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Preventing Mother-to-child Transmission of HIV
What is mother-to-child transmission?
Mother-to-child transmission (MTCT) is when an HIV-positive mother passes the virus to her child during pregnancy, labour, delivery or breastfeeding. Each year around 1.5 million women living with HIV become pregnant, 1 and without antiretroviral drugs (ARVs), there is a 15 to 45 percent chance that their child will also become infected.2 However, among mothers that take a regimen of ARVs for the prevention of mother-to-child transmission (PMTCT), the risk of HIV transmission can be reduced to less than 5 percent.3
How common is mother-to-child transmission today?
In 2011, around 330,000 children under the age of 15 became infected with HIV and an estimated 230,000 died from AIDS.4 Almost all of these infections were as a result of mother-to-child transmission and among children living in sub-Saharan Africa.5
However, mother-to-child transmission can be averted, and in high-income countries mother-to-child transmission has been almost completely eliminated as a result of effective voluntary testing and counselling services, access to antiretroviral therapy, safe delivery practices, and the widespread availability and safe use of breast-milk substitutes. Globally, since 1995, more than 350,000 children have avoided HIV infection due to these interventions.6 If these interventions were available and accessible to women worldwide, they could prevent thousands of children from becoming infected with HIV each year.
Preventing mother-to-child transmission
UNAIDS advocate four key strategies for preventing mother-to-child transmission:
- Keeping women of reproductive age and their partners HIV-negative through reproductive health and HIV prevention services.
- Avoiding unwanted pregnancies among HIV-infected women and women at risk of HIV, through family planning and HIV testing and counselling services.
- Ensuring HIV testing of pregnant women and timely access to effective antiretroviral therapy, both for the health of HIV-infected mothers and for PMTCT, during pregnancy, delivery and breastfeeding.
- Better integration of HIV care, treatment and support for HIV-infected women and their families.
For more on these methods please visit our page on PMTCT in practice.
The challenges facing PMTCT
There are a number of barriers and challenges facing the prevention of mother-to-child transmission. Many countries still do not have enough PMTCT services and too many women live a long way from their nearest health clinic. The cost or unavailability of transport, as well as heavy workloads and other responsibilities, such as the care of children or other dependents, can further inhibit women from accessing PMTCT services.
In many low- and middle-income countries health systems are often poorly staffed and resourced; clinics struggle to provide existing services, let alone new ones. As a result of this limited capacity, many countries are unable to adapt their existing health systems according to World Health Organization (WHO) PMTCT guidelines, which are amended as new evidence becomes available and more cost-effective in the long-term. Therefore, many clinics are not providing HIV-infected women with the most effective drugs. One example of this is the use of single-dose nevirapine, an antiretroviral drug which, despite no longer being recommended by the WHO, in 2011 was still being used in many countries for PMTCT; including India, Egypt, Malawi, Kenya, Haiti, Uganda, China and Vietnam.7 For more information on the recommended treatment regimens for PMTCT, see our page on 'WHO guidelines for PMTCT & Breastfeeding'.
Even where quality PMTCT services are locally available, there may be social, cultural or personal reasons why women do not access PMTCT services. The fear of stigma and discrimination, particularly if a woman is economically dependent on her partner, for example, may prevent her from getting tested, from disclosing her status to a partner or healthcare provider, or from accessing antiretroviral treatment for her own health and for PMTCT. Fear of disclosure is a common reason why women are reluctant to return to their HIV clinic. In the words of a woman from Cote d'Ivoire:
“My husband might see me with the medicines, and he will want to know what they are for. That way he will find out about my [HIV positive test] result. Even the location bothers me, because everyone who comes to the clinic knows what goes on [at the programme]. As soon as a pregnant woman is seen coming here, it's known right away that she is seropositive” - 8
Consequently, around two out of three women in low- and middle-income countries do not know their HIV status9 and the proportion of women, in low- and middle-income countries, accessing effective treatment for PMTCT stands at just over half.
Other challenges that inhibit the prevention of mother-to-child transmission include poor adherence to antiretroviral drugs; not being offered an HIV test; failure to attend follow-up appointments, either for results or treatment monitoring; poor social support; the risk of becoming infected with HIV later in pregnancy; lack of adequate HIV counselling; and difficulties with replacement feeding due to the price of formula and lack of access to clean water. For more information on these issues, visit our page on PMTCT challenges.
For a long time now, virtually all pregnant women living with HIV in high-income countries have had access to ARVs for PMTCT; and as a result, mother-to-child transmission is nearly non-existent. Recognising the potential to avert child infections the world over, in 2001 the member states of the United Nations made a global commitment to the prevention of mother-to-child transmission 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.” - 10
Since setting this target, significant progress has been made in scaling up national PMTCT programmes and as a result, new child HIV infections have dropped 43 percent between 2003 and 2011.11 This commitment was accelerated in 2011 when the United Nations General Assembly (UNGASS) launched the Global Plan, setting a new goal of eliminating all new infections among children by 2015 and keeping their mothers alive.12 Now in low- and middle-income countries, approximately 57 percent of pregnant women living with HIV receive effective antiretroviral drugs for PMTCT, and in the last two years alone, PMTCT services in these countries have prevented approximately 409,000 children from acquiring HIV.13
However, these improvements have not been universal and some countries are making better progress than others.
Of the countries with a generalised epidemic, Ghana, Haiti and Namibia are among those that have reached 75 to 100 percent of pregnant women with PMTCT services. Sierra Leone, Cameroon and Rwanda are among those with 50 to 74 percent coverage and Benin, Burkina Faso and Guinea reached only 25 to 49 percent of pregnant women in 2011. Worryingly, PMTCT coverage remains at less than 25 percent among pregnant women living in Chad, Ethiopia and Nigeria.14
Countries that succeeded in vastly improving coverage of PMTCT services have consequently experienced a significant decline in the number of children newly infected with HIV. In sub-Saharan Africa, home to 92 percent of the world’s HIV-positive pregnant women and 90 percent of infected children, a notable decline of 24 percent in the number of new infections was reported during the period 2009 to 2011.15 Among these countries, Burundi, Kenya, Namibia, South Africa, Togo and Zambia have led the way with the number of new child infections falling by more than half in some places.16 With sufficient effort, other countries could follow these examples.
Several countries in Latin American and the Caribbean - most notably Cuba, the Dominican Republic, Mexico and Guyana - have also succeeded in providing PMTCT services to most pregnant women who attend clinics. As a result, the Caribbean achieved a 32 percent reduction in new child infections and Latin America, already with comparatively low levels of child infections, achieved a further 24 percent reduction between 2009 and 2011.17.
Improvements, however, have not been universal. The Middle East and North Africa failed to achieve a reduction in the number of new child infections and in Angola, Congo, Equatorial Guinea and Guinea-Bissau the number of new child infections has actually risen.18 Therefore, although many regions have seen a marked improvement from previous years there is still a long way to go before we reach our target of universal coverage and zero new infections among children by 2015.
The way forward
All women must have access to high quality life-saving HIV prevention and treatment services, both for themselves and their children; regardless of their wealth, status or geographical location. This means scaling up PMTCT programmes and ensuring that the barriers to PMTCT are overcome, whether they are practical, social or cultural.
Evidence shows that the hundreds of thousands of children that become infected with HIV during pregnancy, labour or breastfeeding can be averted. In some regions MTCT has already been drastically reduced, and not only in high-income countries but also in many low- and middle- income countries. By expanding our efforts and ensuring the delivery of PMTCT services to all women, we can achieve universal access and the elimination of MTCT worldwide.
- 1. WHO/UNAIDS/UNICEF (2011) ‘Global HIV/AIDS Response: Epidemic update and health sector progress towards Universal Access 2011’]
- 2. WHO (2010) 'Antiretroviral Drugs for Treating Pregnant Women and Preventing HIV Infection in Infants: Recommendations for a Public Health Approach 2010 Version'
- 3. UNAIDS (2012) 'World AIDS Day Report - Results’
- 4. UNAIDS (2012) 'Global Report: UNAIDS Report on the Global AIDS Epidemic'
- 5. UNAIDS (2012) 'Global Report: UNAIDS Report on the Global AIDS Epidemic'
- 6. WHO (2012) ‘Global monitoring framework and strategy for the global plan towards the elimination of new HIV infections among children by 2015 and keeping their mothers alive’
- 7. UNAIDS (2011) ‘AIDS at 30: Nations at the crossroads'
- 8. UNAIDS/ WHO (2005, June) 'Questions & Answers III - Selected issues: prevention and care'
- 9. UNAIDS (2012) ‘Women out loud: How women living with HIV will help the world end AIDS’
- 10. United Nations (2001), 'UNGASS Declaration: Resolution adopted by the General Assembly; Declaration of Commitment on HIV/AIDS'
- 11. UNAIDS (2012) 'World AIDS Day Report- Results’
- 12. UNAIDS (2011) ‘Global Plan towards the Elimination of New HIV Infections among Children by 2015 and Keeping Their Mothers Alive'
- 13. UNAIDS (2012) 'World AIDS Day Report- Results’
- 14. UNAIDS (2012) 'Global Report: UNAIDS Report on the Global AIDS Epidemic'
- 15. UNAIDS (2012) 'World AIDS Day Report- Results’
- 16. UNAIDS (2012) 'Regional Fact Sheet 2012: Sub-Saharan Africa'
- 17. UNAIDS (2012) 'Regional Fact Sheet 2012: Latin America and the Caribbean'
- 18. UNAIDS (2012) 'World AIDS Day Report- Results’