Prevention of Mother-to-Child Transmission of HIV (PMTCT)

Introduction

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.

What we know

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Putting it into practice

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Tools and Curricula

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Learn more

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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