In the shade of a tree not far from Lake Malawi, a clinic nurse is in deep conversation with 12 villagers. Each represents a surrounding community, distantly connected to the clinic by dirt tracks or rutted roads, accessible by foot, bicycle, and occasionally an ambulance. As the global health community rallies to kick into high gear a campaign to eliminate the transmission of HIV from mothers to infants, the health system of Malawi and other countries with high rates of HIV face two critical challenges: how to motivate and transport pregnant mothers and their babies to the local clinic or hospital for care, and how to ensure that they get the right care when they do turn up. In this month's Health Affairs journal, researchers from the Institute for Healthcare Improvement show that without better health-care delivery systems to overcome these challenges, the breakthrough medical discoveries that can block transfer of the virus from mother to infant will not be effective, and the dream of an "HIV-free generation" will be deferred.
This year about 1.5 million HIV-infected mothers will discover that they are pregnant. Any joy at that discovery will be muted by fear and uncertainty -- that the mother may harbor a deadly virus that she may pass on to her unborn infant. And if her infant escapes infection while in the womb, she may pass on the virus through the very breast milk that her infant depends on for survival. But this need not be the case. Medical trials have shown that readily available medications can stop in its tracks the transfer of HIV from mother to child. Indeed, in countries like the United States, infection of even one infant with HIV is now considered an unacceptable medical failure.
The global health community was relieved and jubilant at the discovery that drugs can block HIV infection from breast milk. No longer would a mother have to make a terrible choice: feed her infant with breast milk and risk passing on the deadly virus, or feed her infant with artificial formula milk and risk death from the other killers of Africa's infants: diarrhea, pneumonia, and malnutrition. But much damage needs to be undone -- decades of misleading information that promoted formula feeding, and the controversy about the dangers of HIV-infected breast milk, means that fewer than half of infants in affected countries are getting breast milk exclusively for the first six months of life.
Under the umbrella of the Joint United Nations Programme on HIV, global health agencies have set new ambitious goals to be achieved by 2015: to dramatically reduce the HIV infection rate from mother to child and AIDS-related maternal deaths, preventing infection of nearly 400,000 infants each year and avoiding countless orphans. With newly minted guidelines from the World Health Organization, we have the knowledge of what should be done and the available drugs for those mothers and infants who need them. So what could derail this ambitious plan?
Brilliant medical advances, on their own, are not sufficient. Implementing any new clinical breakthrough in out-of-the way clinics with overstretched nurses is not easy. Like every evidence-based intervention deployed at scale across a country's health system, the campaign to eliminate mother-to-child transmission of HIV faces two seemingly obvious challenges: the mother and infant have to turn up for medical care and, when they do turn up, they have to get the right care and treatment -- 100 percent of the time.
The track record for getting mothers and infants to turn up for care is dismal for many countries that are worst affected by HIV. On average, women and infants come to clinic for recommended maternal, newborn, and infant care and treatment only half the time. For mothers who do turn up to clinic, there is no guarantee of getting the recommended HIV tests and treatments. In a study of sub-Saharan countries, researchers found traces of HIV-blocking drugs in the blood of newborn infants exposed to HIV from their mothers only about half the time.
The research in Health Affairs shows that the ambitious goals set by the global health community to stop mother-to-child transmission will not be achieved until these two essential health system challenges -- access to care and efficiency of care delivery -- are overcome. Using available data on access to clinics and effectiveness of the HIV care delivery system in African countries, the research estimates that HIV is being transmitted from mother to child about 20 percent of the time. With no treatment, HIV is transmitted 35 percent of the time. These estimates imply that failure to access care is by far the biggest obstacle to the dream of an "HIV-free generation." Some of the countries with the greatest number of new HIV infections in infants, such as Nigeria and India, have the worst rates of clinic attendance during and after pregnancy -- times that are crucial for delivery of HIV care. None of the HIV-burdened countries reliably attract mother-infant pairs for recommended care after birth.
What can we learn from successes so far? Countries like South Africa and Botswana have achieved stunning results in their efforts to prevent HIV transmission during pregnancy -- achieving, at an unprecedented scale, world-beating low rates of infant infections in their public health care systems. But in both countries, this was achieved on the back of a health system that attracts near-universal attendance at clinic during pregnancy and childbirth. In South Africa's case, they achieved dramatic improvements in performance by redesigning the way care was delivered; improved use of data by clinics, and teaching nurses and managers how to fix failing systems locally -- not simply adding more resources. All attention and resources now need to be directed to making health systems accessible and effective in the worst-affected countries. Without that focus, bringing infection rates of infants down from 20 percent to 5 percent in the next three years simply won't happen, and the dream of an HIV-free generation will remain just that.
There is hope now that attention and money -- through the National Institutes of Health, PEPFAR and others -- are being mobilized to understand how to attract more mothers and infants to clinics and hospitals, and what it will take to deliver effective care for those who do attend. We may discover that enabling problem-solving by the communities and clinic staff themselves -- like the nurse and village volunteers meeting near Lake Malawi -- will prove to be the most effective means yet of solving this problem.
The author is Senior Vice President of the Institute for Healthcare Improvement (www.ihi.org).