Strengthening PMTCT through Communication: A Review of the Literature

This document, published by the Centre for AIDS Development Research and Evaluation (CADRE), offers a literature review on social mobilisation and communication in support of prevention-of-mother-to-child transmission (PMTCT) of HIV.

From the Executive Summary:

"Preventing new HIV infections remains a significant public health challenge for South Africa. The high HIV-infection and mortality rates of under-five-year-olds due to mother-to-child transmission (MTCT) of HIV, together with the continuing need that pregnant HIV-positive women have for antiretroviral drugs (ARVs) and prevention-of-mother-to-child-transmission (PMTCT) interventions, underscore the urgency for renewed efforts to offer quality PMTCT services in South Africa.

This report begins with a historical contextualisation of PMTCT in South Africa by providing a brief overview of the political and operational factors that have shaped policies and interventions concerning HIV and AIDS in general, and factors that have led to delays in implementing the national PMTCT programme more specifically. According to the report, the present conditions indicate an imperative need for coherent policies and a PMTCT programme with a strong communication strategy.

The first half of the report considers communication strategies in the context of HIV and AIDS as well as the key barriers to PMTCT. It suggests that the complex factors that together sustain the HIV/AIDS epidemic in South Africa need to be taken into account in any communication strategy that is eventually adopted. The various limitations of a top-down model of communication draw attention to the need for an approach that is contextually located and involves participatory communication, emphasises dialogue and collective action, and aims for social as well as individual outcomes.

The report gives an overview of the different communication theories and approaches used in the context of PMTCT in sub-Saharan Africa (e.g., behaviour change communication, information education and communication, interpersonal communication, community-oriented behaviour change, targeted education messages, communication for development, and the ACADA process). The social ecology model describes four levels of engagement in communication for social and behavioural change: societal, community, social networks, and individual. These levels are used to categorise the findings of the literature according to the following areas: barriers to PMTCT implementation, the key participants to be addressed, key communication themes and messages, and good practices in planning and implementing successful PMTCT communication campaigns.

The numerous factors inhibiting the up-take of PMTCT services, especially in a resource-constrained setting, are listed and described. Noted barriers to uptake of PMTCT services include:

• Poor healthcare infrastructure, shortages of staff, poor referral links, and a lack of communication between different health services and within the healthcare system. Consequently, PMTCT and family-planning services are poorly integrated.
• Poor-quality counselling and healthcare workers’ poor attitudes and interactions with clients.
• Gender-related issues, particularly the role of the male partner in reproductive issues and his involvement in PMTCT services.
• Poverty and structural barriers.
• Cultural factors concerning appropriate behaviours linked to counselling and testing, PMTCT, and stigma, including perceptions of poor social support and discriminatory perceptions of PMTCT practices.
• Lack of awareness and knowledge about HIV/AIDS and MTCT in the general population and among pregnant women or mothers, particularly regarding PMTCT information and services.
• The reproductive and health needs of youths are not adequately addressed.
• Psychological barriers, such as denial, fear of death, or fear of HIV testing and disclosure.

The second half of the report discusses the key participants to be reached through communication strategies as well as the key themes and messages of PMTCT. The following target stakeholders are discussed:

• Healthcare workers in rural and urban sites.
• Relevant government departments and policymakers.
• Community organisations and influential community members.
• HIV-positive and HIV-negative men and women in rural and urban areas, and the families of HIV-positive women.

Emerging from the literature were key themes or messages concerning PMTCT to be incorporated into PMTCT communication strategies. The importance of consistent and accurate themes and messages is stressed in addition to the need to reach all key participants. Key themes and messages emerging from the available literature on barriers to PMTCT include:

• The importance of non-judgmental and non-discriminatory attitudes and actions towards people living with HIV or AIDS (PLWHA).
• The sexual and reproductive rights of HIV-positive women, and gender equity and women’s rights in general.
• Family-planning options for HIV-positive women and their partners and also youths.
• The importance of males’ support and engagement in PMTCT.
• The key components of HIV prevention at an individual level, including accurate facts about HIV and AIDS, MTCT and PMTCT.
• Stressing the various HIV-testing approaches available to pregnant women.
• The importance of knowing your HIV status and disclosure skills.
• The importance of a family-centred health model and on-going support for mothers.
• The importance of on-going training of healthcare workers and counsellors.
• Various cultural, traditional and religious beliefs in relation to reproduction, childbearing and childrearing.
• The importance of integrated ANC, PMTCT and family-planning services.
• Clear, consistent and up-to-date information on infant-feeding practices for the sake of PMTCT.
• Up-to-date information on PMTCT programme implementation and policies.
• Constraints to the uptake of PMTCT services (e.g., socio-economic and infrastructure).
• The importance of partnering with relevant NGOs, FBOs and CBOs.

The concluding section of the report focuses on the need to strengthen PMTCT through interpersonal and community communication strategies, including mass media communication, and addressing stigma reduction and gender equality. In addition, the report describes how the success of PMTCT efforts could be improved by strengthening health systems and integrating services. The review ends with recommendations for future research."