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


  1. 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 an HIV-positive mother to her infant during pregnancy, labor, delivery, or breastfeeding.

  2. Epidemiological Justification for the Prevention Area

    Approximately one-third of children born to mothers who are living with HIV will acquire HIV infection in the absence of preventive measures. Although only 14 percent of children who breastfeed for up to two years will acquire the infection during breastfeeding, they account for 40–64 percent of children who are HIV-positive. The risk of transmission is particularly high if the mother herself acquires her HIV infection during pregnancy or breastfeeding, because viral loads tend 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 who are living with HIV during pregnancy reduces transmission by at least 75 percent. Ensuring that eligible women receive treatment is critical, not only to prevent MTCT, but to protect women’s health and survival.

    The number of people who are newly infected with HIV is continuing to decline in most parts of the world. There were 2.1 million (1.9 million–2.4 million) new HIV infections in 2013, of which 240,000 (210 000–280 000) were newly HIV-infected children. In addition, reports indicate that providing access to antiretroviral medicines for pregnant women living with HIV has averted more than 900,000 new HIV infections among children since 2009.

    Almost half (48 percent) of all people living with HIV (PLHIV) now know their status. In countries with the highest burden of HIV infection, knowledge of HIV status among PLHIV is higher than before. Some 86 percent of PLHIV who know their status in sub-Saharan Africa are receiving ART, and nearly 76 percent of these have achieved viral suppression. The number of AIDS-related deaths decreased significantly between 2009 and 2013 in several countries, including South Africa, with a 51 percent decrease, the Dominican Republic (37 percent), Ukraine (32 percent), Kenya (32 percent), Ethiopia (37 percent), and Cambodia (45 percent).

  3. Core Programmatic Components

    The World Health Organization (WHO) recommends a four-pronged approach to a comprehensive PMTCT strategy:

    1. Providing 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; antiretroviral prophylaxis or therapy; safe delivery; safer infant feeding and postpartum interventions such as cotrimoxazole prophylaxis; early diagnosis for HIV-exposed infants; and links to treatment and care, as well as standard postpartum child survival interventions.

    The 2013 WHO consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection emphasized ART for HIV infection in adults, adolescents, infants, and children, and pregnant women living with HIV. The guidelines emphasized advances in HIV laboratory diagnostics, simple and safer antiretroviral drug regimen for most populations and age groups, the benefits of ART for HIV prevention, and earlier initiation of HIV treatment. The current guideline recommends Option B+, which is providing lifelong ART to all pregnant and breastfeeding women who are living with HIV, regardless of their CD4 count or WHO clinical stage. After delivery and completion of breastfeeding, these women should remain on ART for the rest of their lives.

  4. Current Status of Implementation Experience

    The Global Plan towards the Elimination of New HIV Infections among Children by 2015 and Keeping their Mothers Alive was launched in July 2011 at the United Nations General Assembly High-Level Meeting on AIDS. The plan prioritizes 22 countries with the highest number of pregnant women living with HIV in need of services: Angola, Botswana, Burundi, Cameroon, Chad, Côte d’Ivoire, Democratic Republic of the Congo, Ethiopia, Ghana, India, Kenya, Lesotho, Malawi, Mozambique, Namibia, Nigeria, South Africa, Uganda, United Republic of Tanzania, Swaziland, Zambia, and Zimbabwe.

    In the 22 Global Plan countries, the proportion of pregnant women living with HIV who received antiretroviral medicines for PMTCT has doubled over the past five years, from 33 percent (31–35 percent) to 68 percent (64–74 percent) and regimens are now more efficacious. In Botswana, Namibia, South Africa, and Swaziland, 90 percent or more of pregnant women living with HIV were receiving antiretroviral medicines in 2013. For the first time, the total number of newly infected children dropped below 200, 000 in the 22 priority countries under the Global Plan.

    National governments, implementing partners, and donors are working closely to implement the Consolidated WHO 2013 guidelines on the use of antiretroviral drugs for treating and preventing HIV infection. All Global Plan countries have moved to Option B+, though at varying rates. This required training of several thousand health care workers, improvement of health services by integrating HIV services with MNCH services; development of high-quality monitoring and evaluation systems, including patient-level data recording to improve client follow up and program monitoring; community engagement in demand creation; and adherence and retention support for mothers and children in HIV care services.

    Eliminating pediatric HIV transmission 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 integrated into full continuum of care, can protect infants from other causes of death as well.

UPDATED 07/2015

What We Know

Consolidated Guidelines on the Use of Antiretroviral Drugs for Treating and Preventing HIV Infection: Recommendations for a Public Health Approach

Word Health Organization (June 2013).

This document combines recommendations from a range of World Health Organization guidelines on antiretroviral therapy (ART) for treating HIV infection in adults, adolescents, infants, children, and pregnant women; and for preventing HIV infection in infants. These guidelines emphasize advances in HIV laboratory diagnostics, simple and safer antiretroviral drug regimens for most population and age groups, the benefits of ART for HIV prevention, and earlier initiation of HIV treatment.

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 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 two-year-old children to be the same whether they were breastfed or not. The authors suggested that for mothers who initiate breastfeeding; (a) breastfeeding should be exclusive; and (b) extended prophylaxis (nevirapine alone or nevirapine with zidovudine) should be given to the infant.

First Population-Level Effectiveness Evaluation of a National Programme to Prevent HIV Transmission from Mother to Child, South Africa

Goga, A. E., Dinh, T. H., Jackson, D. J., et al. Journal of Epidemiological Community Health (March 2015), Vol. 69, Issue 3, pp. 240–248, doi: 10.1136/jech-2014-204535.

This study assessed the early population-level effectiveness of South Africa’s PMTCT program for HIV-exposed infants aged 4–8 weeks through a facility-based survey at the national level. PMTCT programming reduced early mother-to-child transmission (MTCT) to 3.5 percent nationally; each year, the program also averted approximately 82,560 early infant HIV infections among mothers on predominantly single or dual therapy antenatal antiretroviral (ARV) prophylaxis or antiretroviral therapy following a CD4 cell count below 250. The >10-week-long course of azidothymidine and the triple ARV regimen achieved the same level of perinatal effectiveness (just exceeding 2 percent). Breastfeeding (exclusive or mixed) combined with either incomplete or absent ARV prophylaxis was associated with increased perinatal MTCT. This survey provided population-level evidence to demonstrate the impact of recent investments in increasing PMTCT coverage and improving regimens. The survey also illustrated the utility of national surveys in corroborating antenatal survey data, tracking MTCT, and measuring the PMTCT cascade, especially intervention uptake. These data provide clear evidence of early population-level effectiveness for PMTCT within a high-HIV-prevalence setting. However, more data are needed to track the program's progress, specifically the long-term effectiveness of PMTCT and infant HIV-free survival by 24 months postpartum.

Safety of Efavirenz in the First Trimester of Pregnancy: an Updated Systematic Review and Meta-Analysis

Ford, N., Mofenson, L., Shubber, Z., et al. AIDS (March 2014), 28 (2), pp. 123−131, doi: 10.1097.

The authors conducted a systematic review to update evidence on the safety of efavirenz in HIV-infected pregnant women to inform the revision of the 2013 WHO guidelines for antiretroviral therapy in low- and middle-income countries. They included 23 studies that reported the outcomes of a total of 2,026 live births among women exposed to efavirenz during the first trimester of pregnancy up to January 2014, and compared the relative risks of congenital anomalies among the infants of women exposed to efavirenz- and non-efavirenz-based antiretroviral regimens. The pooled analysis found no differences between the two groups in the overall risk of congenital anomalies (relative risk 0.78). The incidence of neural tube defects was low (0.05 percent), and similar to incidence in the general population. Because of the low incidence of central nervous system anomalies in the overall population, and the relatively small number of exposures identified in the current literature, the investigator strongly recommended continued prospective surveillance of birth outcomes.

Maternal or Infant Antiretroviral Drugs to Reduce HIV-1 Transmission

Chasela, C.S., Hudgens, M.G., Jamieson, D.J., et al. New England Journal of Medicine (2010), 362(24), pp.2271–2281, doi: 10.1056/NEJMoa0911486.

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 showed that at one week, 4.9 percent of infants in the two-treatment groups had acquired HIV, 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 developed HIV. The authors concluded that a 28-week treatment with either maternal antiretrovirals or infant nevirapine reduced HIV-1 transmission during breastfeeding.

Peripartum Hair Levels of Antiretrovirals Predict Viral Suppression in Ugandan Women

Koss, C., Bacchetti, P., Cohan, D., et al. (Conference on Retroviruses and Opportunistic Infections 2015).

The Prevention of Malaria and HIV Disease in Tororo, Uganda (PROMOTE) trial (NCT00993031) enrolled 325 HIV-positive, ART-naïve pregnant Ugandan women at 12 to 28 weeks gestation, and randomized them to initiate lopinavir (LPV) or efavirenz (EFV)-based antiretroviral therapy (ART) ART. At 30–34 weeks gestation and 12 weeks postpartum, small hair samples were collected from the women, who had a median CD4 count of 366 cells/mm3 and an average of 17 weeks on ART. The authors conducted multivariate logistic regression to examine predictors of viral suppression (HIV-1 RNA). They found that hair concentrations of EFV and LPV were the strongest predictors of viral suppression at delivery and 24 weeks postpartum, surpassing self-reported adherence and pre-treatment HIV-1 RNA. The authors concluded that hair concentrations are an innovative tool for measuring long-term ARV adherence and exposure, and may be helpful to monitor women during the critical peripartum period.

Global Update on HIV Treatment 2013: Results, Impact and Opportunities: WHO Report in Partnership with UNICEF and UNAIDS

Work Health Organization (June 2013).

This report provides an update of progress in the global scale-up of antiretroviral therapy (ART) services in low- and middle-income countries. The document shows that the number of people receiving HIV treatment has tripled in five years, and reached 9.7 million in low- and middle-income countries in 2012. Despite the ongoing global economic crisis, rapid ART scale-up is continuing; and if this effort is sustained, the world could reach the global target of 15 million people receiving ART by the end of 2015. In 2012, an estimated 900,000 women globally were on ART for PMTCT, one-third more than the total in 2009. These accomplishments reflect the political commitment, community mobilization, technical innovation, domestic and international funding, and other forms of support that have catalyzed the global scale-up of ART. However, HIV treatment is not reaching enough children and key populations. The number of children younger than 15 years receiving ART rose from 566,000 in 2011 to 630,000 in 2012, but the proportional increase was smaller than for adults (11 percent versus 21 percent). A tremendous effort is needed to reach the goal of providing ART to all eligible children by 2015.

Towards an AIDS-Free Generation: Children and AIDS Sixth Stocktaking Report, 2013

United Nations Children’s Fund (2013).

This report focuses on the response to HIV and AIDS among children in low- and middle-income countries and is structured on the first and second decades of a child’s life. The data used for the report show that in the 22 Global Plan priority countries, the number of newly infected children under age 15 fell by 36 percent, from 360,000 in 2009, to 230,000 in 2012. In this period, seven countries (Botswana, Ethiopia, Ghana, Malawi, Namibia, Zambia, and Zimbabwe) halved the number of new HIV infections among children. Yet as the international community reflects on the gains made in the first decade of a child’s life, it cannot continue to neglect the crucial second decade of childhood. Globally, approximately 2.1 million (1.7–2.8 million) adolescents were living with HIV at the end of 2012, and approximately two-thirds of new HIV infections in adolescents aged 15–19 years were among girls. In the period between 2005 and 2012, the number of global AIDS-related deaths for all ages fell by 30 percent, but increased by 50 percent among adolescents. If children are to remain AIDS-free in the second decade of life, stakeholders must focus greater attention on preventing and treating HIV during adolescence.

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), 86(1), pp. 57–62, doi: 10.2471/BLT.07.043117.

The field of preventing transmission of mother-to-child transmission (PMTCT) of HIV has been constrained by a lack of clarity and consensus on the optimal way to measure program effectiveness. The authors of this article discussed the benefits and pitfalls of population-based versus facility-based surveys, and the biases that either approach may introduce. They urged adoption of a validated consensus model for effective PMTCT monitoring. They also proposed using HIV-free child survival as a gold standard measure of program effectiveness, and suggested 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 about infant feeding practices and child deaths, and proposed adding a heel-stick dried blood spot test 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., and Kumaranayake, L. AIDS (2009), 23(8), pp. 987–995, doi: 10.1097/QAD.0b013e32832a17e.

This study examined whether the 2001 United Nations goals for prevention of mother-to-child transmission (PMTCT) were feasible and affordable, using a model based on data on 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 these findings, they recommended assessing human resource capacity when requesting increased funds for PMTCT programs.

Missed Opportunities to Prevent Mother-to-Child-Transmission: Systematic Review and Meta-Analysis

Wettstein, C., Mugglin, C., Egger, M., et al. AIDS (2012), 26(18), pp. 2361–2373, doi: 10.1097/QAD.0b013e328359ab0c.

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. They looked at 44 studies to examine four outcomes on the 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 analysis showed that uptake of opt-out or provider-initiated HIV testing is greater (94 percent), 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. Only about two-thirds returned after 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, involve male partners, or integrate ART provision into standard antenatal care show promise for improving uptake, according to the authors. They recommended 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), 26(16), pp. 2039–2052, doi: 10.1097/QAD.0b013e328359590f.

Data on adherence to antiretroviral therapy (ART) during pregnancy are scarce. The authors performed a meta-analysis of 48 studies to determine levels of ART adherence among pregnant and postpartum women in low-, middle-, and high-income countries. The majority of studies (74 percent) were observational; 26 percent were randomized controlled trials evaluating regimens for prevention of mother-to-child transmission (PMTCT). The studies were conducted in the United States (27 percent), Kenya (12 percent), and South Africa and Zambia (10 percent each). Definitions of "adherent" varied across studies, 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 were 73.5 percent. Adherence was higher among antepartum than postpartum women (pooled proportion 75.7 versus 53 percent, respectively). Adherence was also higher among participants in low- and middle-income countries than in higher-income countries (pooled proportion 76.1 versus 62 percent). Factors inhibiting adherence included physical weakness caused by pregnancy, depression, economic stress, and pill burden. Social support and disclosure to loved ones increased adherence. The review demonstrated that PMTCT adherence is below that recommended for viral suppression. For optimal results, PMTCT programs must reduce adherence barriers and increase motivating factors.

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, doi: 10.1371/journal.pone.0035268.

Integrating programs for prevention of mother-to-child transmission (PMTCT) of HIV 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, based upon the systematic Cochrane review methodology, found limited, non-generalizable evidence of improved uptake of PMTCT interventions in such integrated programs. According to the authors, these findings were 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 found little consensus on how to standardize integrated services; they also found varying definitions of the concept. Regardless of the model, however, each program reviewed failed to achieve target coverage. The authors encouraged 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. They agreed with current guidance that PMTCT program integration must be assessed within the epidemiological context and the health system's readiness for integration. They also encouraged additional research on integration of PMTCT to understand how it affects the 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), 7(2): e28510, doi: 10.1371/journal.pone.0028510.

According to the 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). They developed a pooled analysis of all available clinical trial data in sub-Saharan Africa on prevention of mother-to-child transmission (PMTCT) of HIV over the past 15 years. These findings, they suggested, can be attributed to the immunological immaturity of the fetus and newborn, and the 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 found 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 twice as likely to succumb to infant mortality. Based on these results, the authors stressed the urgency of providing comprehensive care, including antiretroviral therapy, to all women with an antepartum CD4 count lower than 350 cells/ml. They also recommend programming for PMTCT through breastfeeding and early assessment of HIV infection in exposed children.

Stigma and Discrimination: Key Barriers to Achieving Global Goals for Maternal Health and Elimination of New Child HIV Infections

Turan, J., Nyblade, L., and Monfiston, P. Health Policy Project (July 2012).

The Health Policy Project conducted a systematic literature review to examine how stigma and discrimination affected women's access to and uptake of services for prevention of mother-to-child transmission (PMTCT) of HIV. The 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 for successfully completing the sequence of services offered throughout the PMTCT cascade. The document identified numerous barriers to PMTCT at each step in the cascade and also included several modeling exercises showing that a large percentage of infections could be averted by reducing stigma and discrimination. The report offers a number of strategies and recommendations for reducing stigma and discrimination, based on field experience and this literature review.

Putting it Into Practice

Lessons Learned From Early Implementation of Option B+: The Elizabeth Glaser Pediatric AIDS Foundation Experience in 11 African Countries

Kieffer, M.P., Mattingly, M., Giphart, A., et al. Journal of Acquired Immune Deficiency Syndromes (December 2014), Vol. 67, Issue, pp. 188–194, doi: 10.1097/QAI.0000000000000372.

This study analyzed data from 11 African countries supported by the Elizabeth Glaser Pediatric AIDS Foundation (EGPAF) to describe early experience implementing Option B+. All 11 countries in this review (Cameroon, Côte d’Ivoire, Democratic Republic of Congo, India, Kenya, Lesotho, Malawi, Mozambique, Swaziland, Tanzania, Uganda, Zambia, and Zimbabwe) adopted Option B+ as national policy. By the end of 2013, the total proportion of HIV-positive pregnant women in antenatal care who were accessing antiretroviral therapy (ART) in these countries was 80–95 percent. Implementation required expansion of the workforce and task shifting on several levels, including training for thousands of health care providers and lower-level assistants. The document reported that early findings from several EGPAF studies highlighted the importance of counseling and support for pregnant women to increase their acceptance of lifelong ART. The data management also required longitudinal patient-level tracking systems. Several countries began using ART clinic files or cards to monitor client retention. Uganda, Zimbabwe, Mozambique, and Lesotho are adding longitudinal electronic data systems to track ART delivery in MCH clinics. The author emphasized that use of Option B+ for prevention and treatment requires rapid identification of HIV infection and ART initiation, and close adherence to ongoing treatment.

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), 49(3), pp. 276–281, doi: 10.1097/QAI.0b013e318189a769.

This study evaluated the safety and efficacy of highly active antiretroviral therapy (HAART) given to 689 pregnant women treated in an integrated antenatal clinic in 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," since 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), 23(10), pp. 1255–1259, doi: 10.1097/QAD.0b013e32832a5934.

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 and 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 concluded that HIV retesting should be offered in pregnancy to promote PMTCT and identify women living with HIV whose antibody levels were low at first testing.

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), 197(3), pp. S83–89, doi: 10.1016/j.ajog.2007.03.006.

This article focused on the weaknesses of the counseling and testing components of PMTCT. The authors stated 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 suggested that improvements in this aspect of HIV prevention and treatment could lead to multiple benefits. They made 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) and discussed each recommendation in detail. Using data from four African and two United Kingdom studies, they presented and illustrated improved uptake of testing and counseling after the introduction of provider-initiated testing, which uses an opt-out technique for testing.

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), 9(8): e1001295, doi: 10.1371/journal.pmed.1001295.

The authors reported 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. Postpartum follow-up interviews were conducted with a subsample of 411 women—HIV-positive, HIV-negative, and untested—and with 48 community health workers, childbearing women, and family members. Qualitative data from the interviews showed that most women in the study believed 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 were less likely to deliver in a health facility. The authors postulated 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 recommended community-based interventions to counter HIV-related stigma 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 U.S. President's Emergency Plan for AIDS Relief

Chi, B.H., Adler, M.R., Bolu, O., et al. Journal of Acquired Immune Deficiency Syndromes (2012), 60(S3), pp. S78–S87, doi: 10.1097/QAI.0b013e31825f3284.

This article outlined 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) of HIV. PEPFAR's comprehensive PMTCT strategy is based on its Global Plan Towards the 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 strategy seeks to reduce new pediatric infections by 90 percent and halve HIV-related maternal mortality by 2015. The authors endorsed rapid implementation of the World Health Organization's PMTCT guidelines and approaches to retain women in care and help them adhere to prophylaxis and lifelong treatment. They reported that in 51 studies of HIV-positive pregnant and postpartum women, adequate adherence (defined as greater than 80 percent) was significantly higher in the antepartum period than postpartum period (70 percent versus 52 percent). The authors recommended partner-based support and community-based distribution of medications to increase adherence. They also supported partner-based HIV testing to include partners in PMTCT and to integrate HIV care and family planning efforts. Finally, they advised measuring infant HIV prevalence and HIV-free survival at the population level via household surveys or evaluations within infant immunization clinics, with long-term follow-up.

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), 15(4), pp. 1−5, doi: 10.7448/IAS.15.4.17991.

Following an online and in-person consultation with more than 650 people living with HIV (PLHIV) in 60 countries, the Global Network of People Living with HIV and the International Community of Women Living with HIV outlined challenges and potential solutions for successful prevention of vertical transmission of HIV among people living with HIV. According to the authors, health care workers' attitude about PLHIV was the most important barrier to service access, with two-thirds of e-survey respondents reporting that they have experienced stigma in health care settings. One-fifth of e-survey participants reported that they had been pressured to make decisions involving sexual abstinence, tubal ligation or hysterectomy, abortion, and/or condom use, without access to any other family planning option. Confidentiality was also a problem, with more than half of e-survey respondents reporting that their right to have health information kept confidential was violated at least once. Potential solutions to such challenges include prevention of gender-based violence; use of peer counselors and support groups; sexual and reproductive health services for women and girls; counseling on family planning and safe conception, particularly for PLHIV; decentralization of services; 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), 366(25), pp. 2368–2379, doi: 10.1056/NEJMoa1108275.

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 different ART 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 these 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"). The authors found an overall average transmission rate of 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 concluded 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): Article 602120.

This article reported on a study that examined the use of a rapid results initiative (RRI), implemented between April and June 2011 at 119 Kenyan health facilities, and designed to effect organizational change and improve performance over a limited time period to mitigate challenges in delivery of services for prevention of mother-to-child transmission (PMTCT) of HIV. RRI includes two distinct phases: needs assessment, and implementation and monitoring. 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 the 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 postulated that this increase would 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 eligibility for highly active antiretroviral therapy, or HAART, as a result of improved CD4 testing; and a 30 percent increase in polymerase chain reaction 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 encouraged 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, where 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. The authors reported that a major decrease in MTCT (66 percent) was achieved within a short period as a result of better programming; 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 cited 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, which helps reduce HIV infections in children and lowers mortality in mothers and infants. The authors detected challenges in the current MTCT programming, including ongoing high rates of maternal HIV prevalence and HIV diagnosis late in pregnancy. They stated that early HIV testing, and provision of ART regimens throughout the breasting period for at least 90 percent of HIV-positive women, are essential to reach the overall target of 5 percent or less for prevention of mother-to-child transmission by 2015.

Tools and Curricula

Expanding and Simplifying Treatment for Pregnant Women Living With HIV: Managing the Transition to Option B/B+

Interagency Task Team (updated 2015).

As more countries adopt Option B/B+, there is a need for guidance and tools to help countries determine the roadmap, funding requirements, and realistic timeframes required for effective implementation. This toolkit provides technical guidance to countries that are planning and implementing Option B or B+, in support of achieving the goals of the Global Plan Towards the Elimination of New HIV Infections among Children by 2015 and Keeping Their Mothers Alive. The kit is a collection of assessment tools and checklists that describe key considerations when transitioning to Option B/B+. Two 2012 updates from the World Health Organization (Use of ARVs for Treating Pregnant Women and Preventing HIV Infection in Infants and Use of Efavirenz in Pregnancy: A Public Health Perspective) informed the development of the toolkits. The toolkit has seven sections developed by different member organizations of the Interagency Task Team:

  • Option B/B+: Key Considerations for Country Programmes
  • Moving Toward Option B/B+: Readiness Assessment Checklist and Discussion Guide
  • Costing Tool
  • Human Resources for Health
  • Procurement and Supply Chain Management
  • Enhanced Monitoring and Evaluation Systems
  • Community Engagement.

It is expected that Ministries of Health, implementing partners, and technical assistance organizations will use the toolkit.

Zimbabwe HIV Prevention E-Toolkit

K4Health (2012).

The toolkit offers a selection of research papers, books, training materials, and behavior change communication materials across the spectrum of HIV-prevention topics. Readers can access materials and resources on condom use, family planning, HIV service integration, male circumcision, multiple and concurrent partners, prevention of mother-to-child transmission, and voluntary counseling and testing. Swaziland and Zambia toolkits are also available.

Additional Resources

2014 Progress Report on the Global Plan: Towards the Elimination of New HIV Infections among Children by 2015 and Keeping Their Mothers Alive

Joint United Nations Programme on HIV/AIDS (UNAIDS) (2014).

The Global Plan set the ambitious goal of reducing new HIV infections among children by 90 percent and having AIDS-related maternal and pediatric mortality between 2009 and 2015. The results of this report showed that the 21 Global Plan countries located in sub-Saharan Africa have reduced new HIV infections among children by 43 percent since 2009. Eight priority countries have realized declines of 50 percent or more, but in the other 13 countries, progress has been gradual or stagnant. The report also showed that the priority Global Plan countries have a 7 percent mother-to-child transmission rate at six weeks; this increases to 16 percent after breastfeeding ends. Whereas the Global Plan posits reducing maternal HIV incidence by 50 percent, in 2013 the reduction in these 21 countries was only 17 percent. The report indicated that despite significant investment, only 39 percent of children exposed to HIV in priority countries received virological testing within their first two months of life. The report indicated that in the remaining 500 days, all partners must continue pushing toward gains, urgently identify bottlenecks and obstacles, and develop rapid responses to remove the obstacles if they are to eliminate new HIV infections among children and keep their mothers alive.