Prevent mother-to-child transmission of HIV
|The Goal of the Global Plan|
|Elimination of new HIV infections in children by 2015 and keeping their mothers alive.|
In 2010, an estimated 1.49 million (1.3–1.6 million) pregnant women in low- and middle-income countries were living with the human immunodeficiency virus (HIV). Close to 90 per cent of all pregnant women living with HIV in low- and middle-income countries live in 22 priority countries†, and about 75 per cent are concentrated in 10 countries, which include Kenya, Mozambique, Nigeria and South Africa.
Expanding HIV testing and counselling among pregnant women is critical for identifying those in need of follow-up care and increasing coverage of subsequent interventions to reduce the risk of mother-to-child transmission of HIV. This is even more important as too few pregnant women are aware of their HIV status. In 2010, an estimated 35 per cent of the estimated 123 million pregnant women in low- and middle-income countries received an HIV test, up from 26 per cent in 2009, 21 per cent in 2008 and 8 per cent in 2005.
Reducing HIV transmission from a pregnant woman living with HIV to her infant requires a range of interventions beginning with voluntary and confidential counselling and testing for pregnant women; followed by antiretroviral prophylaxis for pregnant women with HIV and their newborn baby or antiretroviral therapy for the mother if eligible; and safe delivery practices and guidance in selecting a suitable infant-feeding option in order to prevent mother-to-child transmission (PMTCT) of HIV.
With growing political support for prevention of mother-to-child transmission, an important push is now being made to virtually eliminate mother-to-child transmission by 2015. Specific, time-bound targets have been developed at global level and adapted by countries to support this goal.
Virtual elimination of PMTCT
A global consensus emerged between 2010 and 2011 to prioritize the reduction of mother-to-child transmission of HIV and call for its effective elimination by 2015, as well as improving the health of mothers and children to accelerate progress towards achieving the related Millennium Development Goals, including Millennium Development Goal 6 on HIV/AIDS. In June 2010, under the leadership of the Executive Directors of UNICEF and UNAIDS and the Director-General of WHO, United Nations agencies and key global partners committed to work towards eliminating the mother-to-child transmission of HIV by 2015.
At the United Nations General Assembly High-level Meeting on AIDS in June 2011, the United Nations Secretary-General launched the Global Plan towards the elimination of new HIV infections among children by 2015 and keeping their mothers alive, which lays out key actions needed at both the global and country level to expedite progress toward these goals. The plan focuses on reaching pregnant women living with HIV and their children – from the time of pregnancy until the mother stops breastfeeding. It recognizes the need to better integrate HIV interventions with broader maternal, newborn and child health programmes to expand coverage, ensure the sustainability of service delivery and ultimately improve the survival of mothers and children in countries with a high burden of HIV.
Monitoring framework of the Global Plan
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Many countries are making substantial progress towards preventing mother-to-child transmission of HIV. In 2010, 59 per cent (53–66 per cent) of pregnant women living with HIV in low- and middle-income countries (872,400 of 1.49 million pregnant women with HIV) received antiretroviral drugs to prevent HIV transmission to their infants, including antiretroviral therapy for their own health.
The estimated coverage of most effective antiretroviral regimens (excluding single-dose nevirapine) for preventing the mother-to-child transmission of HIV in low- and middle-income countries was 48 per cent [44–54 per cent] in 2010. In addition, 11 per cent pregnant women – more than 150,000 – received single-dose nevirapine, a regimen which is no longer recommended by WHO.
Coverage of antiretroviral medicine for preventing mother-to-child transmission: Most effective regimens and single-dose nevirapine, low- and middle-income countries, by region, 2010±
± Single-dose nevirapine is no longer recommended by WHO.
Source: UNICEF calculations based on data reported in Global HIV/AIDS Response: Epidemic update and health sector progress towards universal access, Progress Report 2011. Regions were recalculated according to UNICEF classification of regions.
The 2001 Declaration of Commitment on HIV/AIDS set a target of 80 per cent coverage of antiretroviral medicine to reduce mother-to-child transmission by 2010. The target has nearly been achieved in Eastern Europe and Central Asia (with a coverage with the most efficient regimens) of 80 per cent. In Eastern and Southern Africa, the subregion with the highest number of pregnant women living with HIV has achieved 64 per cent coverage. But, in addition, 13 per cent of women only received a single dose of nevirapine instead of the most effective regimens recommended by WHO. Coverage remained low in West and Central Africa (18 per cent) and the Middle East and North Africa (4 per cent) and in South Asia (<1 per cent), where most women continue to receive only single-dose nevirapine.
The 2010 WHO guidelines recommend that all infants born to HIV-positive mothers should receive antiretroviral prophylaxis. Although the coverage of antiretroviral prophylaxis among infants was still less than the coverage among mothers in 2010, the reported coverage among infants increased between 2009 and 2010 from 32 per cent [29–36 per cent] to 42 per cent [38–48 per cent] of the estimated 1.49 million infants born to mothers living with HIV. Despite this increase, the gap between infants’ and mothers’ uptake of antiretroviral medicine is still substantial, suggesting problems with providing the postpartum prophylaxis to the infant and reporting on infant prophylaxis or early loss to follow-up of mother-infant pairs.
Percentage of pregnant women living with HIV and their infants who received antiretroviral medicine for preventing mother-to-child transmission, low- and middle-income countries, 2005–2010
Source: Global HIV/AIDS Response: Epidemic update and health sector progress towards universal access, Progress Report 2011.
* Coverage in 2010 cannot be compared with previous years which included single-dose nevirapine which is no longer recommended by WHO.
** This includes only the initial (4–6 weeks) prophylaxis for infants.
In general, coverage of antiretroviral therapy for PMTCT depends on a multitude of factors, including uptake of HIV testing, early reporting of women for antenatal care, attendance at delivery by skilled personnel, and health-system infrastructure, including laboratory and human resource capacity. Strong political commitment and leadership, enabling policies and the adoption of innovations in service delivery – namely, the introduction of provider-initiated testing and counselling, combined with rapid testing with same-day results, within antenatal and delivery care settings – have contributed to increasing access and uptake of HIV testing in the context of PMTCT. Despite the marked increase in access to PMTCT services during the past year, great challenges still exist to meet the Global Plan targets. Poor geographical service reach, aggravated by weak health systems, and the fear, stigma and denial that discourage women from being tested for HIV are significant barriers to wider uptake of PMTCT services.
† At the United Nations General Assembly High-level Meeting on AIDS in June 2011, the United Nations Secretary-General launched the Global Plan towards the elimination of new HIV infections among children by 2015 and keeping their mothers alive. Within the Global Plan, 22 countries have been identified as priority countries for intensified support. These countries are Angola, Botswana, Burundi, Cameroon, Chad, Côte d’Ivoire, Democratic Republic of the Congo, Ethiopia, Ghana, India, Kenya, Lesotho, Malawi, Mozambique, Namibia, Nigeria, South Africa, Swaziland, Uganda, United Republic of Tanzania, Zambia and Zimbabwe.
UNAIDS, Countdown to Zero: Global plan towards the elimination of new HIV infections among children by 2015 and keeping their mothers alive, 2011-2015, UNAIDS, Geneva, 2011.
UNAIDS, Global Report: UNAIDS report on the global AIDS epidemic, 2010, UNAIDS, Geneva, 2010.
UNICEF, UNAIDS, WHO, UNFPA and UNESCO, Children and AIDS: Fifth stocktaking report, UNICEF, New York, 2010.
WHO, UNAIDS and UNICEF, Global HIV/AIDS Response: Epidemic update and health sector progress towards universal access, Progress Report 2011, WHO, Geneva, 2011.