Ending the HIV epidemic requires fully engaging those who are pregnant and postpartum
by Nthuseng Marake, Rosemary Njura Njogu, Tigistu Adamu Ashengo, Lisa Noguchi and Kelly Curran
While global health and well-being universally stand to benefit as self-care interventions expand, to meet the goal of ending the HIV epidemic by 2030, two very special and specific types of clients must be engaged more meaningfully: those who are pregnant and postpartum.
Historically, HIV prevention efforts have focused on key populations, including sex workers, men who have sex with men and people who inject drugs. More recently, adolescent girls and young women have been recognized as a priority population. However, data show that people who are pregnant and postpartum are also particularly vulnerable to HIV infection. The time is past due for us to not only partner with these clients, but also offer self-care options to provide services that traditionally have been limited to health care professionals. As co-designers and contributors to their own care, these clients can help accelerate progress toward the 2030 goal of ending an epidemic that has killed over 42 million people since 1981.
We know that being pregnant increases the risk of acquiring HIV threefold, and being postpartum increases that risk fourfold, compared to other times in people’s lives. The reasons are not completely clear but may be biological, behavioral or cultural.
Research reveals that if a person acquires HIV during pregnancy or the postpartum period, there is a higher risk of vertical transmission (of the baby acquiring HIV) than if the mother acquired HIV prior to pregnancy. In fact, an estimated 23% of vertical transmissions globally are due to HIV infections that happen during pregnancy and the postpartum period. All this evidence points to the pregnancy and postnatal periods as critical times of opportunity for expanding access to HIV prevention services—particularly those options that increase a client’s agency and protect their privacy.
Imagine two women living in Africa. One is a single pregnant teenager who, experiencing poverty, depends on transactional sex to buy food and clothing. She was relieved when an HIV test given early in her pregnancy was negative. The other woman is a 30-year-old mother of five young children—including a breastfeeding infant. Her husband, a fisherman, doesn’t use condoms; he hides the fact that he sometimes has other sexual partners when he travels away from his village for work.
Both of these women—already facing the possibility of acquiring HIV—are much more likely to acquire HIV when they are pregnant or postpartum. It’s common around the world for people who are pregnant to get tested for HIV and be offered HIV treatment if needed to protect themselves and their babies. But it’s rare that they know about the heightened risk of HIV during pregnancy and postpartum, and that there are safe and effective HIV prevention options.
Evidence shows that oral pre-exposure prophylaxis (PrEP) and the dapivirine vaginal ring are safe during pregnancy and breastfeeding, as is post-exposure prophylaxis (PEP) for those who may be exposed to HIV unexpectedly. Our collective experience as clinicians, program managers and researchers working across disciplines in HIV/AIDS and reproductive health convinces us there needs to be expanded access—beyond PrEP clinics—to all these options. If we take away barriers to knowledge and care for people who are marginalized, those who are pregnant and postpartum will access what they need for themselves and their babies to be healthy.
With 2030 looming, and the Sustainable Development Goals (SDGs) in the balance, the world has only around 15 percent of the number of nurses and midwives needed. The global shortage of physicians is also dire, especially in areas most impacted by the HIV epidemic. Despite efforts to expand, design, execute and incentivize an adequate health care workforce, the majority of global citizens don’t have adequate access to health care providers.
Ending HIV/AIDS as a public health threat depends on our kick-starting a radical re-shaping of client care. While the world looks to expanding primary and community-based health care, those who are pregnant and postpartum should not be left behind.
As a complement to building more comprehensive, high-quality antenatal and postnatal care services, HIV testing and a range of PrEP and PEP options that are safe during pregnancy and postpartum—including self-care methods—could be made fully available and accessible to all. Online pharmacies and local community pharmacies, which are open from dawn until almost midnight, could offer these services to those who fear being stigmatized if they seek a test or HIV prevention options. With strong alignment with local regulatory frameworks, appropriate health system linkages and community engagement, this approach holds great promise, and the feasibility and acceptability of these new options deserve to be tested and better understood.
Fostering a dramatic evolution of client-centered care requires putting HIV prevention into the hands of those who need it most, including those who are pregnant and postpartum. If prevention is the ultimate in self-care, which we believe it is, then it stands to reason that sustainable health systems and our achievement of global goals depend upon putting HIV prevention squarely and securely in the hands of all priority populations, including pregnant and postpartum people.
Nthuseng Marake, MBChB, BSc. (Hons), is the HIV Treatment and Care Officer with the Ministry of Health of Lesotho.
Rosemary Njura Njogu is a Senior Technical Advisor with Jhpiego
Tigistu Adamu Ashengo, MD, MPH, is Jhpiego’s Chief Medical Officer.
Lisa Noguchi, PhD, CNM, FACNM, is Jhpiego’s Director for Maternal, Newborn and Child Health and a member of the Guideline Development Group for the WHO guideline on self-care interventions for health and well-being, 2022 revision.
Kelly Curran, MHS, is Jhpiego’s Senior Director for HIV and Infectious Diseases. She also directs the PEPFAR/USAID-funded Reaching Impact, Saturation and Epidemic Control (RISE) Project.