When I was in South Africa last year I had the opportunity to hear the story of Juliet, a young Ugandan woman who on the day she had heard the joyous news that she was expecting twins, she also discovered that she was living with HIV. Fearing that she would be ostracized by her husband, family and friends, she did not disclose her status and did not return for medication, finding it difficult to justify repeated monthly visits to the clinic, particularly given the family's limited resources. After five months she became very ill with tuberculosis (TB) and for the same reasons found it difficult to adhere to treatment. When the twins were born, one tragically fell sick and died at four months. When the second one became ill with TB, she finally sought the care she and her baby needed.
Sadly, Juliet's story is all too familiar, particularly in the Sub-Saharan setting. The statistics paint a grim picture. Despite being preventable and curable, TB is the top infectious disease killer globally. While men are generally more at risk of TB than women, it has particularly severe consequences for women during their reproductive years. TB in pregnant women is associated with a six-fold increase in perinatal deaths and twice the risk of premature birth and low birth-weight.
In those living with HIV, TB is associated with more than double the risk of vertical transmission of HIV to the unborn child, and a three-fold increase in the risk of maternal and infant mortality. A disease of poverty that affects the most vulnerable populations, where gender inequities are all too common, TB also has a complex relationship with other social determinants such as nutrition and education. And, as Juliet's story so clearly shows, access to the necessary services and continuity of care is further exacerbated by the associated stigma and discrimination, which is made worse by TB's relationship with HIV.
There is immense opportunity presented by antenatal and mother and child health clinics for increasing access to TB and HIV services, and, thereby, reducing preventable mortality among mother and child. However, this opportunity is squandered if we do not have integrated services. It does not make any sense for a pregnant woman to have to travel to different clinics for antenatal, HIV and TB services. Not only does it have cost and time implications for the pregnant woman herself, but it will also affect others in the family, perhaps even interfering with the education of the older children who might have to care for the younger ones.
Not only should the services be available at a decentralized level and in the same place, but there should also be effective patient support and health education at a grassroots level to maximize adherence and ensure a healthy birth. Involvement of communities plays a crucial role here. In fact, after Juliet's recovery she herself joined a non-governmental organization, mothers2mothers, and has worked for them as a "mentor mother", helping to improve the health and wellbeing of mothers like herself, their babies and their families.
As delegates gather together at the Women Deliver conference in Copenhagen this month to discuss how to make development matter most for girls and women, TB and HIV-associated TB, clearly cutting across the Sustainable Development Goals (SDGs), must have a place in these discussions. If we are to end the global epidemics by 2030, as outlined in the SDGs, we need to mobilize support at global and national levels to remove underlying risk factors and assure gender-equitable access to TB and HIV prevention, diagnosis, treatment, care and support for women. Strategic partnerships and synergies across the health system and within communities must be fostered to maximize entry points to TB prevention and care for women.
There are far too many Juliets in the world who are struggling to give birth to healthy babies and raise healthy families. We must establish integrated health systems that address all of the health needs of mothers and their children. And we must hold all stakeholders accountable for the delivery of comprehensive services, including TB prevention, diagnosis and treatment. Only then, can we begin to say that we are delivering real results for women in need across the globe.