I. Definition of the Prevention Area
Prevention of mother-to-child transmission (PMTCT; also known as prevention of vertical transmission) refers to interventions to prevent transmission of HIV from a mother living with HIV to her infant during pregnancy, labor and delivery, or during breastfeeding.
II. Epidemiological Justification for the Prevention Area
Approximately one-third of children born to mothers living with HIV will acquire HIV infection in the absence of preventive measures. Although only 14 percent of children who breastfeed up to 2 years will acquire the infection during breastfeeding, they account for 40 to 64 percent of children infected with the virus. The risk of transmission is particularly high if the mother herself acquires her HIV infection during pregnancy or breastfeeding because viral load tends to be highest during the early stages of infection. Mixed infant feeding in the first six months is also associated with an increased rate of mother-to-child transmission (MTCT).
Under ideal conditions, comprehensive prevention programs can reduce MTCT rates to about 1 to 2 percent. Antiretroviral therapy (ART) given to medically eligible women living with HIV during pregnancy reduces transmission by at least 75 percent. Ensuring that treatment eligible women receive treatment is critical not only to prevent MTCT but to protect women’s own health and survival.
UNAIDS estimates that in 2008, 2.1 million children under 15 years of age were living with HIV; 430,000 were newly infected; and 280,000 died from AIDS-related causes. MTCT still accounts for a substantial, although decreasing, portion of new HIV infections in many African countries. Optimal PMTCT coverage has not yet been achieved. United Nations agencies report that in 2008, in low- and middle-income countries:
• Twenty-one percent of pregnant women were tested for HIV
• Forty-five percent of pregnant women living with HIV received antiretroviral drug (ARV) regimens or ART
• Thirty-two percent of infants born to mothers living with HIV received ARV prophylaxis at birth.
III. Core Programmatic Components
The World Health Organization (WHO) recommends a four-pronged approach to a comprehensive PMTCT strategy:
1. Primary prevention of HIV infection among women of childbearing age
2. Preventing unintended pregnancies among women living with HIV
3. Preventing HIV transmission from women living with HIV to their infants
4. Providing appropriate treatment, care, and support to mothers living with HIV and their children and families.
This resource describes the third strategy: PMTCT. Preventive interventions consist of a cascade of services, including HIV testing and counseling; ARV prophylaxis or ART; safe delivery; safer infant feeding and postpartum interventions such as cotrimoxazole prophylaxis; early infant diagnosis for HIV-exposed infants; and links to treatment and care, as well as standard postpartum child survival interventions. To achieve maximum impact of PMTCT, acceptable levels of coverage, access, utilization, and in some cases, adherence must be attained across the entire continuum of care.
The 2010 WHO recommendations for PMTCT are based on recent program experience and scientific findings. Highlights include lowering the eligibility threshold for ART for pregnant women to 350; immediate initiation of ART (regardless of gestational age) for treatment eligible women; and provision of ARVs to non-treatment eligible women and/or their infants in the postnatal period to prevent breastfeeding transmission. It is now recommended that mothers known to be HIV-infected (and whose infants are not infected or whose status is unknown) exclusively breastfeed their infants for the first six months of life, introducing appropriate complementary foods thereafter, and continue breastfeeding until the infant is at least a year old.
IV. Current Status of Implementation Experience
Eastern and Southern Africa, the most affected regions, have made progress in PMTCT. In 2008, 21 percent of pregnant women in low- and middle-income countries were tested for HIV. However, in South Africa 78 percent of pregnant women were tested and in Namibia, 90 percent of pregnant women were tested. Among pregnant women living with HIV, 45 percent received ARV or ART and 40 percent of HIV-exposed infants received ARV prophylaxis.
National guidelines and policies warrant revision in order to effectively implement the 2010 WHO PMTCT recommendations. This would include the scale-up of CD4 testing for pregnant women infected with HIV; the revision of training curricula; the retraining of health workers; the improvement of follow-up of mother/baby pairs; and the enhancement of access to ARVs.
Eliminating pediatric HIV/AIDS is now regarded as achievable, and PMTCT is considered an essential part of maternal, newborn, and child health care. PMTCT programs not only reduce transmission of HIV, but if well implemented as part of a full continuum of care, they can result in HIV-free survival, meaning that infants are protected from other causes of death as well.
Read these summaries of the research providing the evidence-base that supports the prevention approach
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Antiretroviral Drugs for Treating Pregnant Women and Preventing HIV Infection in Infants: Towards Universal Access
The WHO guidelines Antiretroviral therapy for HIV infection in infants and children are based on a public health approach to HIV care. The update of these guidelines is harmonized with the treatment guidelines adopted for adults, pregnant women, and prevention of mother-to-child transmission (PMTCT). The present guidelines are part of WHO’s commitment to achieve universal access to the prevention, care and treatment of HIV infection in infants and children.
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Interventions for Preventing Late Postnatal Mother-to-Child Transmission of HIV
Horvath, T., Madi B. C., Iuppa, I. M., et al. Cochrane Database of Systematic Reviews (2009), CD006734.
This systematic review of clinical trials examined approaches to PMTCT during breastfeeding, when up to 42 percent of mother-to-child transmission occurs. Mothers who had a high viral load, were young, did not breastfeed exclusively, or who had breast lesions were more likely to transmit HIV to their infants. In low-resource areas with poor sanitation, infants who were not exclusively breastfed were more likely to die of diarrheal diseases and pneumonia, causing overall death rates among 2-year-old children to be the same whether they were breastfed or not. The authors suggest that for mothers who initiate breastfeeding, a) breastfeeding should be exclusive, and b) extended prophylaxis should be given to the infant (nevirapine alone or nevirapine with zidovudine).
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Antiretroviral Treatment and Prevention of Peripartum and Postnatal HIV Transmission in West Africa: Evaluation of a Two-tiered Approach
Tonwe-Gold, B., Ekouevi, D. K., Viho I., et al. PLoS Medicine (2007), Vol. 4 No. 8, p. e257.
The World Health Organization now recommends that treatment-eligible pregnant women receive antiretroviral therapy (ART) during pregnancy. This study, conducted in Côte d’Ivoire, evaluated the impact of providing treatment-eligible pregnant women with highly active antiretroviral treatment (HAART) and treatment-ineligible women with short-course antiretroviral therapy (scARV). All infants were treated with seven days of zidovudine and single-dose nevirapine on day three. Seventy-five percent of infants were breastfed for a median of five months. Overall HIV transmission just after birth was 2.2 percent and increased to 5.7 percent at one year. The natural transmission without intervention could exceed 30 percent. The authors say that treating all pregnant women living with HIV with three highly active antiretroviral drugs, regardless of their immune status, could avoid the HIV resistance associated with scARV.
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Maternal Highly Active Antiretroviral Treatment (HAART): Does it Improve Child Survival?
Taha, T., Kumwenda, J., Kafulafula, G., et al. Abstract, 5th IAS Conference on HIV Pathogenesis, Treatment, and Prevention, 19-22 July 2009, Cape Town.
This clinical trial conducted in Malawi evaluated HIV-free survival rates of children whose mothers were categorized into one of three groups: group A, highly active antiretroviral therapy (HAART)-ineligible (defined as a CD4 count of 250 or greater); group B, HAART-eligible but untreated women; and group C, HAART-eligible and treated women. At 24 months, HIV-free survival of infants was 82 percent in Group A, 68 percent in group B, and 81 percent in group C. When survival rates were adjusted for various infant prophylaxis regimens, the risk of death among the children of treated mothers and treatment-ineligible mothers were each approximately half that of the children of treatment-eligible but untreated women.
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Triple-antiretroviral (ARV) Prophylaxis During Pregnancy and Breastfeeding Compared to Short-ARV Prophylaxis to Prevent Mother-to-Child Transmission of HIV-1 (MTCT): The Kesho Bora Randomized Controlled Clinical Trial in Five Sites in Burkina Faso, Kenya
De Vincenzi, I. Abstract, 5th IAS Conference on HIV Pathogenesis, Treatment, and Prevention, 19-22 July 2009, Cape Town.
This study, conducted in Burkina Faso and Kenya, randomized 824 pregnant women living with HIV and with CD4 counts of 200 to 500 to receive either triple antiretroviral (ARV) prophylaxis or short-ARV prophylaxis. Over three-quarters of infants in both groups were breastfed. Infants in both groups were treated with single-dose nevirapine. At 12 months, the cumulative HIV infection rates among infants born to women receiving triple-ARV and short-ARV were 5.6 percent and 9.3 percent, respectively; however, there was no statistically significant difference in overall mortality.
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Antiretroviral Regimens in Pregnancy and Breast-Feeding in Botswana
Shapiro, R., Hughes, M., Ogwu, A., et al. New England Journal of Medicine (2010), Vol. 362,No.24,pp.2282-94.
Five hundred and sixty women living with HIV with CD4 counts of 200 or higher were randomized to receive one of two triple drug regimens (referred to by the authors as highly active antiretroviral therapy): Arm A received abacavir/zidovudine/lamivudine and Arm B received lopinavir/ritonavir/Combivir, which were prescribed at 26 to 34 weeks of pregnancy through 6 months following birth. A control group of 170 women with CD4 counts less than 200 were treated with nevirapine/Combivir. Seven of 10 mothers breastfed for five months or longer. Neither infant mortality nor HIV transmission differed significantly among the groups. Infant mortality at six months did not differ by groups and was very low in all arms.
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Maternal or Infant Antiretroviral Drugs to Reduce HIV-1 Transmission
Chasela CS, Hudgens MG, Jamieson DJ, et al. New England Journal of Medicine (2010), Vol. 362 No. 24, pp.2271- 2281.
This study randomized 2,637 mother-infant pairs, in which the mothers had CD4 counts higher than 250, to receive either maternal triple drug prophylaxis (referred to by the authors as highly active antiretroviral therapy), infant nevirapine, or no additional prophylaxis (all pairs were treated with single-dose nevirapine and one week of two-drug prophylaxis immediately after birth). Treatment extended up to 28 weeks of breastfeeding, and mothers breastfed exclusively for 24 weeks, followed by rapid weaning. Preliminary data show that at one week, 4.9 percent of infants in the two treatment groups were infected, reflecting transmission during pregnancy. At 28 weeks, 6.4 percent of infants in the control arm (those with no additional treatment) developed HIV; 3.0 percent of infants born to mothers treated with triple drug prophylaxis became HIV-positive; and 1.8 percent of infants treated with nevirapine became infected. Revised results will be published in an upcoming issue of the New England Journal of Medicine.
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Increased Infant Human Immunodeficiency Virus-type One Free Survival at One Year of Age in Sub-Saharan Africa with Maternal Use of Highly Active Antiretroviral Therapy During Breast-feeding
Marazzi, M. C., Nielsen-Saines, K., Buonomo, E., et al. Pediatric Infectious Disease Journal (2009), Vol. 28 No. 6, pp. 483-487.
This cohort study of infants born to mothers living with HIV in Mozambique assesses HIV-free survival at one year among infants of mothers given three highly active antiretroviral drugs (referred to by the authors as highly active antiretroviral therapy, although it was used only as prophylaxis in some women and as therapy plus prophylaxis in others). Mothers were advised to breastfeed exclusively for six months. Treatment and/or prophylaxis was initiated as early as the 15th week of pregnancy and was continued for six months following birth (indefinitely if CD4 count was less than 350). Infant HIV-free survival at 12 months was 94 percent. Deaths among mothers and infants were reduced by 41 percent and 67 percent, respectively, based national death rate data.
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Towards Universal Access: Scaling Up Priority HIV/AIDS Interventions in the Health Sector. Progress Report 2009
WHO, UNAIDS, & UNICEF. (2009).
This report provides an update on global progress in 2008 toward scaling up priority health sector interventions for HIV prevention, treatment, and care toward the internationally endorsed goal of universal access. Section 5, “Scaling up HIV Services for Women and Children,” reports on PMTCT indicators. A key indicator, the percentage of pregnant women living with HIV who receive antiretroviral drugs for PMTCT in low- and middle-income countries, is low but increased from 35 percent of women in 2007 to 45 percent in 2008. Access to testing and counseling was also low but increased from 15 percent in 2007 to 21 percent in 2008. The report indicates that national political commitments to expand HIV prevention, treatment, and care services for women and children have intensified. An executive summary and the full report are available through the link below.
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Children and AIDS: Fourth Stocktaking Report, 2009
UNICEF, UNAIDS, WHO, & UNFPA. (2009).
This report includes a section devoted to PMTCT. Overall, only 21 percent of pregnant women in low- and middle-income countries receive HIV testing and counseling. Those rates are higher in South Africa (78 percent), Botswana (87 percent), and Namibia (90 percent). However, of pregnant women living with HIV, only 45 percent received antiretroviral (ARV) prophylaxis in 2008 while 32 percent of HIV-exposed infants received ARV prophylaxis. These data are a subset of the overall body of data reported in the Towards Universal Access report (above). The report summarizes current challenges and identifies innovations necessary to improve scale-up and coverage of PMTCT.
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Missing the Target 7. Failing Women, Failing Children: HIV, Vertical Transmission, and Women’s Health. On the Ground Research in Argentina, Cambodia, Moldova, Morocco, Uganda, and Zimbabwe
International Treatment Preparedness Coalition. (2009).
This report by activists and researchers describes the perceived failure of PMTCT programs in six developing countries: Argentina, Cambodia, Moldova, Morocco, Uganda, and Zimbabwe. The authors call into question the United Nations’ claims of success in PMTCT coverage and cite the poor quality of PMTCT programs in resource-poor countries. Reasons given for these failures include an overly-narrow focus on antiretroviral prophylaxis; lack of consistency and coordination among donors, United Nations agencies, and governments (especially with regard to infant feeding issues); inadequate integration among health services; and stigma, discrimination, and violence against women living with HIV. The authors use case studies from the six focus countries to support their findings.
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Monitoring Effectiveness of Programmes to Prevent Mother-to-Child Transmission in Lower-Income Countries
Stringer, E. M., Chi, B. H., Chintu, N., et al. Bulletin of the World Health Organization (2008), Vol. 86 No. 1, pp. 57-62.
The PMTCT field has been constrained by a lack of clarity and consensus around the optimal way to measure program effectiveness. The authors discuss benefits and pitfalls of population-based surveys versus facility-based surveys, and the biases that can be introduced. They urge adoption of a validated consensus model for effectiveness monitoring PMTCT. They also propose using HIV-free child survival as a gold standard measure of program effectiveness, and they suggest adapting the existing Demographic and Health Surveys (DHS) to routinely measure HIV-free child survival. The World Health Organization authors recommended adding questions to the DHS survey about infant feeding practices and child deaths, and they propose adding a heel-stick to obtain blood samples for HIV testing of children younger than two years old.
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The Global Strategy to Eliminate HIV Infection in Infants and Young Children: A Seven-Country Assessment of Costs and Feasibility
Nakakeeto, O. N., & Kumaranayake, L. AIDS (2009), Vol. 23 No. 8, pp. 987-995.
This study examines whether the 2001 United Nations goals for PMTCT were feasible and affordable, using a model based on data from actual costs, resource needs, and PMTCT and pediatric treatment budgets in Burkina Faso, Cameroon, Côte d’Ivoire, Malawi, Rwanda, Tanzania, and Zambia. The model included family planning promotion for people living with HIV; HIV testing and counseling; pediatric treatment; and cotrimoxazole prophylaxis. The authors concluded that more funds than are currently available in many countries will be needed to successfully scale-up PMTCT, and that human resource constraints are even more challenging than funding constraints. Based on this, the authors recommend that human resource capacity be assessed together with requests for increased funds for PMTCT programs.
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Evaluation of PMTCT Coverage in Four African Countries: The PEARL Study
Coetzee, D., Stringer, E. M., Chi, B. H., et al. Abstract, 5th IAS Conference on HIV Pathogenesis, Treatment, and Prevention, 19-22 July 2009, Cape Town.
To assess PMTCT coverage at a population level, researchers collected cord blood samples from 43 delivery centers in Cameroon, Côte d’Ivoire, South Africa, and Zambia, where all sites used nevirapine (NVP) for prophylaxis, either alone or in combination with other drugs. Cord blood was tested for the presence of antiretroviral drugs. Of nearly 30,000 cord blood samples collected, 12 percent were HIV positive. Among positive cases, complete charts were available for just over 3,000 cases; of those, roughly half of mother/baby pairs received both mother and infant nevirapine. Service-related failures occurred at every step of the PMTCT cascade and included HIV testing not being offered, mothers declining testing, HIV results not being given, NVP not being dispensed, mothers not taking NVP, and infants not being dosed. Better performance at each step of PMTCT is recommended.
Read these summaries of promising interventions
Summary of Research Articles |
Reports and Briefs
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Antiretroviral Therapy in Antenatal Care to Increase Treatment Initiation in HIV-Infected Pregnant Women: A Stepped-wedge Evaluation
Killam, W. P., Tambatamba, B. C., Chintu, N., et al. AIDS (2010), Vol. 24 No. 1, pp. 85-91.
Few women in low- and middle-income countries have been able to access antiretroviral therapy (ART) early in pregnancy. This study evaluated whether integrating ART provision into antenatal care (ANC) clinics in Lusaka, Zambia, would improve the proportion of treatment-eligible women initiating ART during pregnancy. The researchers compared a large control cohort of pregnant women with an intervention cohort of over 17,000 women who received care at an integrated ANC-ART center. Of the 1,566 treatment-eligible women, a larger proportion of those attending an integrated care center (33 percent) received ART during pregnancy compared to the control arm (14 percent).
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Safety and Efficacy of Initiating Highly Active Antiretroviral Therapy in an Integrated Antenatal and HIV Clinic in Johannesburg, South Africa
Black, V., Hoffman, R. M., Sugar, C. A., et al. Journal of Acquired Immune Deficiency Syndromes (2008), Vol. 49 No. 3, pp. 276-281.
This study evaluated the safety and efficacy of highly active antiretroviral therapy (HAART) given to 689 pregnant women treated in an integrated antenatal clinic of Johannesburg Hospital, South Africa. Only 302 mother-infant pairs completed follow-up, and of those, the transmission rate was 5 percent. Clinically significant adverse reactions to HAART included life-threatening skin reactions (Stevens-Johnson syndrome), non-fatal hepatitis, and mitochondrial toxicity. The authors caution that the retrospective, observational nature of this study, and the failure of many women to follow-up, is “likely to bias the data” as women who followed up could represent a distinctly different socioeconomic group. Nonetheless, the researchers concluded that initiating pregnant women on HAART was feasible, safe, and effective.
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High HIV Incidence During Pregnancy: Compelling Reason for Repeat HIV Testing
Moodley, D., Esterhuizen, T. M., Pather, T., et al. AIDS (2009), Vol. 23 No. 10, pp. 1255-1259.
The researchers sought to determine the percentage of women who develop HIV during pregnancy (women who test HIV-negative in early pregnancy and test HIV-positive later in pregnancy). Of 5,233 pregnant women registered for antenatal care in the Eastern Cape and Free State of South Africa, 79 percent agreed to an HIV test. Of the 2,377 women who initially tested negative, only 1,278 accepted a repeat HIV test between 36–40 weeks of pregnancy; of those, 72 (3 percent) tested positive. This number represents an incidence rate of HIV of 10.7/100 pregnant-woman-years. The authors conclude that HIV retesting should be offered in pregnancy in order to promote PMTCT and to identify women living with HIV whose antibody levels were low at first testing.
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Preventing Mother-to-Child Transmission of HIV in Resource-limited Settings: The Elizabeth Glaser Pediatric AIDS Foundation Experience
Spensley, A., Sripipatana, T., Turner, A. N., et al. American Journal of Public Health (2009), Vol. 99 No. 4, pp. 631-637. Epub 2008 Aug 13.
The Elizabeth Glaser Pediatric AIDS Foundation has one of the world’s largest PMTCT program datasets. The authors reviewed more than six years of program data from several countries, covering 2.6 million pregnant women through June 2006. They review the number of women who received counseling and testing services, and the number of women and infants receiving antiretroviral prophylaxis. The authors describe a dramatic increase in HIV testing after a policy change from “opt-in” testing to “opt-out” testing, in which the test is presented as a routine part of pregnancy testing that women can decline if they desire. They discuss their wide promotion of single-dose nevirapine for prophylaxis and some of the controversy surrounding this approach.
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Approaches for Scaling-up Human Immunodeficiency Virus Testing and Counseling in Prevention of Mother-to-Child Human Immunodeficiency Virus Transmission Settings in Resource-Limited Countries
Bolu, O. O., Allread, V., Creek, T., et al. American Journal of Obstetrics and Gynecology (2007), Vol. 197 No. 3, pp. S83-89.
This article focuses on the weaknesses of the counseling and testing components of PMTCT. The authors state that overall global PMTCT coverage is just 8 percent. Because testing and counseling serves as an entry point for multiple downstream services, such as comprehensive family-centered HIV care, as well as for PMTCT, the authors suggest that improvements in this aspect of HIV prevention and treatment could lead to multiple benefits. The authors make 10 key recommendations, including provider-initiated testing and counseling; group pre-test counseling; use of rapid HIV tests; and the use of auxiliary health care workers. Each of the 10 recommendations is discussed in detail. Data from four African and two United Kingdom studies are presented and illustrate improved uptake of testing and counseling after the introduction of provider-initiated testing, which uses an opt-out technique for testing.
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Reducing the Risk of Mother-to-Child Human Immunodeficiency Virus Transmission: Past Successes, Current Progress and Challenges, and Future Directions
Fowler, M. G., Lampe, M., Jamieson, D. J., et al. American Journal of Obstetrics and Gynecology (2007), Vol. 197 No. 3, S3-9.
The authors review historical events and key research issues relevant to PMTCT. They describe interventions that have succeeded in the United States and Europe and how they have lagged in developing countries. The authors discuss program gaps or challenges to PMTCT in the United States, such as the practice of providers offering testing only to pregnant women felt to be at high-risk, rather than offering it to all pregnant women. Another pitfall is the failure to retest pregnant women who initially test HIV-negative. International gaps and challenges include limited ability to provide PMTCT services at the time of birth and shortly after because many women in resource-limited areas deliver at home. Some successful approaches to these problems are described.
Adapt and use these program materials, including tools, curricula, and models
Link to important additional materials and websites
PMTCT: Expert Panel Report and Recommendations to the U.S. Congress and U.S. Global AIDS Coordinator
Independent Expert Panel. (2010).
This report was commissioned by the U.S. Congress to review PMTCT activities supported by the U.S. President’s Plan for Emergency Aid Relief (PEPFAR) and others, and to make recommendations to appropriate congressional committees. The report makes numerous recommendations to achieve the goals of legislation enacted in 2008, which has as its central goal that PMTCT services will by 2013 “reach at least 80 percent of pregnant women in those countries most affected by HIV/AIDS in which the United States has HIV/AIDS programs.” The report outlines PMTCT achievements in the 15 focus countries that receive PEPFAR support. Of these, three focus countries, Botswana, Guyana, and South Africa, have achieved 80 percent coverage of counseling and testing. Family planning services and efforts to prevent unintended pregnancies among women living with HIV are seen as integral to PMTCT. Challenges in achieving PMTCT goals are described and include the difficulty of offering the full continuum of care of PMTCT services within the short pregnancy and postpartum period; ambiguity around the definition of PEPFAR targets and goals; and funding constraints. Finally, the report contains a detailed section that describes the scientific evidence for PMTCT.
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AIDS Epidemic Update
UNAIDS & WHO (2008)
This report provides a detailed review globally and by region of HIV/AIDS epidemiologic data and trends including estimates of HIV/AIDS in women of reproductive age and in children. The authors caution that some increase in the prevalence of HIV is due to improved care as people with HIV are living longer. They conclude that it is possible to reduce new HIV infections among children through increased coverage of PMTCT. Under ideal conditions, PMTCT interventions can reduce mother-to-child transmission from an estimated 30–35 percent (with no interventions) to 1–2 percent with a full complement of interventions. Global and regional estimates are provided of the annual number of infant infections averted through the provision of antiretroviral prophylaxis globally from 1996 to 2008. A qualitative discussion is provided for PMTCT programming in each region and is based on data provided regarding specific patterns of HIV transmission and conditions in each region.
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