February 4, 2015

Moving forward on preventing mother to child transmission of HIV

Written by Saku Mapa, International Planned Parenthood Federation's (IPPF) HIV Officer: Prevention, Treatment and Care

This post originally appeared on IPPF’s website here. Reposted with permission.

Preventing mother to child transmission of HIV (PMTCT) has been attracting a lot of attention at the International AIDS conference here in Melbourne.

The statistics are high. In 2013, 54% of pregnant women in low- and middle income countries did not receive an HIV test. 1.5 million women living with HIV gave birth but only 42% of infants born to mothers living with HIV in low and middle income countries received the HIV test within two months as recommended by WHO. Without voluntary counselling and testing of pregnant women and children for HIV, they will not access treatment which is vital to their survival and well-being.

As the global community prepares to assess progress towards global health goals in 2015, standardized processes and criteria are been developed to assess and validate not only elimination of mother to child transmission (EMTCT) of HIV but syphilis as well.

The new set of guidance released by the World Health Organisation (WHO) with support from UNAIDS, UNFPA and UNICEF, builds consensus on criteria for validation of EMTCT of HIV and/or syphilis across both high- and low-prevalence settings.

The belief is that dual elimination will help to improve a broad range of maternal and child health (MCH) outcomes and also directly contribute to the Millennium Development Goals (MDGs), specifically MDGs 4 and 5, which aim to reduce child mortality and improve maternal health, and MDG 6, which aims to reduce the spread of HIV, malaria, and other diseases.

The goal for EMTCT initiatives is to reduce MTCT of HIV and syphilis to a very low level, such that it is no longer a public health problem. The term “validation” is used to attest that a country has successfully met criteria for EMTCT of HIV and/or syphilis at a specific point in time.

At IPPF we have an evidence based strategy to reduce transmission, commonly known as the 4 prong approach, i.e primary prevention of HIV among girls and women of reproductive age, prevention of unintended pregnancies among those living with HIV, effective access to testing, counselling, antiretroviral therapy (ART), safe delivery practices, and appropriate infant feeding practices (including access to antiretroviral drugs to prevent HIV transmission to infants).

Our work is focused on reducing maternal mortality and morbidity through integrated sexual and reproductive health and rights. Our main contribution to the Global plan is to reduce primary prevention among women of reproductive age and avoid unintended pregnancies among women living with HIV ensuring their sexual and reproductive rights.

Through the Japan Trust Fund for HIV and reproductive health, we have programmes in Africa and Asia implementing PMTCT for the most vulnerable women to ensure they access an integrated package of quality SRH services.

So what do these new guidelines mean in technical terms? A country wanting to be validated as having reached EMTCT will need to ensure two impact targets to meet in one year:

  1. <−50 new paediatric HIV cases per 100 000 live births and a transmission rate of either <5% in breastfeeding populations or <2% in non-breastfeeding populations;
  2. <−50 cases of congenital syphilis per 100 000 live births.

In addition, the 4 process targets below need to be met for two years in at least one of the lowest-performing sub-national administrative units:

  1. antenatal care coverage of >− 95%;
  2. coverage of HIV and/or syphilis testing of pregnant women of >− 95%;
  3. antiretroviral treatment coverage of HIV-positive pregnant women of >− 90%;
  4. treatment of syphilis-seropositive pregnant women of >− 95%.

A harmonized approach to eliminating MTCT of HIV and syphilis is encouraged. But, depending on the progress of national EMTCT efforts, countries may choose to validate the elimination of MTCT of HIV, syphilis, or both.

We think this is a good thing. As dual validation process will promote an integrated approach for better maternal and child health. However, we believe elimination of both HIV and syphilis should be promoted rather than one.

Although the impact and process targets focuses on newborn and pregnant women, the Indicators to support validation of EMTCT of HIV and/or syphilis emphasizes the need to work with all women of reproductive age, i.e. before they get pregnant. This is important as we know that age of a mother, gap between pregnancy, disease burden all play an important factor in reducing maternal mortality and morbidity.

So the need to ensure EMTCT starts much before pregnancy! This means that the emphasis on prevention is strengthened even more at the local provider level and that means more lives can be saved. Furthermore pregnant women who are not HIV positive should be supported to remain negative through primary prevention interventions.

With all this said, there is a huge risk that female sex workers and adolescent girls and women living with HIV will be forgotten in the national response. The impact targets for EMTCT don’t require a country to reach 0 cases mainly due to current strategies for preventing vertical transmission carries about 5% risk.

But whatever way we use this approach, all interventions must reach the most marginalized and poorest of poor with HIV and sexual and reproductive health services to ensure that no one is left behind in EMTCT of HIV and Syphilis.

Otherwise, this will again leave those who face the most burden and health inequality right by the wayside.