Governments are on board with Option B+ for prevention of mother-to-child transmission (PMTCT). In Part I, Adherence: Going the last mile in PMTCT, we discussed how women must adhere throughout the entire perinatal and postpartum period, and through the duration of breastfeeding to achieve the full benefits of PMTCT for herself and for her infant. Counseling helps women understand the importance of their full treatment period, but squeezing in time for counseling is difficult in crowded public-sector facilities.
Can the private sector scale up PMTCT services? AIDSFree is looking at how to expand PMTCT service delivery and alleviate challenges by engaging the private sector, including civil society organizations (CSOs).
Engaging the private sector has the potential to expand access to PMTCT and reduce the burden on public clinics. Many private facilities have the structure and space to offer PMTCT, thus expanding options for women to receive PMTCT services, including antiretroviral therapy (ART), at the point of care. Broader access can also save women time previously spent traveling or waiting at the facility—as well as transportation costs. Moreover, with a percentage of patient load transitioning to private clinics, public health facilities may be better able to provide quality services.
However, the private sector lags behind the public in terms of skills and resources for PMTCT. Historically, the public sector has managed HIV cases; funding for drugs and capacity building efforts have been channeled into public facilities. Private providers have not been invited to training and do not receive subsidies for ART drugs; as a result, private-sector services are often very expensive, and are perceived to offer lower-quality services. According to Gupta’s 2015 study, private hospitals in India did not follow PMTCT protocols, and none of the private hospitals participating in the study provided ART.
More importantly, the private sector needs to make a profit, and HIV services are not as profitable. The current challenge is to convince private sector clinics that engaging in PMTCT services will benefit them and the public clinics providing services. Fully engaging in the roll-out of PMTCT services, for example, can lead to increased client load for the private sector, and thus more profit.
One way for governments to engage the private sector in PMTCT is to make ART provision mandatory for all health facilities that provide other HIV services. Malawi has led the way in expanding private-sector engagement in HIV treatment. The Malawi Government has integrated the private sector—which provides about 40 percent of health services nationwide, according to Abt Associates Inc.—into its service delivery process, and supervises both the private and public sectors. The private sector receives the same drugs, uses the same monitoring and evaluation tools, and reports back to the Ministry of Health just as the public sector does.
Nonprofit agencies also offer avenues for increasing access to PMTCT. Globally, CSOs, including nongovernmental organizations and faith-based organizations (FBOs) are important providers of health services. Faith-based organizations can have a significant impact on community engagement in and awareness of PMTCT. In Malawi, for example, 45 percent of health facilities are faith-based. CSOs can also play critical advocacy roles. The Malawi Network of People Living with HIV/AIDS (MANET+)—an umbrella group representing HIV-positive individuals and groups from around the country—has played a crucial part in advocating for and developing PMTCT policies. MANET+ also works at the community level to support adherence to PMTCT, establishing support groups and mothers’ groups to help women maintain PMTCT adherence and stay in treatment. Local CSOs also play a role in fighting stigma and misconceptions about HIV, which in turn helps women with access to and retention in services.
To reach an AIDS-free generation, it’s urgent to harness all available resources. Models for private-sector engagement exist—there are many more than we’ve mentioned here. Bringing for-profit, CSO, and FBO actors into the HIV arena, and equipping them with the knowledge and tools they need, can only strengthen adherence to PMTCT.