Globally, HIV and complications of childbearing are the leading causes of death among women of reproductive age. The epicenter of poor maternal health outcomes associated with HIV is sub-Saharan Africa, where 90% of pregnant women living with HIV reside. In this region, women with HIV are six to eight times more likely to die during pregnancy and the postpartum period than HIV-negative women, approximately a quarter of maternal deaths are due to HIV, and WHO estimates that maternal mortality has actually increased in eight countries with high HIV prevalence over the past 20 years. Addressing the intersections between HIV and maternal health in sub-Saharan Africa is necessary to make good on international and country commitments to end preventable maternal mortality and achieve an AIDS-free generation.
Fortunately, we know what some of the problems are and how to address them:
- In 2012, only 49% of pregnant African women were tested for HIV—scaling-up voluntary HIV counseling and testing to reach 90% of women attending prenatal care is needed to support women to access treatment for their own health and to prevent mother-to-child transmission of HIV. African countries like Botswana, Mozambique, South Africa and Zambia have shown it can be done.
- To achieve better outcomes coverage of interventions that can radically reduce maternal and neonatal mortality, such as provision of antiretroviral therapy (ART), malaria and tuberculosis screening and treatment, and family planning must increase through better integration of HIV and Maternal-Child Health (MCH) services.
- Too many pregnant and postpartum women either do not begin or drop out of HIV and MCH services. HIV stigma, disrespect and abuse, gender discrimination, and financial and geographic barriers are associated with low uptake and retention in care and treatment. Social support for pregnant and postpartum women and community mobilization to promote women’s health and rights can contribute to increased demand for and delivery of high-quality, respectful HIV and MCH services.
Addressing maternal morbidity and mortality among women living with HIV and improving outcomes for all pregnant and postpartum women requires health system strengthening, integration of HIV and MCH services, and transformation of the social context.
Research and evaluation is needed for better policy and programs. The forthcoming Research and Evaluation Agenda for Maternal Health and HIV in sub-Saharan Africa identifies three priorities:
- Clinical Questions about Maternal Mortality and HIV: What is the relationship between HIV infection and rates and causes of maternal morbidity and mortality? How can increased illness and death among women with HIV be prevented? How will new treatment guidelines and increased availability of ART for women living with HIV effect maternal and neonatal health outcomes?
- Integrating Health Service Delivery to Address Maternal Health and HIV: What are the most effective models for integrating HIV testing, treatment and care with antenatal, intrapartum, postpartum and family planning services? How can additional critical interventions—specifically screening and treatment for malaria and tuberculosis, postpartum family planning, and preconception counseling—be integrated into the continuum of HIV and MCH services while maintaining quality? What levels of staffing and mix of skills are needed to safely and effectively deliver integrated services? How does service integration effect coverage, quality, retention and satisfaction of users and providers, and health outcomes?
- Transforming the Social Context to Improve Maternal Health: What are the effects of programs which reduce HIV-related stigma and discrimination, disrespect and abuse in maternity care, and violence against women on uptake and retention in HIV and MCH services, adherence to antiretroviral treatment, disclosure of HIV status, and postpartum depression? How does increasing social support for pregnant and postpartum women and community mobilization to promote respectful, high-quality HIV and MCH services, effect maternal health outcomes?
The 2013 World AIDS Day theme “Shared Responsibility: Strengthening Results for an AIDS-Free Generation” is a call for researchers, policymakers, healthcare providers and women living with HIV and their communities to redouble efforts to improve responses to HIV and maternal and child health in sub-Saharan Africa.