Making it happen, level 2

F yson Kasenga (1) describes the detrimental effect HIV has had on public health in Malawi. This was recently highlighted particularly for maternal mortality (2). Malawi is one of the countries where the impact of the HIV epidemic is clearly visible on the maternal mortality rate (MMR) (Fig. 1). Only after the year 2000 it is possible to see some positive trend in the MMR in Malawi, supposedly due to extensive HIV testing and the provision of antiretroviral treatment. Fyson Kasenga further describes the development of the programme for prevention of mother-to-child transmission (PMTCT) of HIV-1 at Malamulo Hospital, a private not-for-profit missionary hospital in Malawi. Several of the observations done in this setting are actually generalisable to other antenatal care (ANC) settings. The first observation is that PMTCT performs much better after a couple of years when nurses and midwives have learned how to correctly perform PMTCT in a good manner. The second observation is that after switching from voluntary counselling and testing (VCT) to routine counselling and testing (RCT), the programme soon becomes much more acceptable to the community and even to the health workers themselves. With the introduction of RCT, all the issues surrounding HIV have become less stigmatis-ing within the health institution and health workers, generally, are able to treat HIV as an ordinary disease like tuberculosis without stigmatising the clients. A growing number of reports from a variety of countries are describing the same positive shift after moving to RCT in ANC. In Scandinavia, routine testing was introduced as soon as there were reliable tests, i.e. in Sweden as early as in 1987, more than 20 years ago! The third observation is that in Malamulo, the government's initiative to provide free maternal care largely facilitated the task of carrying out PMTCT. It seems an inevitable conclusion that part of the effort to prevent HIV infections in low-income settings is to invest more resources in health care, particularly reproductive health care. In December 2009, WHO launched new guidelines for PMTCT and for infant feeding in the context of HIV (3, 4). The new guidelines propose that all HIV-positive mothers should receive antiretroviral treatment or prophylaxis during pregnancy, delivery and breast-feeding. If the immune status of the mother is weakened (with a CD4 count below 350), then she should receive lifelong highly active antiretroviral treatment (HAART) for her own health. This treatment should be started immediately and …