Recommendations for PMTCT Communication in Latin America and the Caribbean

Recommendations for PMTCT Communication inLatin American and the Caribbean

The Cuernavaca Consultation was a meeting aimed at reviewing the experiences of communication supportfor the Prevention of Mother to Child Transmission (PMTCT) and making recommendations for PMTCT communications in Latin America and the Caribbean. It was organised byPAHO/WHO, UNICEF, and Censida-Mexico. For more information about the Cuernavaca Consultation, click here

Recommendation 1

PMTCT communication needs to be strategic and sustainable

Every communication initiative should be strategic and sustainable. However, due to lack of adequate human and financial resources, and to other constrains, some communication initiatives, including the ones employed in the response to HIV/AIDS, are still too often developed without a proper strategic planning methodology.

PMTCT communication requires a more strategic approach because:

• It has very complex goals (early attendance to antenatal care, testing acceptance, adherence totreatment, breastfeeding practices, primary HIV prevention, family and community support, etc)
• It addresses health conditions with very complex behavioral determinants
• It has ties to different health care services (HIV/AIDS, antenatal care, maternal and child health,nutrition, the workplace, gender, etc)
• It is part of a larger package of services (counseling, testing, ARVs, infant feeding nutrition,male/partner involvement, care & support from family and community, treatment of opportunistic infections)
• It needs to reach a variety of audiences, some of which are constantly changing (children, parents,grandparents, youth, men and women of reproductive age, HIV-positive women, HIV-negative women, health professionals, decision makers, communities, etc.)

Therefore, communication for PMTCT needs to be based on a comprehensive, research-based planning methodology. Most tested and successful planning methodologies include assessment and analysis of the problem, on-going research, setting up of measurable communication objectives, monitoring and evaluation mechanisms, and pre-testing of any messages and materials that are developed. During the Cuernavaca Consultation the participants became familiar with one of these methodologies, the ACADA1 communication planning process, which UNICEF has used for PMTCT communication in Asia and Africa since May 2000. This communication planning process has also been used for a variety of other programs, including Polio Eradication.

While planning takes time, in the long run it saves time and resources because it ensures that the PMTCTcommunication intervention is strategic, audience-appropriate and, therefore, more effective. Good1 ACADA stands for "Assessment, Communication Analysis, Design and Action" planning is the best way to avoid the need to make substantial changes and corrections in later phases of the intervention.

Participants noted that in Honduras the national PMTCT communication component had to be significantly modified once the project leaders conducted a knowledge, attitude and practice survey with the target audience. Examples like this, that use a research-based approach, should be used to encourage the use of a planning methodology from the outset of the PMTCT communication interventions.

Specific recommendations:

• Use a proven, research-based planning methodology for PMTCT communication.
• Identify long term financial and human resources required for effective implementation.
• Use low maintenance tools.
• Integrate your program with existing programs such as antenatal care, HIV/AIDS/STD prevention,infant nutrition, family planning, HIV/AIDS in the workplace, gender programs, etc.

Implications for Latin America and the Caribbean:

PMTCT communication in LAC needs to move away from a focus on production of materials and messages to a focus on behavior development. New interventions should limit production of messages and materials to a minimum until a research-based strategy has been developed, and there is a rationale for the identification of specific activities. The research needed to inform the communication plan does not need to be too lengthy and elaborated, and can include something as simple as community-based focus groupsdiscussions or utilisation of rapid assessments. The result of the research conducted will allow the team toidentify the behaviors to change, the barriers to achieving the desired behavior changes, the communicationobjectives, audiences, messages, materials and communication channels. The example of Honduras, wheresignificant changes took place after a knowledge, attitude and practice survey was conducted, highlights thebenefits of having this information at earlier stages of the intervention.

Recommendation 2

PMTCT communication needs to consider a wide range of audiences

The identification of primary and secondary audiences is an important part of the communication planning methodology. Which specific audience should be addressed by a PMTCT communication component depends on the local reality and will vary from one setting to another. The participants in the Cuernavaca Consultation, however, were able to identify some audiences who seem to be fairly universal for PMTCT communication.

Specific recommendation:

It was suggested that PMTCT communication initiatives in LAC consider if the following audiences are relevant for their reality:

Communities and community leaders - Communities play a crucial role in creating more caring and supportive environments for HIV-affected families, particularly when communities and community leaders have a correct understanding of issues related to the prevention of the HIV infection and the prevention of mother to child transmission. Better understanding and support of the PMTCT program service package, understanding the benefits of VCT and knowing one's HIV status, understandinginfant feeding options for HIV-positive mothers, the importance of exclusive breastfeeding for HIVnegative mothers, involvement of partners and families, etc., all contribute to enhanced community support, and make it easier for an HIV-positive mother to take advantage of PMTCT services without fear of stigmatisation and discrimination.

Decision-makers - Some decision-makers already support PMTCT initiatives because, among other reasons, PMTCT can show tangible results in a relatively short time, which is not always the case of other HIV/AIDS interventions. But decision-makers at all levels need to be on board to ensure that the necessary services for PMTCT are available, as well as to increase their support to other, non-PMTCT, HIV/AIDS prevention and antenatal care-related strategies.

Health professionals – Partnering with health professionals is a key component of PMTCT success in LAC, since a large part of the PMTCT intervention happens within the health care setting. PMTCT communication can support health professionals to provide their services (counseling, testing, and treatment) in a high quality manner, and can also motivate them to adopt a more supportive, nondiscriminatory and non-judgmental attitude towards the clients of the PMTCT intervention.

HIV-negative women - With the increasing availability of HIV testing, a large number of women will be able to learn about their status for the first time. Therefore PMTCT represents an excellent opportunity to develop realistic primary prevention options and skills enhancement for women and couples who test negative.

HIV-positive women - Prevention of transmission of the virus from HIV-infected women to their infants, before, during or after delivery is a key strategy of PMTCT interventions. In addition to that, these women need support to treat opportunistic infections, improve their nutritional practices, adopt healthier lifestyle and further prevent HIV through sex, IDU etc.).

Men and women of reproductive age - PMTCT is also an excellent opportunity to approach men and women of reproductive age and their families (children, parents and grandparents). Men in particular constitute a very important audience. Several participants stressed the need to include men as a target audience for PMTCT communication. Among other things, PMTCT communication should

1. Promote primary HIV/AIDS-STI prevention among men and women of reproductive age, regardless ofthe event of pregnancy;
2. Educate men on female reproductive issues and infant feeding for HIVpositive and HIV-negative mothers;
3. Encourage pregnant women and their partners/families to utilise antenatal care services from the first trimester of pregnancy onwards.

In addition to these audiences, the Cuernavaca Consultation participants mentioned several other audienceswho are relevant to HIV/AIDS communication programs including educational, religious and private sectors, trade and labor unions, people living with HIV/AIDS, marginalised groups and human rights groups.

Implications for Latin America and the Caribbean:

The Cuernavaca Consultation produced the above list of audiences. PMTCT practitioners working in Latin America may want to use it as a checklist to assure they are considering all the audiences they want to reach and all behavior changes they want to achieve. The definition of the primary and secondary audiences and of the behavioral barriers should be based on local research.

Recommendation 3

PMTCT communication needs to support the UN three-prong strategy for PMTCT

There are three main strategies to prevent HIV transmission to children:

• Strategy 1: Women should be protected against infection (therefore, the focus should be on women themselves, regardless of their HIV tatus, rather than on the women's potential for transmitting the virus to their infants).
• Strategy 2: Unintended pregnancies to be avoided among HIV-infected women and women at risk.
• Strategy 3: Prevention of transmission of the virus from HIV-infected women to their infants before, during or after delivery. Currently, most PMTCT communication initiatives in LAC focus almost exclusively on the third strategy – the actual PMTCT service package at antenatal care clinics. The Cuernavaca Consultation participants considered that working on the other two strategies is equally important. In areas of lower HIV prevalence, in particular, protecting women against HIV infection and keeping them HIV-negative is one of the best ways to effectively reduce the number of children infected with HIV through MTCT. In addition, in LAC countries where the HIV prevalence among pregnant women is low, it will be easier to justify the use of resources for PMTCT if all of the three strategies are implemented.
  
  Lower prevalence countries could focus not on how many HIV-positive pregnant women they can reach, but rather on how many pregnant women they can help to remain HIV-negative. This reverse thinking can positively impact a government's ability to see the benefits of supporting PMTCT programs.Participants noted that the availability of testing and counseling in the antenatal care setting gives healthworkers a new entry point for reaching HIV-negative women and helping them to remain negative.

Specific recommendation:

PMTCT communication initiatives should support the internationally agreed-upon three-prong strategy forPMTCT.

Implications for Latin America and the Caribbean:

This recommendation creates an opportunity for PMTCT communication initiatives in LAC to go beyond supporting the antenatal care service package (prevention of "vertical transmission") to a more holistic approach to PMTCT. This includes, among other possibilities, developing primary prevention interventions with HIV-negative women, but may also include using PMTCT to develop prevention skills among couples, reduce HIV/AIDS stigma in the community, motivate health professionals to adopt a non-discriminatory attitude etc.

Recommendation 4

PMTCT communication should be integrated with other health communication strategies

Participants noted that the broader PMTCT services should be integrated within related health care servicesparticularly the antenatal care and family planning services. Similarly, PMTCT communication should beintegrated within these services also.

PMTCT messages and materials tend to be more accepted, less threatening and less stigmatising when theyare integrated into existing information about antenatal care, maternal and child care, family planning and/or Integrated Management of Childhood Illnesses (IMCI). Therefore, whenever possible, PMTCT messages and materials should be integrated with messages and materials from these services.

Specific recommendations

• PMTCT communication strategies should be integrated with the broader health communication strategies, particularly those related to the antenatal care and family planning services.
• PMTCT communication messages and materials should be integrated with the messages and materials produced by these and other relevant services.

Implications for Latin America and the Caribbean:

Currently many of the messages and materials developed in LAC (posters, brochures, and videos) focus exclusively on the PMTCT component in an HIV/AIDS context. Because of the stigma associated with being seen with such information, it would be preferable that PMTCT information be incorporated into broader informational materials. For example, information on infant feeding does not need to focus only on infant feeding for HIV-positive mothers. Rather, it can be infant feeding information for all mothers, with a special section on infant feeding and HIV and other illnesses/conditions. The development of new messages and materials should consider the benefits of integration among PMTCT and other relevant services. Examples of successful integration of materials should be shared throughout the region, so that countries with low resources can adapt existing integrated materials from other countries to suit their local needs.

Recommendation 5

PMTCT communication should support the improvement of antenatal care, PMTCT and other HIV/AIDS services

Participants acknowledged that the success of PMTCT communication depends in large part on the qualityof and access to the antenatal care system, including laboratory exams, counseling, ARVs and safe deliverypractices. In addition to that, the existence of a good surveillance system was also considered essential for apositive outcome of the PMTCT communication intervention. There was a general consensus that PMTCT communication should therefore be used to help improve these services.

One way to achieve that is through the development of advocacy goals. During the Cuernavaca Consultation the participants became familiar with a Communication for Development model that supports the synergistic use of three communication strategies: behavior development communication, social mobilisation and advocacy - the latter particularly important to obtain the necessary support and resources for antenatal care, PMTCT and HIV/AIDS services.

At the same time, participants noted that the PMTCT intervention itself could help improve the broaderresponse to HIV/AIDS. This has happened in Curitiba, Brazil's first municipality to fully integrate the PMTCT intervention within the primary health units.

At the beginning of the program implementation, there was opposition to HIV screening in Curitiba's primary health units, considering that centralised units were in charge of all HIV diagnosis and treatment. Professionals who worked in the centralised units did not feel that primary health care units were the adequate place to offer counseling and testing even for pregnant women. But the primary health care workers were interested in the program and, with adequate support, some training and the implementation of a communication intervention, the program was launched successfully.

As a consequence of expanding PMTCT testing and counseling to the primary units, not long after that Curitiba became the first municipality to offer HIV testing and counseling to the general population across the primary health system. In other words, the PMTCT intervention triggered the decentralisation of HIV prevention and care from centralised units to the primary health system.

Specific recommendation:

PMTCT communication should be used to help improve antenatal care, PMTCT and other HIV/AIDS services, including raising support and resources from public and private sector and international agencies.

Implications for Latin America and the Caribbean:

The availability of PMTCT and other HIV/AIDS services is changing at a fast pace in LAC, as more countries in the region are now able to implement an amplified response to the epidemic. This includes not only the increased availability of ARVs, but also a whole range of services for prevention and comprehensive care. However, the needs still greatly surpass the availability of these services. PMTCT communication practitioners should help obtain more support and resources to these services. Specificadvocacy goals to this end should be considered in their communication planning process.

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