The following is final part of a series of project updates from the Centre for Development and Population Activities (CEDPA). The MHTF is supporting their project, Working on Integration Issues of HIV/AIDS and Maternal Health. More information on MHTF supported projects can be found here.
With an estimated 27 million deliveries taking place annually in India, approximately 40,6311 HIV positive women become pregnant and give birth to a number of HIV infected babies each year. The Government of India’s National AIDS Control programme (NACO) has been providing Prevention of Parent to Child Transmission (PPTCT)2 services in the country since 2001, reaching pregnant women and babies annually. However, only one third of the total pregnancies get tested for HIV and PPTCT coverage. Gaps and challenges exist such as inadequate coverage of PPTCT and maternal, newborn, and child health (MNCH) services, low proportion of institutional deliveries, low involvement of male partners and the limited involvement of the private sector in the program even though a large number of institutional deliveries occur in the private sector. In India, parent to child transmission is the most significant route of transmission of HIV infection in children below 15 and accounts for 5.4 per cent of the overall HIV transmission in the country.3 India like many countries across the world is responding to the need for increased access to quality MNCH services, reducing morbidities, improving pregnancy outcomes and HIV services. One of the strategies being adopted is integration of two traditionally separate services – maternal and child health and prevention of mother to child transmission (PMTCT). In India, PPTCT and MNCH integration is still in the beginning stages and some benefits and models are emerging.
Initiating dialogue among stakeholders
CEDPA India with support from Maternal Health Task Force (MHTF) conducted a series of consultative workshops on maternal health (MH) and HIV integration in late 2011-2012 at the state level in Rajasthan, Madhya Pradesh, and Maharashtra and at the national level in New Delhi. The main purpose of these workshops was to initiate a dialogue among stakeholders to understand the state of integration of MH and HIV in the states and at the national level and come up with recommendations for the national and state level.
There were some common discussions that emerged from the consultations while there were some issues that emerged that were specific to the states. During these consultations, it was emphasised that in India, there was a need to reduce maternal mortality and this could effectively be accomplished and sustained through integration of maternal health and HIV. It was discussed that integrating these two departments was challenging and difficult in India. It was further mentioned that maternal and child health was integrated and now HIV was slowly being integrated with these services.
During the consultations, when the best practises and promising models were shared. It was highlighted that the models of integration across the globe were still in the initial stages. Most of the examples were from Africa, while the models from Asia were fewer. From India, there were very few examples in their early stages. The challenges of integration of MH and HIV services was discussed, and it was shared that factors, such as socio-cultural and gender related barriers, funding weaknesses, human, logistical and technical resources, were responsible for failure in integration.
In India, efforts of integration have been made in some states. It was shared that integration efforts in Rajasthan had started well but faced problems later as testing kits were not available for practitioners. For the last year, the Madhya Pradesh government has included HIV indicators for MH programs and orders were released mentioning the need for HIV testing during antenatal care. As a result, this saved money of clients and time of laboratory technicians. It was felt that if there is a political will, integration of MH and HIV is possible.
Through the consultations discussions emphasised that there are different stages of integration and points of integration between MH and HIV and there is a clear difference between linkage and integration. During the consultations it was explained that integration needs to be understood in context of the parallel operating services of both MH and HIV and linkages are points where these services meet.
In the context of India, integrating the two parallel services has been a challenge. In fact there was a time when maternal health and child health were treated separately. Now integrating HIV to MH will be equally challenging.
During the national consultation in Delhi, Dr. Suresh K. Mohammed from the Ministry of Health and Family Welfare expressed his disappointment at not having seen much action in the area of implementation post the August 2010 government order on integration. Integration, according to him, was yet to become part of a robust and well coordinated national effort. Talking of impediments to integration, Dr. Mohammed stated that funding issues would no longer be an area of concern, with the 12th Five Year Plan taking up MH-HIV integration within RCH sans support from development partners. He was of the view that HIV testing had to be demystified and the current counselling and pre-testing strategies redesigned. He also felt that as a part of the ANC routine, existing auxiliary nurse midwives and nurses within the healthcare care system must double up as counsellors.
He also stated that “We need champions in HIV who can be part of RCH and other programs. 2012 must see a new chapter in integration. Let there be a national level, Government of India campaign that has champions of HIV weaving in RCH messages effectively.”
Dr Naina Rani, Deputy Director, PPTCT-NRHM [National Rural Health Mission] Integration from Karnataka shared that within her state, PPTCT was viewed as an essential component of the mother and child health program and was a cost-effective and sustainable model. It followed a horizontal approach – joint ownership rather than a vertical program. Karnataka has been one of the pioneering states to have integrated their PPTCT – maternal health programs. Dr. Charles Gilks, UNAIDS Country Coordinator, India was of the view that in spite of best practices and efforts, integration in India must be re-energized to move forward.
During the consultation in Bhopal, one of the senior officials from the Government of Madhya Pradesh’s Department of Health stated that the maternal mortality ratio of the state is still high and HIV is under control in the state. It is a good time to integrate it with, not only maternal health, but with child health as well. As a part of integration between NRHM and Madhya Pradesh States AIDS Control Society (MPSACS), HIV testing was made a quality indicator of health service. This was a major step which was taken to integrate HIV and maternal health. Another example of integration in Madhya Pradesh NRHM was that of a single window sampling in which blood to be extracted for testing would be done only once from the mother’s body and would be shared among the different tests including the HIV test.
Presentations by speakers and discussions by participants in these consultations led to a list of suggested recommendations based on participants’ own experiences, observations and thinking around integration of HIV and MH programs at the state and national level. The important recommendation and strategies that came up were the importance of capacity building of health practitioners during pre service medical training and in service and ongoing training. It was also recommended that there should be legislative control over private practices as they are accountable and private services should be accredited. There should be sensitisation of health service providers. It was also proposed that post test services should be strengthened through referral system accessible treatment and there should be decentralisation of these services. It was also suggested that certain NGOs should dedicate themselves in working on stigma related to HIV.
The speakers and participants were hopeful that the consultations would pave the way for a stronger and more reinforced commitment on the part of the national government, state health departments and implementing partners to take up some of the recommendations. Hoping for a strong mention in the Government of India’s 12th Five Year Plan and National AIDS Control program (NACP) IV, the stakeholders looked forward to integrating plans and budgets as they revisited some of the older mechanisms across departments to bring about greater convergence and integration in MH-HIV programs.
1 India PPTCT Country Factsheet July 2011
2 In India, PMTCT is known as Prevention of Parent to Child Transmission
3 NACO 2011