What’s the problem?
IN 2008, 430,000 children aged under 15 become infected with HIV. Almost all of these infections occur in developing countries, and more than 90% are the result of mother-to-child transmission during pregnancy, labour and delivery, or breastfeeding. Without interventions, there is a 20-45% chance that a baby born to an HIV-infected mother will become infected.
Most infant HIV infections could be averted. The problem is that very few of the world’s pregnant women are being reached by prevention of mother-to-child transmission (PMTCT) services.
How can transmission be prevented?
Preventing mother-to-child HIV transmission in Mozambique
The most effective way to prevent mother-to-child transmission of HIV involves a long course of antiretroviral drugs and avoidance of breastfeeding, which reduces the risk to below 2%. In developed countries the number of infant infections has plummeted since this option became available in the mid-I 990s.
Since 1999, it has been known that much simpler, inexpensive courses of drugs can also cut mother-to-child transmission rates by at least a half. The most basic of these comprises just two doses of a drug called nevirapine — one given to the mother during labour and the other given to her baby soon after birth. These short-course treatments, combined with safer infant feeding, have the potential to save many tens of thousands of children from HIV infection each year.
Recognising this potential, the member states of the United Nations set targets for preventing mother-to-child transmission in 2001, as part of a landmark agreement called the UNGASS declaration. In this document the world’s leaders made the following pledge:
“By 2005, reduce the proportion of infants infected with HIV by 20 per cent, and by 50 per cent by 2010, by: ensuring that 80 per cent of pregnant women accessing antenatal care have information, counselling and other HIV prevention services available to them.”
The current situation
Since the UNGASS target, PMTCT services have been significantly scaled up. In 2005, only 15% of HIV-infected pregnant women received preventive drugs — barely making a dent in the number of infant infections. In 2006 the proportion was 23%, and by 2008 an estimated 45% of pregnant women living with HIV in low- and middle-income countries received antiretroviral drugs to prevent HIV transmission to their infants.
Despite this increase, many countries still do not have enough PMTCT services and existing services are not reaching many of the local women in need.
Availability of PMTCT services
To achieve wide coverage, PMTCT programmes must be integrated into existing public health systems, with services provided by all antenatal and delivery clinics. So far, only a few developing countries have achieved this goal.
One reason given for the slow progress is that most health systems are poorly resourced: clinics are struggling to provide conventional services, let alone new ones. Yet although some improvements in infrastructure may be required, there is abundant evidence that PMTCT programmes are feasible even in the poorest parts of the world. 6 These interventions are cost effective and deserve to be seen as a necessary part of maternal and child health care. 7 8 Moreover, as researchers have noted:
“Should infrastructural improvements be necessary, the cost of these should be considered in the wider context of all the potential benefits to other health care areas. Thus the mobilizing of resources for MTCT prevention programmes should be seen as a catalyst for improving other areas of maternal and child health, and other areas of primary HIV prevention.”
Several countries in Latin American and the Caribbean — most notably Brazil — have already succeeded in providing PMTCT services to most pregnant women who attend clinics.
Thailand, too, has provided wide access since 1999.
In Southern Africa, where HIV is very widespread among pregnant women, Botswana leads the way. High quality PMTCT services are provided in all of the country’s public facilities through the Maternal Child HealthlFamily Planning system, which serves over 95% of pregnant women. 12 Test results from between November 2006 and February 2007 indicate that less than 4% of babies born to HIV positive mothers in Botswana were infected – a rate comparable with the USA and Western Europe.’
With sufficient effort, other countries could follow these examples.
Efficiency of PMTCT services
Preventing mother-to-child transmission might seem simple: just hand out lots of pills. In fact there’s much more to it than that. To begin with, the vast majority of women in the developing world have never been tested for HIV and don’t know whether they’re infected. This means that effective PMTCT programmes must provide counselling and testing services to determine which women need assistance.
And even if a clinic offers counselling and testing to every pregnant woman, the reality is that not all of them accept. Others, having been tested, fail to return to receive their results. This is just the beginning of a series of steps that leads to the ideal outcome, which is to reduce the risk of transmission as far as possible. At each step, some women drop out. By the end, it’s possible that only a minority will remain. The entire process is illustrated below.
This phenomenon can be seen in data from pilot PMTCT programmes supported by UNICEF between January 2000 and June 2002. Of more than half a million women who attended clinics in twelve countries, only 71% received counselling; of those who were counselled, only 70% took an HIV test; among women who tested HIV positive, only 49% received preventive drugs. Assuming that HIV prevalence among all women was similar to the rate among those who were tested, fewer than one in four HI V-infected women who attended a clinic went on to receive the drugs that they needed.
Many other studies in very poorly resourced areas have shown that such high drop-out rates are not unusual. 1516 17 18 19 However, they have also found that some PMTCT programmes perform much better than others.
Improving efficiency means looking at nine main issues: accessibility; clinic resources; testing methods; fear and distrust; disclosure and discrimination; drug effectiveness; treatment for mothers; feasibility of replacement feeding; and male visits to antenatal clinics.