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.
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).
Core Programmatic Components
The World Health Organization (WHO) recommends a four-pronged approach to a comprehensive PMTCT strategy:
- Providing primary prevention of HIV infection among women of childbearing age
- Preventing unintended pregnancies among women living with HIV
- Preventing HIV transmission from women living with HIV to their infants
- 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.
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.