HIV/AIDS is a critical development issue in Sub-Saharan Africa, where a disproportionate number of all HIV/AIDS infections occur. HIV prevalence is now as high as 40% among antenatal care attenders in some parts of Africa. At the same time, in many Sub-Saharan African nations, maternal deaths from direct obstetric causes are also extraordinarily high compared to other regions. Almost half of all maternal deaths that occur each year take place in Africa. AIDS-related maternal deaths have increased dramatically and have recently begun to outpace the already alarming number of deaths from obstetric causes. The high prevalence of both obstetric-related maternal mortality and HIV among pregnant women in most African nations clearly indicates the need for programs that simultaneously address both problems.

One disturbing aspect of the HIV/AIDS pandemic is the number of infants who become HIV+ through maternal transmission of the HIV virus that can occur during pregnancy, birth, and during breastfeeding. It is estimated that in 2001 800,000 infants were infected with HIV through mother-to-child transmission, almost 90% of them in Sub-Saharan Africa. At country level, this translates to an estimated 40,000 AIDS-related infant deaths in Uganda, and 56,000 in Kenya each year.

Interventions to prevent mother-to-child transmission of the HIV virus (PMTCT) are now an important part of HIV/AIDS reduction programs worldwide. During the past several years, researchers have learned many valuable lessons about reducing Mother-to-Child Transmission (MTCT) of HIV in resource-poor settings. One of the greatest challenges facing program planners is the need to translate lessons learned from short-term clinical trials to date into effective, actionable, large-scale program interventions. This discussion paper is intended to encourage dialogue and generate feedback from PMTCT and Safe Motherhood (SM) program planners and implementers who share the responsibility for shaping interventions to prevent mother-to-child transmission of HIV, and to improve maternal and newborn survival through conventional safe motherhood interventions. The paper reviews research results and field experience from a behaviour change perspective, to see what can be applied to develop and strengthen the essential behaviour change component of PMTCT programs. It briefly discusses some of the operational challenges faced by PMTCT programs documented in the literature, and how a behaviour change approach could help to address them.

The paper focuses on those PMTCT program elements related to improved obstetric practice and discusses the potential synergies of integrating PMTCT and SM programs, particularly the behaviour change components. It makes literature-based recommendations for increasing the emphasis on and funding for the improved obstetric practice component of PMTCT programs; and shows how the PMTCT literature supports the need to prioritize operations research to better document the contribution of improved obstetric practice to reduce MTCT during labour, delivery and early postpartum.

Both PMTCT and SM program planners may not always prioritize behaviour change interventions (BCI)among the many program elements they are responsible for. This paper identifies the common behavioral objectives of PMTCT and SM programs - emphasis behaviours - and logical ways to integrate promotion of joint objectives. It suggests a framework and rationale for a set of integrated strategic ehaviour change interventions to support PMTCT and SM programs. It proposes next steps required for policy makers and planners to begin to develop and implement integrated field programs. Extensive references are provided for readers who want more detail on specific topics.

The review of the literature contained in this paper is an essential first step in developing research-based behaviour change interventions. The paper briefly describes the CHANGE Project approach to behaviour change, and some innovative methodologies already used by CHANGE and other safe motherhood programs that could be applied to PMTCT behaviour change programmes as well. It highlights the contribution that innovative behaviour change methodologies could make to increasing acceptability and utilisation of PMTCT services and treatment regimens; identifies key areas where a strategic multi-level approach to behaviour change could enhance current PMTCT programme results; and suggests developing a set of standardised tools that can accelerate scaling-up of strategic, integrated behaviour change interventions that support SM, PMTCT and newborn survival programmes.

Barriers to Preventing Mother-to-Child HIV Transmission

There are three main mechanisms that are essential for maximally effective reduction of MTCT: 1)reducing maternal viral load with ART, 2) preventing avoidable exposure to maternal virus at birth through improved obstetric practice and 3) reducing exposure to HIV through breastfeeding. Currently, improved obstetric practice is not receiving equal program emphasis. All three mechanisms should be addressed in PMTCT programs, especially in the behaviour change program component. Despite impressive achievements in a short timeframe, the current level of success of PMTCT programs in reaching pregnant women and their newborns with ART and other program components demonstrates the need for rapid action to refine and strengthen PMTCT behaviour change strategies. Documented barriers, all of which can be addressed with behaviour change interventions, include:

• missed opportunities to offer, or low uptake of, VCT during routine ANC
• low levels of acceptance of HIV testing where it is available, by both pregnant women and partners
• failure to return for HIV test results where rapid testing is not available
• inadequate acceptance of ART offered to HIV+ women at ANC
• insufficient use of facility-based delivery where improved obstetric practices can be used, and ART for mother and newborn can be supervised
• poor adherence to "take-home" ART for mother and newborn when given to HIV+ women at ANC
• low coverage of newborns with ART even when delivered in facility
• low uptake of recommended infant feeding behaviours to minimise MTCT

Integrating Behavior Change to Promote PMTCT and SM

Several key interventions to improve both maternal and newborn survival are common among safe motherhood, PMTCT and Saving Newborn Lives (SNL) programs. Many take place around the time of labour, delivery, and early postpartum. One of the most important potential linkages between PMTCT, SM and SNL programs is collaboration to identify, strengthen and integrate overlapping program emphases, and to access the substantial expertise and experience in the safe motherhood community. Vertical PMTCT programs with emphasis solely on PMTCT may miss valuable opportunities to help avert common obstetric and newborn emergencies. This could result in successfully preventing mother-to-child transmission of HIV, only to have the new mother or newborn die from an avoidable obstetric-related cause.

Key points:

• The most significant overlap between behaviour change objectives of PMTCT and SM programmes occurs in the area of improved obstetric practices.
• Most perinatal transmission of HIV occurs during delivery, so this period should be the target of the most intensive PMTCT programme efforts.
• Much more emphasis should be placed on accumulating an evidence base for the contribution of improved obstetric practices to reducing MTCT.
• A suggested point of entry to begin integrating SM/PMTCT behaviour change interventions is to focus on reducing delays in obstetric care seeking, in order to reduce prolonged labor and ruptureof membranes (ROM) longer than four hours. Both are important contributing factors to MTCT of HIV.
• It is estimated that every year more than a million women infected with HIV deliver babies at home without professional help. One of the most important PMTCT behaviour change interventions may be to inform communities and professional and traditional birth attendants that whether a birth takes place at home or in a health facility, there are improvements in childbirth-related behaviours that can help to reduce HIV transmission not only to newborns, but also to birth attendants and others who may be present during and immediately after birth.
• In addition to improving obstetric practices in maternity facilities, a set of simple, realistic obstetric behaviours to reduce MTCT during home births should be a component of all PMTCT programmes insettings where home births predominate.
• Timely use of skilled obstetric care and reducing delays in seeking, reaching and receiving skilled childbirth care should be part of behavior change objectives of PMTCT programmes.
• Behaviours that potentially reduce prolonged exposure to ruptured membranes should be emphasised to both skilled and traditional birth attendants, families and communities.
• "Nesting" recommended PMTCT behaviours in already established SM programmes may help to minimise stigma and "normalise" PMTCT interventions as part of routine maternity care.
• PMTCT programme emphasis on ART and infant feeding without addressing obstetric practices may result in deterioration rather than improvement in obstetric practices.

Behavior Change Approach

Behavior change methodologies and approaches that could be more widely utilised in integrated PMTCT/SM programmes include:

• Reinforce need for strategic, multi-level, research-based behaviour change (BC) interventions.
• Develop and promote a set of EMPHASIS BEHAVIOuRS that contribute to the common goals ofPMTCT, SM, and SNL programmes.
• Develop setting-specific approaches that are tailored to the needs of PMTCT/SM programmes, for example in areas with low use of facility-based childbirth; high use of facility-based childbirth,"mixed" use of facility birth.
• Add innovative methods such as concept testing, trials of improved practices (TIPS), and positivedeviance (doer/non-doer) to research methods used to date.
• Use "generic" PMTCT/SM behaviour framework as a broad guide; validate locally and adapt.
• Integrate separate frame works for stigma, PMTCT, BCC that are now in use to create one comprehensive BCI approach.

Next Steps

There are many steps that must be taken to speed both the integration of PMTCT and safe motherhood programmes. Some activities to support this at the global/donor level include:

• Plan a meeting of representatives of key organisations working in PMTCT and SM behaviour change to accelerate development of PMTCT BC support materials for country programmes.
• Collaboratively outline next steps for implementing comprehensive PMTCT behaviour change programme components.
• Develop strategies and activities to help PMTCT and SM programmes more rapidly integrate programme objectives, behaviour change objectives, and delivery of integrated services.
• Develop plans for operations research to provide needed information on the potential effectiveness of improved obstetric practice in facilities and in communities, even in settings where NVP treatment is not yet offered; and on the effectiveness of various PMTCT BC approaches.
• Develop a "diagnostic" tool to assess local capacity to adapt and implement comprehensive PMTCT behaviour change interventions. This BC-specific tool would complement the country assessment tools now being used in several countries.
• Develop a simple, standardised set of qualitative research instruments that all PMTCT programmes could use. Results would be comparable and more easily compiled to determine trends.
• Develop and pretest PMTCT BC materials, including a set of facility-based and community-based" PMTCT Counseling Cards" and a Users Guide, that contain simple information on the full set of PMTCT behaviours. The two sets of cards should be appropriate for health facility use by providers, or community health workers in homes and communities, and should contain the basic information required for families to make informed choices about options for the many PMTCT behaviors.

This is a discussion paper. Please send your comments, questions, suggestions to The CHANGE Project at changeinfo@aed.org