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HIV Prevention Knowledge Base
Biomedical Interventions: Prevention of Mother-to-Child Transmission of HIV (PMTCT)
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.
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.
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).
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
Missed Opportunities to Prevent Mother-to-Child-Transmission: Systematic Review and Meta-Analysis
Wettstein, C., Mugglin, C., Egger, M., et al. AIDS (2012), Vol. 26 No. 18, pp. 2361-2373.
Programs to prevent mother-to-child transmission (PMTCT) of HIV decrease the risk of vertical transmission and identify HIV-positive infants for treatment. To assess how well PMTCT programs reach women and infants and retain them in services, the authors conducted a meta-analysis of a decade of research (2002-12) on PMTCT involving more than 75,000 women in 15 African countries. The authors looked at 44 studies to examine four outcomes: percentage of pregnant women tested for HIV, initiating antiretroviral prophylaxis, being tested for CD4 cell count, and beginning combined antiretroviral therapy (ART). Two outcomes were examined for children: early infant diagnosis for HIV and combined ART initiation. The authors found that uptake of opt-out, or provider-initiated HIV testing is greater, with 94 percent of women getting tested, compared with 58 percent for opt-in, or patient-initiated, testing. The authors also found that 40 percent of ART-eligible women did not receive any form of ART. For infants, only about two-thirds returned after the birth for early infant diagnosis; even fewer returned for HIV testing between 12 and 18 months of age. Interventions that provide convenient access for mothers and their children, that involve male partners, or that integrate ART provision into standard antenatal care show promise for improving uptake, according to the authors. They recommend further research to understand the barriers to care that many of the region's pregnant women experience.
Adherence to Antiretroviral Therapy During and After Pregnancy in Low-Income, Middle-Income, and High-Income Countries: A Systematic Review and Meta-Analysis
Nachega, J.B., Uthman, O.A., Anderson, J., et al. AIDS (2012), Vol. 26 No. 16, pp. 2039-2052.
There is scarce data on antiretroviral therapy (ART) adherence during pregnancy, and no existing review has explored this subject. The authors performed a meta-analysis to determine the level of ART adherence among pregnant women and during the post-partum period in low-, middle-, and high-income countries. The meta-analysis included all studies that reported on adherence levels among women during pregnancy and/or postpartum—48 studies in all. The majority (74 percent) were observational; others (26 percent) were randomized controlled trials evaluating PMTCT regimens. Most studies (27 percent) were conducted in the United States; Kenya (12 percent), South Africa (10 percent), and Zambia (10 percent) were also represented. Across the studies, definitions on the meaning of “adherent” differed, with thresholds ranging from 80 to 100 percent. Also varying was how the studies measured adherence, whether based on self-reported data (51 percent), pill counting (18 percent), pharmacy refills (10 percent), or measuring blood levels (9 percent). Pooled adherence levels across all studies was found to be 73.5 percent. Adherence was higher among women in the antepartum period than postpartum (with pooled proportion 75.7 percent versus 53 percent respectively). Adherence was higher among participants in low- and middle-income countries than in higher-income countries (with pooled proportion 76.1 percent versus 62 percent). Factors inhibiting adherence included: advanced HIV disease; physical weakness caused by pregnancy; depression; economic stresses; and pill burden. Social support and disclosure to loved ones were found to motivate higher adherence. In conclusion, the review demonstrated that adherence among PMTCT clients is below that recommended for viral suppression. Therefore, to achieve optimal results, PMTCT programs must address adherence barriers and motivators.
Integrating Prevention of Mother-to-Child HIV Transmission Programs to Improve Uptake: A Systematic Review.
Tudor, C., Van Velthoven, M.H., Brusamento, S., et al. PLoS One (April 2012), Vol. 7 No. 4: e35268, e-publication ahead of print.
Integrating programs for prevention of mother-to-child transmission (PMTCT) programs with other health care services within facilities has long been considered essential to successful PMTCT program scale-up. This meta-analysis of five studies in sub-Saharan Africa, built upon the systematic Cochrane Review methodology, finds limited, non-generalizable evidence of improved uptake of PMTCT interventions in such integrated programs. According to the authors, these findings are consistent with a recent Cochrane review that found evidence lacking for the effectiveness of strategies for integrating primary health services at the point of PMTCT service delivery in lower-income countries. The authors find little consensus on how to standardize integrated services as well as varying definitions of the concept. Regardless of the model, however, each program reviewed failed to achieve target coverage. The authors encourage programs and future research studies to evaluate additional outcomes of integration, including cost-effectiveness and impact on quality of care, human resources, stigma, and context. The authors agree with current guidance that PMTCT program integration must be assessed within the epidemiological context and the health system's readiness for integration. They also encourage additional research on integration of PMTCT to understand how it affects scale-up of effective PMTCT programs.
Children Who Acquire HIV Infection Perinatally Are at Higher Risk of Early Death Than Those Acquiring Infection through Breastmilk: A Meta-Analysis
Becquet, R., Marston, M., Dabis, F., et al. PLoS One (2012), Vol. 7 No. 2: e28510.
According to the study authors, children who acquire HIV postnatally are more likely to survive (with 36 percent mortality rate at 18 months) than those who acquire HIV during delivery (whose mortality rate is 60 percent). These results are from a pooled analysis of all available clinical trial data in sub-Saharan Africa on mother-to-child HIV transmission prevention over the past 15 years. The authors suggest that these findings can be attributed to the immunological immaturity of the fetus and newborn and consequent difficulty in controlling the virus, in contrast to the greater immunological maturity of infants who acquire HIV postnatally from infected breast milk. The authors also find that maternal health affects infant survival: the rate of infant mortality at two years was one-third higher among women with a CD4 count lower than 350 cells/ml than mothers with a higher CD4 count. Children of mothers who died during the first two years postpartum were also two times more likely to succumb to infant mortality. Based on these results, the authors stress the urgency of providing comprehensive care, including antiretroviral therapy, to all women with an antepartum CD4 count lower than 350 cells/ ml, to improve the survival not only of the mothers but also of their infected and uninfected children. The authors also recommend programming for prevention of mother-to-child HIV transmission due to breastfeeding as well as early assessment of HIV infection in HIV-exposed children.
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).
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.
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.
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.
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.
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.
The Role of HIV-Related Stigma in Utilization of Skilled Childbirth Services in Rural Kenya: A Prospective Mixed-Methods Study
Turan J.M., Hatcher, A.H., Medema-Wijnveen, J., et al. PLoS Medicine (2012), Vol. 9 No. 8: e1001295.
The authors report on the results of the Maternity in Migori and AIDS Stigma Study (MAMAS), a prospective, mixed-methods study of how pregnant women’s perceptions of HIV-related stigma affect their use of maternity services. In 2007, MAMAS surveyed 1,777 pregnant women of unknown HIV status at their first antenatal care visit in a high-prevalence region of rural Kenya. These baseline data revealed that more than two-thirds of the respondents anticipated experiencing stigma if they were to test HIV positive. Follow-up interviews were conducted postpartum with a subsample of 411 women—HIV positive, HIV negative, and untested—as were interviews with 48 community health workers, childbearing women, and family members. Qualitative data from the interviews showed that most women in the study believe that delivering in a health facility is preferable for pregnant women with HIV or other health complications. Quantitative data revealed that women with stronger negative attitudes about persons living with HIV are less likely to deliver in a health facility. The authors postulate that women who deliver at a health facility are more likely to be labeled as HIV positive by their communities. Because health outcomes are far better for clinic-based deliveries, the authors recommend community-based interventions to counter HIV-related stigma in order to reduce women’s concerns about using health facilities for childbirth.
Progress, Challenges, and New Opportunities for the Prevention of Mother-to-Child Transmission of HIV under the US President's Emergency Plan for AIDS Relief
Chi, B.H., Adler, M.R., Bolu, O., et al. Journal of Acquired Immune Deficiency Syndromes (2012), Vol. 60 Suppl. 3, pp. S78-S87.
This article outlines five priorities for the U.S. President's Emergency Plan for AIDS Relief (PEPFAR), as well as other donors, in programming for prevention of mother-to-child transmission (PMTCT). PEPFAR's comprehensive PMTCT strategy is based on its Global Plan Toward Elimination of New HIV Infections Among Children by 2015 and Keeping Their Mothers Alive, co-published with the Joint United Nations Programme for HIV/AIDS (UNAIDS). The PMTCT strategy seeks to reduce new pediatric infections by 90 percent and to halve HIV-related maternal mortality by 2015. The authors endorse rapid implementation of the World Health Organization's PMTCT guidelines and of innovative approaches to retain women in care and to help them adhere to prophylaxis and lifelong treatment. According to the authors, in 51 studies of HIV-infected pregnant and postpartum women, adequate adherence (defined as greater than 80 percent) was significantly higher in the antepartum period than postpartum (70 percent versus 52 percent). The authors recommend partner-based support and community-based distribution of medications to increase adherence. They support partner-based HIV testing to more effectively include partners in PMTCT and to integrate HIV care and family planning efforts. Finally, the authors advise measurement of infant HIV prevalence and HIV-free survival at the population level, via household surveys or evaluations within infant immunization clinics, with long-term infant follow-up. At the International AIDS Conference in 2012, dozens of presentations discussed ongoing research and innovation in PMTCT programming, including Option B+, which provides lifelong triple antiretroviral therapy to all pregnant women regardless of their CD4 count.
Community Voices: Barriers and Opportunities for Programmes to Successfully Prevent Vertical Transmission of HIV Identified Through Consultations Among People Living with HIV.
Anderson, G., Caswell, G., Edwards, O., et al. Journal of the International AIDS Society (2012), Vol. 15 No. 4, pp. 1-5.
Following an online and in-person consultation with more than 650 people living with HIV (PLHIV) in approximately 60 countries, the Global Network of People Living with HIV and the International Community of Women Living with HIV outlined challenges and potential areas for success within the Draft Strategic Framework (2010-1015) for Primary Prevention of HIV and the Prevention of Unintended Pregnancies in Women Living with HIV in the Context of PMTCT. According to the authors, health care workers’ attitudes about PLHIV were identified as the single most important barrier to service access, with two-thirds of e-survey respondents reporting that they have experienced stigma in health care settings. More than half the respondents said that health care workers’ negative attitudes threatened their ability to access safe contraception. One-fifth of e-survey participants reported that they had been pressured to make sexual and reproductive health decisions, decisions involving sexual abstinence, tubal ligation or hysterectomy, abortion, and/or condom use, without access to any other family planning option. Lack of confidentiality was also cited as a major issue, with more than 50 percent of e-survey respondents reporting that their right to have their health information kept confidential had been violated at least once. Potential solutions to such challenges include: capacity building and training; prevention of gender-based violence; use of peer counselors and support groups; sexual and reproductive health services designed for women and girls; counseling on family planning and safe conception, particularly for PLHIV; decentralization of services; male involvement; and support for disclosure in HIV-discordant relationships.
Three Postpartum Antiretroviral Regimens to Prevent Intrapartum HIV Infection
Nielsen-Saines, K., Watts, D.H., Veloso, V.G., et al. New England Journal of Medicine (2012), Vol. 366 No. 25, pp. 2368-2379.
According to this research study, rapid initiation of antiretroviral therapy (ART) in infants is feasible, acceptable, and effective. The authors evaluated the safety and efficacy of three ART different regimens in infants born to late-presenting HIV-positive mothers who did not receive ART during pregnancy. Within 48 hours of birth, 1,684 formula-fed infants born to HIV-positive mothers were given one of three regimens: zidovudine for six weeks (the “zidovudine-alone group”); zidovudine for six weeks, plus three doses of nevirapine during the first eight days of life (the “two-drug group”); or zidovudine for six weeks along with nelfinavir and lamivudine for two weeks (the “three-drug group”). According to the authors, the overall transmission rate averaged 8.5 percent in all three groups, with a rate of 11 percent in the zidovudine-alone group. The two- and three-drug groups had similar rates and fared better than the zidovudine-alone group. Based on these results, the authors conclude that prophylaxis with a two- or three-drug ART regimen is more effective than zidovudine alone. They also found that the two-drug regimen, which uses liquid nevirapine, is easier to administer than the three-drug regimen, which requires reconstitution of nelfinavir powder before each dose is ingested.
Towards Elimination of Mother-to-Child Transmission of HIV: The Impact of a Rapid Results Initiative in Nyanza Province, Kenya
Dillabaugh, L.L., Kulzer, J.L., Owuor, K., et al. AIDS Research and Treatment (2012): 602120.
This article reports on a study that examined the use of a Rapid Results Initiative (RRI)—which is designed to effect organizational change and improve performance in a limited period—to address challenges in delivery of services for prevention of mother-to-child transmission of HIV (PMTCT) implemented between April and June 2011 at 119 Kenyan health facilities. RRI includes two distinct phases: first, needs assessment; then, implementation and monitoring. According to the authors, this RRI was developed to increase service provision and uptake of antiretroviral therapy (ART) for HIV-positive mothers and infants. The authors found that following RRI initiation, ART uptake increased by more than 40 percent among all HIV-positive pregnant women, a rate that continued to improve post-RRI. The authors believe this increase will bring health facilities closer to the goal of providing ART to 30 percent of all eligible HIV-positive women. They also found a 13 percent increase in assessment for HAART eligibility as a result of improved CD4 testing as well as a 30 percent increase in polymerase chain reaction (PCR) testing leading to improved early infant diagnosis and increased male involvement. Attributing part of this success to community mobilization as well as to Ministry of Health leadership and involvement, the authors encourage further research to determine the RRI’s longer-term impact on improving high-quality, cost-effective PMTCT services.
Elimination of Paediatric HIV in KwaZulu-Natal, South Africa: Large-Scale Assessment of Interventions for the Prevention of Mother-to-Child Transmission
Horwood, C., Vermaak, K., Butler, L., et al. Bulletin of the World Health Organization (2012), Vol. 90 No. 3, pp. 168-175.
Large-scale elimination of pediatric HIV appears feasible in KwaZulu-Natal, South Africa, whose HIV prevalence is among the world’s highest. This study was designed to determine the rates of mother-to-child transmission (MTCT) in KwaZulu-Natal, using all infants receiving their first immunizations as a population proxy. According to the authors, a major decrease in MTCT (66 percent) was achieved within a short period as a result of better programming for prevention of mother-to-child transmission; 90 percent of mothers reported that they had been tested for HIV during their most recent pregnancy, and 9 percent knew they were infected before their most recent pregnancy. The authors also cite the rapid transition of the province’s health facilities to providing dual antiretroviral prophylaxis, which offers more protection than nevirapine alone, and to providing HIV-positive mothers with lifelong antiretroviral therapy. According to the authors, lifelong treatment will contribute significantly to reducing HIV infections in children as well as to lowering mortality in mothers and infants (currently, 14 percent of HIV-positive mothers in KwaZulu-Natal are enrolled in a lifelong treatment program). The authors detected challenges in the current MTCT programming, including ongoing high rates of maternal HIV prevalence and HIV diagnosis late in pregnancy. According to the authors, early HIV testing and ART regimens through the period of breastfeeding for at least 90 percent of HIV-positive women will be essential to reach the overall target of 5 percent or less for prevention of mother-to-child transmission by 2015.
Rapid Advice: Use of Antiretroviral Drugs for Treating Pregnant Women and Preventing HIV Infection in Infants.
These recently-updated, evidence-based recommendations on PMTCT serve as a reference for countries to adopt and adapt according to conditions found at the national level (resource availability and limitations, etc.). They are intended to simplify and standardize previous recommendations by making guidelines for initiating antiretroviral therapy (ART) for pregnant women the same as for nonpregnant women and by taking into account programmatic considerations that affect implementation. They provide guidance for policymakers and program managers responsible for PMTCT programs and serve as a resource for health workers involved in prevention, care, and treatment of pregnant women and their infants.
The recommendations focus on two key areas: treatment and prophylaxis. The authors review drugs of choice for treatment-eligible women and when to start the drugs, and they discuss drugs of choice for prophylaxis in women who do not need ART for their own health and when to start those drugs for the mother and/or the child. Recommendations are given for both breastfeeding and non-breastfeeding infants.
New recommendations include: 1) earlier use of ART for a larger proportion of pregnant women living with HIV; 2) longer provision of antiretroviral (ARV) prophylaxis for pregnant women who do not need ART for their own health; and c) provision of ARVs. These recommendations form part of a larger guideline which is expected to be published and disseminated in 2010.
2010 World Health Organization Guidelines on HIV and Infant Feeding
These World Health Organization guidelines were updated in 2010 in response to significant new programmatic experience and evidence regarding HIV and infant feeding. The 2010 recommendations recognize the important impact of ARVs during the breastfeeding period, and recommend that national authorities in each country decide which infant feeding practice, i.e. breastfeeding with an ARV intervention to reduce transmission or avoidance of all breastfeeding, should be promoted and supported by their Maternal and Child Health services. The document includes the principles, recommendations, and summary of the evidence. Nine key principles focus on overall HIV-free survival; integrated versus vertical infant feeding interventions; setting national strategies for infant feeding; information and counseling for mothers; and promoting breastfeeding among the general population. Seven recommendations are provided on breastfeeding and young child feeding practices.
Prevention of Mother-to-Child Transmission of HIV Generic Training Package
WHO & CDC, in partnership with the François-Xavier Bagnoud Center of the University of Medicine & Dentistry of New Jersey, School of Nursing. (2008).
This generic training package, updated in 2008, provides all the tools needed for a five-and-a-half day PMTCT course, with an optional half-day field visit. The course is based on 75 resource documents, 17 of which are key World Health Organization guidelines. The course was updated in 2008 and serves as a comprehensive, evidence-based course that can be adapted and implemented in country or regional resource-constrained settings. Materials include a participant manual comprised of nine modules, a set of slides or overhead projections, and a trainer manual, which is aimed at nurses, midwives, physicians, social workers, outreach workers, counselors, and program managers working in PMTCT programs. Guidance is given for closing the course, offering an optional field visit, and answering frequently asked questions. A glossary is also made available. The document may be freely reproduced, in whole or in part.
Stigma and Discrimination: Key Barriers to Achieving Global Goals for Maternal Health and Elimination of New Child HIV Infections
Turan, J., Nyblade, L., Monfiston., P. 2012.
The Health Policy Project conducted a systematic literature review to examine how stigma and discrimination affected women’s uptake of and access to services for prevention of mother-to-child transmission of HIV (PMTCT). Findings were the basis for programmatic recommendations on how to reduce stigma and discrimination in PMTCT, antenatal care, and services for maternal, neonatal, and child health. The Health Policy Project defined the various steps to successfully complete the sequence of services offered through PMTCT and called it “the PMTCT cascade.” Numerous barriers to PMTCT were identified at each step in the cascade. A couple of modeling exercises demonstrated that a large percentage of infections could be averted by reduction of stigma and discrimination. The report offers a number of strategies and recommendations based on field experience and this literature review.
Use of Antiretroviral Drugs for Treating Pregnant Women and Preventing HIV Infection in Infants: Programmatic Update
World Health Organization (2012).
This programmatic update provides the latest recommendations on antiretroviral treatment for HIV-positive pregnant women to prevent transmitting HIV to their infants and outlines important changes and considerations from the 2010 version. For example, this new version offers a third option for antiretroviral programs for preventing HIV transmission—Option B+. Following this protocol, an HIV-positive pregnant woman will begin antiretroviral therapy at the antenatal clinic and will continue treatment for the rest of her life. The report also provides details on the regimen’s efficiency and its advantages and challenges, and answers questions relating to the new option. A more comprehensive guidelines revision is planned for early 2013.
Zimbabwe HIV Prevention E-Toolkit
The toolkit offers a selection of different materials including research papers, books, training materials, and behavior change communication materials across the spectrum of HIV prevention topics. Readers can access materials and resources on behavior change communication, condom use, family planning and HIV service integration, male circumcision, multiple and concurrent partners, prevention of mother-to-child transmission, and voluntary counseling and testing.
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.
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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