions. There has been intense debate about the extent to which vertical investments producehealth system ‘distortions’ (e.g., disproportionate allocations of scare health systemresources towards the AIDS response, leaving few resources for other health priorities),but a recent WHO review suggests the opposite: HIV investments health systems,partly by increasing overall resources for health, and partly by introducing a series of innovations in how services are delivered, such as using standardized drug regimens,simplied clinical guidance and expanding health workforce capacity throughstrategies such as Treat, Train, Retain (19) (20). Financing, communicable diseasesurveillance, and supply and procurement systems have also beneted from increased

domestic, bilateral and multilateral investments.

Global health advocates, NGOs, domestic health departmentsand multilateral agencies are also recognizing that bettercoordination of services provided by a wide range

of organizations and aid groups (in keeping withthe principles of the Paris Declaration on Aid

Effectiveness) is required to strengthenhealth system capacity and disease-

specic services. The Global Fundprovides an illustrative example

of how AIDS nancing can beleveraged to address both the

need for disease-specicinterventions and the needfor strengthened healthsystems.

HIV investments are strengthening health systems,

partly by increasing overall resources

for health, and partly by introducing a series of innovations in how services are

delivered, such as using standardized drug regimens, simplified clinical guidance andexpanding health workforce capacity




4.0The Global Fund’s Role in AcceleratingProgress on MDGs 4 and 5

The Global Fund has proven to be an extraordinarily effective and innovative nancingmechanism, nancing (together with the President’s Emergency Plan for AIDS Relief)the majority of programmes and services combating the diseases that contribute mostto morbidity and mortality among low and middle-income countries. The Global Fundallocates substantial resources to addressing the continuum of care required for pre-pregnancy, pregnancy, birth and child care, contributing substantially to the scale-up of coverage for these populations. The Global Fund’s contributions to MCH and broaderhealth systems investments can be broken down into four areas (21):

1. Country-level development assistance for health (supporting countries to reach theWHO-recommended target per capita health expenditure of US $45).

2. HIV, TB and malaria interventions for women and children, including sexual andreproductive health services, and treatment of sexually transmitted infections.

3. Strengthening health and community systems as part of its grants architecture,thereby allowing countries to expand primary care for women and children (e.g.,scale-up of Health Surveillance Assistants who supervise a range of services,including supervision of birth attendants, disease surveillance, and family planningand nutrition advice.

4. Promotion of gender equality and the creation of an enabling environment toaddress the health needs of women and children through implementation of itsGender Equality Strategy.

To the end of 2009, 790,000 women received a WHO-recommended course of ARVsto prevent vertical transmission as a result of Global Fund nancing (22). Progress inreducing vertical transmission has been so impressive that the Global Fund launched amajor campaign in March 2010, Born HIV Free, which advocates for the nancing andcoordinated action required to eliminate vertical transmission by 2015.

The country-driven, performance-based grants architecture of the Global Fund has, ina relatively short time, achieved substantial success, not only in substantially increasingintervention coverage (such as access to ART and the supply of insecticide-treated bednets to prevent malaria), but in improving health outcomes: approximately ve millionlives have been saved as a result of Global Fund-nanced programmes, which deliverprevention, care, treatment and support services in 144 countries (22). By the end of December 2009, programmes nanced by the Global Fund were providing ART to

2.5 million people. Programmes and services nanced by the Global Fund will reachan estimated 6 million orphans and other vulnerable children with food, healthcare,clothing, bedding, shelter, education and psychosocial support by the end of 2010(23). Modelled estimates of the impact of Global Fund investments on mortality andlife-years gained include 2 million life-years gained by averted deaths from ART in 2011alone; 63 million life-years gained (cumulatively) through insecticidal net distribution at2011 levels (because children die in disproportionate numbers from malaria comparedto adults).




Programmes andservices financed by the Global

Fund will reach an estimated 6 million orphans and other vulnerable children with food, healthcare, clothing, bedding,

shelter, education and psychosocial support by

the end of 2010

Yet the Global Fund is facing a potentially disastrous nancial shortfall in its Third Voluntary Replenishment. It needs at least 20$ billion to continue scaling up thecountry-level programmes that have achieved such impressive results to date, and

this gure does not include what are expected to be signicant increases in requiredresources as a result of updated WHO guidance recommending earlier ART initiation(24).

5.0Recommendations

A recent Lancet commentary was unambiguous about the implications of recent

progress reports on improving MCH: “This latest evidence... supports growing calls tointegrate maternal and child survival programmes into a vertical funding mechanismfor the MDGS, such as the Global Fund to ght AIDS, tuberculosis and malaria” (25).

The Global Fund alone cannot address all of the multiple factors contributing to slowprogress on MDGs 4 and 5, but the scientic evidence outlined in this discussion papersupports the argument that increasing investments in the Global Fund will accelerateprogress on MDGs 4 and 5, as well as on MDG 6.

The Global Fund has demonstrated unequivocally that it is an effective and efcientaid nancing instrument. However, its success over the next three years of its grantcycle is entirely dependent on increasing replenishment pledges from the donorcommunity to meet the demand of quality, country-driven programmes that are savinglives and reducing illness in communities around the world. The international response

to AIDS has fundamentally shifted the approach to global health challenges over thepast decade by demonstrating that international leadership, collaboration,

innovation and investment can achieve impressive resultsagainst seeming intractable health and development

problems. The question is whether politicalleaders will capitalize on their investments

by increasing the nancing requiredto accelerate progress on all

health MDGs, or whether theywill effectively abandon their

commitments in the decitreduction frenzy that

appears to be emergingas the scal zeitgeist.




on improving maternal and child health, as

well as reversing the AIDS, tuberculosis and

malaria epidemics, ICASO recommends that

political leaders:

Increase bilateral, domesticand multilateral investments tostrengthen health care systems inlow and middle-income countries

Increase nancing for maternal and childhealth beyond the $5 billion MuskokaInitiative to scale up all necessary components of the continuum of care

Increase nancing to the Global

Fund to Fight AIDS, Tuberculosis andMalaria for the next Replenishment to aminimum of $20 billion

Increase nancing for AIDS to meet the2005 commitment to universal accessto HIV prevention, care, treatment andsupport for all in need

To accelerate progress

Footnotes1. Marilyn Waring, Robert Carr, Anit Mukherjee and Meena Shivdas, Who Cares? The Economics of

Dignity. London: Commonwealth Secretariat, forthcoming.

2. Information on all eight MDGs and the upcoming MDG Review Summit is available at http://www.un.org/millenniumgoals.

3. These estimates of need were based on 2006 WHO ART treatment guidelines, which have beensubsequently revised; revised UNAIDS needs estimates are due for release in July 2010.




Works Cited1. Medecins Sans Frontieres. Punishing Success: Early Signs of a Retreat from Commitment. November

2009.

2. —. No Time to Quit: HIV/AIDS Treatment Gap Widening in Africa. May 2010.3. WHO/UNAIDS/UNICEF. AIDS Epidemiological Update 2009. Geneva : s.n., 2009.

4. Every death counts: Use of mortality audit data for decision making to save the lives of mothers,babies and children in South Africa. Bradshaw D, et al. 2008.

5. WHO/UNAIDS/UNICEF. Towards Universal Access: 2008 Progress Report on Priority Interventions inthe Health Sector. Geneva : s.n., 2009.

6. World Health Organization. The Global Burden of Disease - 2004 Update. Geneva : WHO, 2008.

7. UNAIDS. Estimate of the annual number of infant infections averted through the provision of antiretroviral prophylaxis to HIV-positive pregnant women globally, 1996 - 2008. 2009.

8. Maraia BJ, Gupta A, Starke JR and Sony AE. Tuberculosis in Women and Children. s.l. : Lancet, May19, 2010.

9. Countdown to 2015 for maternal, newborn, and child survival: the 2008 report on tracking coverage

of interventions. Countdown Coverage Writing Group. s.l. : Lancet, April 12, 2008, Vol. 371.10. WHO. Priority Interventions: HIV/AIDS Prevention, Care and Treatment in the Health Sector. Geneva :

WHO, April 2009.

11. Neonatal, postneonatal, childhood, and under-5 mortality for 187 countries, 1970 - 2010: asystematic analysis of progress twoards Millennium Development Goal 4. Rajaratnam J, et al. s.l. :Lancet, May 24, 2010.

12. WHO/UNAIDS/UNICEF. Towards Universal Access: Scaling up priority HIV/AIDS interventions in thehealth sector - Progress Report 2009. Geneva : s.n., 2009.

13. Life Expectancy in Botswana Has Fallen by 29 Years Since 1990. Progressive Policy Institute.Washington : PPI Trade Fact of the Week , September 6, 2006.

14. 14. XVI International AIDS Conference. Stoneburner R, Montagu D, Pervilhac C, et al. Toronto : s.n.,2006. Abstract THLB0507.

15. Mortality in HIV-infected Ugandan adults receiving antiretroviral treatment and survival of their HIV-

uninfected children: a prospective cohort study. Mermin J, Were W, Ekwaru JP, Moore D, Downing R,Behumbiize P, Lule JR, Coutinho A, Tappero J, Bunnell R. 9614, s.l. : Lancet, Mar 1, 2008, Vol. 371.

16. A decline in early life mortality in a high HIV prevalence rural area of South Africa: associated withimplementation of PMTCT and/or ART programmes? . Ndirangu J, Bland R, Newell MJ. Cape Town :5th IAS Conference on HIV Pathogenesis, Treatment and Prevention, 2009. Abstract WEAD105.

17. The clinical burden of tuberculosis among HIV-infected children in western Kenya and the impact of of combination antiretroviral treatment. Braitstein P, et al. 7, s.l. : Paed Infect Disease Journal, July 2009,

Vol. 28.

18. Assessment of the health system and polic environment as a critical component to trackingintervention coverage for maternal, newborn and child health. Systems, Countdown Working Groupon Health Policy anbd Health. s.l. : Lancet, 2008, Vol. 371.

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20. World Health Organization. Treat, Train, Retain: The AIDS and Health Workforce Plan. May 2006.

21. The Global Fund to Fight AIDS, Tuberculosis and Malaria. Report on Global Fund Contribution toMillennium Development Goals 4 and 5. s.l. : [Report prepared for deliberations of the 21st GlobalFund Board Meeting], April 2010.

22. —. The Global Fund 2010: Innovation and Impact. Geneva : s.n., March 2010.

23. —. Financial and Health Impacts of Continued Support to the Three Diseases: Long-Term Estimates.March 2010.

24. —. Resource Scenarios 2011 - 2013. Geneva : s.n., March 2010.

25. R, Horton. Maternal Mortality: Surprise, hope and urgent action. s.l. : Lancet, April 12, 2010.sdfdfsd

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