Fowkes et al. BMC Medicine (2016) 14:202 DOI 10.1186/s12916-016-0753-9 OPINION Open Access Achieving development goals for HIV, tuberculosis and malaria in sub-Saharan Africa through integrated antenatal care: barriers and challenges Freya J. I. Fowkes1,2,3,4*, Bridget L. Draper1, Margaret Hellard1,2 and Mark Stoové1,2 Abstract Background: The global health community is currently transitioning from the Millennium Development Goals (MDGs) to the Sustainable Development Goals (SDGs). Unfortunately, progress towards maternal, newborn and infant health MDGs has lagged significantly behind other key health goals, demanding a renewed global effort in this key health area. The World Health Organization and other institutions heralded integrated antenatal care (ANC) as the best way to address the inter-related health issues of HIV, tuberculosis (TB) and malaria in the high risk groups of pregnant women and infants; integrated ANC services also offer a mechanism to address slow progress towards improved maternal health. Discussion: There is remarkably limited evidence on best practice approaches of program implementation, acceptability and effectiveness for integrated ANC models targeting multiple diseases. Here, we discuss current integrated ANC global guidelines and the limited literature describing integrated ANC implementation and evidence for their role in addressing HIV, malaria and TB during pregnancy in sub-Saharan Africa. We highlight the paucity of data on the effectiveness of integrated ANC models and identify significant structural barriers in the health system (funding, infrastructure, distribution, human resources), the adoption system (limited buy-in from implementers, leadership, governance) and, in the broader context, patient-centred barriers (fear, stigma, personal burdens) and barriers in funding structures. We highlight recommendations for action and discuss avenues for the global health community to develop systems to integrate multiple disease programs into ANC models of care that better address these three priority infectious diseases. Summary: With the current transition to the SDGs and concerns regarding the failure to meet maternal health MDGs, the global health community, researchers, implementers and funding bodies must work together to ensure the establishment of quality operational and implementation research to inform integrated ANC models. It is imperative that the global health community engages in a timely discussion about such implementation innovations and instigates appropriate actions to ensure advances in maternal health are sufficient to meet applicable SDGs. Keywords: Antenatal care, HIV, Tuberculosis, Malaria, Integrated services * Correspondence: [email protected] 1Macfarlane Burnet Institute of Medical Research, Melbourne, Australia 2Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia Full list of author information is available at the end of the article © The Author(s). 2016 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Fowkes et al. BMC Medicine (2016) 14:202 Page 2 of 10 Background been suggested to enhance the achievement of the The 2000 Millennium Development Goals (MDGs) estab- SDGs [3]. The World Health Organization (WHO) and lished a global development framework aimed at improving other institutions have endorsed integrated antenatal health and saving the lives of the world’s poorest [1]. Three care (ANC) as the best strategy to address the inter- of the eight MDG targets related directly to health: redu- related health issues of HIV, TB and malaria, as well as cing child mortality (goal 4); improving maternal health other vaccine-preventable infectious diseases and nutri- (goal 5); and combating HIV, malaria and other diseases tional deficiencies, in the high risk groups of pregnant (goal 6) (Table 1). The health outcomes described in these women and infants [4–8].Byprovidingacomprehen- goals have overlapping risk exposures that lend themselves sive disease prevention approach, integrated ANC ser- to common and integrated responses. Health remains a key vices can help accelerate progress towards maternal, focus of the Sustainable Development Goals (SDGs), which newborn and child health goals (MDG achievements again encourage an integrated response to major global and current burden of disease are outlined in Table 1) health issues [2]. by offering an efficient mechanism to counter the im- In the SDGs, combating HIV, tuberculosis (TB) and pact of fragmented service delivery. An integrated ANC malaria now resides within a broader health goal – Ensure approach to these diseases seems highly plausible and healthy lives and promote well-being for all at all ages intuitively beneficial. The global reach of ANC pro- (goal 3) – with a specific call to end the epidemics of HIV, grams is extensive, with ANC coverage being approxi- TB and malaria by 2030 [2] (Table 1). Given the promi- mately 70% in sub-Saharan Africa, the region that nence of maternal, newborn and child health across harbours the highest burden of HIV, malaria and TB multiple goals, classifying goals targeting the same globally and where ANC often represents a woman’s beneficiaries as distinct and interdependent clusters has first contact with the healthcare system [4, 9]. Statistics Table 1 Millennium and Sustainable Development Goals addressing HIV, TB and malaria or maternal, newborn and child health and sub-Saharan African achievements and statistics Millennium Development Goals [1] 2015 sub-Saharan Africa achievement [1] Goal 4: Reduce Child Mortality Target 5: Reduce by two-thirds, between 1990 and 2015, the under-five 52% reduction in child mortality mortality rate Goal 5: Improve Maternal Health Target 6: Reduce by three-quarters, between 1990 and 2015, the maternal 49% reduction in maternal mortality ratio mortality ratio Goal 6: Combat HIV/AIDS, Malaria and Other Diseases Target 7: Have halted by 2015 and begun to reverse the spread of HIV/AIDS 51% reduction in new HIV infections Target 8: Have halted by 2015 and begun to reverse the incidence of 69% reduction in malaria mortality in the under-five malaria and other major diseases age group Sustainable Development Goals [2] 2015 sub-Saharan burden of disease Goal 3: Good Health and Well-being 3.1: By 2030, reduce the global maternal mortality ratio to less than 70 per 546 per 100,000 live births [75] 100,000 live births 3.2: By 2030, end preventable deaths of newborns and under-five children, Neonatal and under-five mortality is 29 and 83 per with all countries aiming to reduce neonatal mortality to at least as low 1000 live births, respectively [75] as 12 per 1000 live births and under-five mortality to at least as low as 25 per 1000 live births 3.3: By 2030, end the epidemics of AIDS, TB, malaria and neglected tropical 2.6 (0–20.1) new HIV infections per 1000 uninfected diseases and combat hepatitis, water-borne diseases and other populationa [76] communicable diseases 281 (22–852) new TB cases per 100,000 populationa [76] 268.6 (3.6–460.9) new malaria cases per 1000 population at riska [76] 3.8: Achieve universal health coverage, including financial risk protection, HIV treatment coverage 0–70%b [77] access to quality essential healthcare services and access to safe, TB treatment coverage 10–70%b [77] effective, quality and affordable essential medicines and vaccines IPTp coverage 17–40% [37] for all Use of ITNs 10–70%b [77] ITN insecticide-treated net, TB tuberculosis, IPTp intermittent preventive therapy in pregnancy a2014 statistics for WHO Africa region b2015 statistics for WHO Africa region Fowkes et al. BMC Medicine (2016) 14:202 Page 3 of 10 on the potential impact of integrating these services into ANC intervention within a framework that first ad- ANC remain limited, with no available published data on dresses health system strengthening to deliver quality the impact of HIV services integrated into ANC on mater- service models through the development and mainten- nal morbidity or mortality, despite 25% of maternal deaths ance of adequate physical and technical infrastructure. in sub-Saharan Africa being attributable to HIV [10]. Second, we consider the adoption of the system and the Additionally, there is no data estimating the potential role need for buy-in from local governments and ANC staff of integrated ANC services on preventing mother-to-child to support integrated ANC models. Finally, we use the HIV transmission, except for a recent systematic review framework to consider the broader contextual factors (three of the four studies were based in sub-Saharan such as the community and psycho-social impact of Africa) where a higher than two-fold increase was ob- delivering prevention and care interventions, negative served in pregnant women commencing antiretroviral social attitudes to specific diseases, siloed and disease- therapy (ART) in ANC clinics integrating ART within specific funding models, and implementation and funding their service compared to women attending