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Preventing Mother-to-child Transmission (PMTCT) in Practice
Preventing mother-to-child transmission is achievable. Between 2009 and 2011, 409,000 new infections were averted among children.1 Successfully preventing HIV transmission from mothers to their children requires multiple interventions not only during pregnancy, labour and breastfeeding, but among all women and girls.
This page looks at some of the barriers that make preventing mother-to-child transmission of HIV a challenge.
Making PMTCT programmes successful
To ensure PMTCT programmes successfully prevent HIV transmission from mother-to-child, PMTCT and antenatal services must be available, efficient and accessible; mothers must be able to access antenatal services early and be retained on PMTCT programmes from beginning to end. In reality, however, and due to a range of interacting factors, explored below, many women do not follow this essential pathway.
This diagram shows the number of different stages that a woman must progress through to complete a PMTCT programme.
Of 3,244 HIV-positive pregnant women, across four countries, who delivered at health centres offering PMTCT services, only 1,590 completed the PMTCT process; demonstrating the high rate of loss to follow up during this period.2 Reducing the number of women who fail to complete PMTCT programmes is integral to eliminating mother-to-child transmission.
As ‘PMTCT: An Introduction’ outlines, PMTCT begins with the non-pregnant woman.3 By educating all women of childbearing age how to stay HIV-negative, the risk of HIV transmission from mother-to-child is significantly reduced. This is reliant not only on national HIV prevention programmes, but on the availability and accessibility of family planning services. Access to family planning is also crucial for HIV-positive women to control their pregnancies and to reduce unplanned pregnancies.
Maintaining the sexual health of women both through their pregnancies and beyond is reliant on antenatal and PMTCT services reaching women who need them; yet as is discussed below, many women continue to struggle to access these services.
Travelling to clinics
Pregnant women in low- and middle-income countries are often unable to easily access antenatal and PMTCT services. Besides caring for their children they are expected to work hard preparing food, fetching water or tending crops. Many live a long way from their nearest health facility and have little access to transport. Between 2005 and 2011 nearly a third of pregnant women, in WHO South-East Asia Region, Eastern Mediterranean Region and African Region, did not attend an antenatal clinic.4 Women that do visit an antenatal clinic often only do so once during their pregnancy. This greatly reduces the number of women that can be reached by PMTCT programmes.
To increase attendance, clinics should aim to be as accessible as possible. Improvements might include providing travel services or changing opening hours.
Women who are HIV-positive should be encouraged to give birth at a clinic, as this reduces the risk of maternal mortality and MTCT. However, this is often not possible due to the distance between home and clinic. In some clinics, waiting mothers shelters provide accommodation for women nearing the end of their pregnancy to ensure they deliver within a healthcare setting.5
Access to treatment
As many women still deliver at home, it is important to ensure that those who test positive for HIV have access to the necessary antiretrovirals needed for PMTCT, including treatment for the infant. Option B+ is the latest treatment option recommended by the WHO for PMTCT.6 Unlike other treatment options, Option B+ recommends that all HIV-positive pregnant women are placed onto a triple antiretroviral regimen for PMTCT, irrespective of their CD4 count, and continuing for life. This approach protects the health of the mother, whilst also reducing the risk of HIV transmission to her child and all future pregnancies. Option B+ also provides mothers with antiretroviral treatment without waiting for laboratory results, as this wait can lead to a delay in accessing treatment or to mothers being completely lost to follow up.7
Previous treatment options, such as Option A (which is no longer recommended by WHO) recommended that pregnant women, receiving treatment solely for PMTCT, should take a number of different drugs, throughout various stages of pregnancy (antenatal, delivery and postpartum). This option made PMTCT interventions complicated and difficult to implement successfully. For instance, in settings where access to treatment and clinics is difficult, mothers may fail to return for each treatment stage. Using the same standard fixed-dose combination regimen for both PMTCT and first-line treatment in adults, as recommended in Option B and B+, enables a more efficient treatment supply-chain.8 It makes it easier to monitor supply levels and thus predict the amount of each drug that needs ordering. See: Drug Effectiveness and Adherance, below, for more information about antiretrovirals for PMTCT.
To be fully effective, antiretroviral medication needs to reach newborn babies as well as their mothers. Infant doses are given in syrup form and are usually available only to women who give birth in clinics.9 Some programmes have however succeeded in dispensing the syrup in advance, inside sealed oral syringes, so it can be given after home births.10
PMTCT programmes can increase acceptance of self-administered drugs by working with traditional birth attendants, who attend the majority of home deliveries. With sufficient training, traditional midwives might also be able to provide other services such as HIV education, testing and counselling, and advice on infant feeding.11
Preventing mother-to-child transmission of HIV is reliant on strong healthcare systems and infrastructure. However, in many countries there is a short supply of healthcare workers, which can adversely affect the standard of care and capacity of clinics. Moreover, an inefficient supply of PMTCT drugs or testing kits and the separation of core services can make visits to health clinics prolonged or unnecessary.12 These negative experiences of health clinics can dissuade pregnant mothers from accessing these key services. A lack of capacity and coordination may also result in gaps in the care delivered to mothers; for example an overworked healthcare worker may fail to deliver a key PMTCT intervention, such as an initial HIV test.
Ultimately, the best solution is to recruit more health workers. In the shorter term, better training, greater support and motivation can improve the efficiency of existing staff. Another proven remedy is the recruitment of lay counsellors, either paid or unpaid, to help provide counselling. With a few weeks training and ongoing supervision, lay counsellors can give a good quality service and lighten the workloads of full-time professionals.13 14 15
The services that pregnant women access during their pregnancy are often situated across a number of locations. These can include: Maternal, neonatal, child healthcare facilities, labour and delivery, ART centres and laboratory diagnostic services; all services play a role in the prevention of mother-to-child transmission and the health of mothers.16 Coordinating and integrating these services can improve uptake and make the functioning of health clinics more efficient.
The conventional form of HIV testing in antenatal clinics is called VCT - voluntary counselling and testing; this is when women are offered an HIV test. An alternative model is routine testing, whereby women are told that HIV testing is a standard part of antenatal care, but they can opt out if they want to. Removing the special status that is often given to HIV testing helps to make it more acceptable.
Numerous studies have found that switching from VCT to routine testing can dramatically improve uptake of testing in PMTCT programmes. For example, at one hospital in rural Uganda, the proportion of pregnant women with documented HIV status at discharge more than doubled from 39 percent to 88 percent after routine testing was introduced.17 When Botswana changed its testing procedure nationwide in 2004, it immediately increased testing rates from 75 percent to 90 percent.18 Further supporting this was a review of 44 studies carried out across 15 countries, which found that uptake of HIV testing among pregnant women was 94 percent when the test was opt-out; compared to 58 percent when this service was provided as opt-in.19
Nevertheless, despite an increased focus on MTCT in recent years, and evidence that testing uptake among pregnant women has nearly doubled in low- and middle- income countries20; 40 percent of pregnant women in low- and middle- income countries received an HIV test in 2012.21 The process of delivering HIV testing can be even more successful if the basic information given before testing is addressed to small groups instead of individuals. One-to-one counselling on personal issues can then follow as required.22 Importantly, however, the choice whether to test for HIV must remain with the mother. It is evident that in some ‘opt-out’ settings women do not feel that HIV testing is their choice, but perceive testing as compulsory if they wish to access antenatal care. This shows that there is a discrepancy between global targets and local realities of antenatal HIV testing.23
There are huge benefits for pregnant women to receive an HIV test, yet unless a woman returns to receive her results these benefits are lost. This is why PMTCT programmes use rapid testing at a woman's first antenatal clinic visit. Unlike conventional HIV tests, which take days or even weeks, rapid tests can produce a result in as little as twenty minutes.24 This helps to enroll women, found to be HIV-positive, immediately into PMTCT programmes, reducing the number that are lost to follow-up.25 26
PMTCT interventions can still be effective in the third trimester, during labour and even after delivery. Programmes should therefore seize every opportunity to offer testing to women of unknown HIV status. They should also consider retesting women who were previously negative, in case they have since become infected.27 A study of eight hundred pregnant women in Botswana showed an estimated 2 percent of pregnant women who had previously taken part in routine testing for HIV and were found to have a negative status developed HIV later in pregnancy or during postpartum. Therefore, women who had been tested immediately after being infected with HIV ('primary' or 'acute' infection), and before HIV antibodies were produced, and those who became infected after routine testing, were missed. Using these results researchers estimated that 43 percent of mother-to-child infections in Botswana during 2007 may have been due to undetected HIV infection late in pregnancy and postpartum. By integrating HIV counselling and testing into all parts of the maternal and child health system - including family planning clinics, labour and delivery services, postpartum care and even immunisation clinics - PMTCT programmes can reach significantly more women.28 29
Stigma, fear and disclosure
“Tragically...reports of forced abortion and sterilisation of HIV-positive women, often during labour, remain”
HIV-related stigma and discrimination are found in all societies and can lead to social isolation and even the support of partners, family and community. Fear of such prejudice can cause some women to refuse HIV testing, or to not return for their test results. The lack of confidentiality among healthcare workers must be addressed in order to attain public confidence in the privacy of HIV testing.30
Among pregnant women who do take a test and are found to be HIV-positive, a high proportion (sometimes up to 70 percent) choose not to tell their partners.31 32 Most are afraid of violence or abandonment: in many societies it is common for men to blame their partners for being infected, even if they too have HIV. As many women are reliant on the support of their male partners, the risk of losing this, particularly financial, support can dissuade them from testing, or from disclosing their HIV status.
An HIV-positive, pregnant woman who has not disclosed her diagnosis to her partner, family or friends is generally less likely to accept preventive drugs and to practise unconventional methods of infant feeding, for fear of revealing that she is infected. PMTCT programmes should therefore seek to make disclosure less difficult for their clients, for example by running support groups or anti-stigma campaigns.33They might also try to identify and assist those who wish to avoid or defer disclosure.34 Involving male partners in PMTCT programmes has been shown to improve the reach and success rate of PMTCT, see: Male Involvement below.
Tragically, in a number of countries, reports of forced abortion and sterilisation of HIV-positive women, often during labour, remain.35 36 Stigma and fear of healthcare settings can cause HIV-positive women to be fearful of prenatal services, which may prevent them from attending clinic and thus from accessing PMTCT services.
Moreover, pregnant women who engage in behaviours, such as sex work or drug use, are at an increased risk of HIV-infection. They may not, however, due to policies that criminalise these practices, access HIV testing services or, if they do test HIV-positive, PMTCT services, for fear that their child will be removed from their care. As UNAIDS emphasises:
“It is not enough for services to exist: the conditions that enable women to make use of them must be in place” - UNAIDS (2012) 'Women Out Loud'
A study from Kenya revealed that where women are supported and accompanied by their male partners, they are more likely to consistently visit antenatal clinics.37 Few men usually accompany their wives on visits to antenatal clinics for fear of being ridiculed by peers. However it has been shown that when male partners are involved, both partners can get tested for HIV, know their status, and therefore improve the baby's chances of a healthy survival.38 Following a strict infant feeding method is a key part of PMTCT; yet such methods are often contrary to traditional feeding methods, which may involve supplementing breast milk with porridge or other solids. Diversions from the chosen infant feeding method are less likely, however, if both parents are involved in this decision.
Furthermore, if couples are counselled and tested together then there is less potential for blame and recrimination. Counsellors can emphasise the man's responsibility for protecting the health of his partner and family, and can promote the use of PMTCT and other services, resulting in much higher rates of treatment uptake.39 40 41
Rwanda is one country that has greatly increased their focus on the participation of men in PMTCT. An estimated 81 percent of pregnant women who tested for HIV in 2010 had male partners who had tested in the last twelve months, many of whom received testing with their partner during the antenatal care process.42 Moreover, in Uganda, male partner testing in antenatal care has risen from 5.9 percent to 76 percent over the last decade, as a result of peer sensitisation and the establishment of male-friendly areas in antenatal facilities.43 This has immense benefits; one Kenyan study found that the involvement of men decreased the risk of vertical transmission by 40 percent.44 However, there are issues that need to be addressed. Occasionally, women leave the PMTCT process completely when asked to bring their partner to a clinic due to a fear of domestic repercussions if they are found to be positive. It has even been found that for some women, involving their partner in HIV testing during the antenatal period has put them in danger of domestic violence, particularly when the woman is found to be positive and the man negative.45
For male involvement to work antenatal clinics have to be accessible to men and messaging around HIV testing during pregnancy needs to be equally targeted at men.46 Possible ways to increase male participation include hand delivered invitations and routine testing for men who accompany their partners.47 Unfortunately, it is usually far from easy to persuade men to attend what they regard as women's clinics dealing with women's issues.48 49
Drug effectiveness and adherence
The treatment option used by PMTCT programmes varies between countries and is determined at a government level. Some treatment options are more effective than others, however, which option is recommended in national guidelines, is largely associated with the level of available resources.50 Updating national guidelines to adopt the latest recommended treatment regimen, currently Option B+, involves purchasing more expensive drugs and adapting current PMTCT programmes to distribute them; including further staff training and increasing capacity. This is a major factor that deters low-income countries from distributing the most effective, available drug treatment regimens for PMTCT.
Until 2006, the most common treatment regimen used to prevent mother-to-child transmission was single-dose Nevirapine.51 A straightforward regimen where both the mother and the child receive a single-dose of Nevirapine each. Overtime, however, after greater research and investment into treatments for the prevention of mother-to-child transmission, this treatment option was replaced by a more complex, yet safer and more effective treatment approach – Option A (no longer recommended).52
Unlike Option A and single-dose nevirapine, the latter of which the WHO now recommends be phased out of PMTCT programmes, Option B and B+ are not only more effective at preventing MTCT and less likely to lead to future drug resistance, but are also easier for health systems to implement and for patients to adhere to. This is down to the standard triple-antiretroviral drug regimen that is used for all pregnant women, irrespective of their CD4 count. The treatment is available as a single-pill fixed-dose combination, made up of a first line regimen of Tenofovir (TDF), Lamivudine (3TC), and Efavirenz (EFV).
Whilst Option B and B+ are more effective, and as a result of the one-pill approach easier to adhere to, some challenges remain surrounding these treatment options; for example research to monitor the safety of Efavirenz in early pregnancy, and the difficulty ensuring good adherence to treatment when placing women on treatment for life; many may not have any symptoms of HIV, and yet may experience treatment side-effects.
Keeping mothers healthy
The survival of children is reliant not only on mothers receiving treatment for PMTCT, but also on mothers receiving treatment for their own health. This has been shown in studies that found the risk of death increased among children whose mother had died, irrespective of whether or not the child was infected with HIV. Yet, despite longstanding recommendations that all pregnant women with a CD4 count of less than 350 cells/m3 should begin life-long antiretroviral treatment and, more recently, evidence of the numerous benefits of placing all pregnant mothers on antiretroviral treatment for life, irrespective of CD4 count, more than two thirds of pregnant women eligible to receive treatment remain without it.56
The goal of “Eliminating new HIV infections among children by 2015 and keeping their mothers alive” was launched by UNAIDS in 2011.57 Achieving the second half of this goal “keeping their mothers alive” relies on overcoming many of the barriers that also make implementing PMTCT services a challenge; fear and stigma of testing, difficulty accessing healthcare services, a need for integrated services – particularly PMTCT and adult HIV treatment services. In addition to this, are difficulties expanding access to antiretroviral treatment to universal levels, such as, political commitment, lack of infrastructure and availability of funding. Also important, however, is the development of community support networks, that provide care and support to women living with HIV.
Feasibility of replacement feeding
Because HIV can be transmitted through breast milk, a mother's method of infant feeding has a strong influence on the likelihood that her baby will become infected. The only certain way to avoid transmission is to abstain from breastfeeding and provide replacement foods instead but this is not possible for a woman living in an area with unsafe water or inconsistent formula milk. In this situation, women should be recommended to exclusively breastfeed alongside taking an extended drug regimen. For more information on these recommendations, please read our PMTCT Guidelines page.
Replacement feeding is not feasible and safe unless mothers have access to a reliable supply of safe water and fuel, as well as the ingredients for the food itself, and even then it can be time-consuming and expensive. These issues are discussed in more detail in our HIV and breastfeeding page.
It may seem obvious that PMTCT programmes should assist HIV-positive mothers by offering free supplies of infant formula. However, there are some drawbacks to this approach. The most significant worry is that by distributing formula, clinics may inadvertently encourage mothers to give up breastfeeding, even if they don't have HIV.58 In addition, mothers who have the resources to practise safe replacement feeding are the least likely to need free formula. In situations where free infant formula has been provided, supplies have been reported to be stopped, leaving many HIV-positive women with a difficult dilemma.59 Therefore some people argue that supplying free formula is not an effective use of money.60
In recent years, efforts to widen access to antiretroviral treatment have caught the attention of politicians, non-governmental organisations and the global media. Apart from some large donors and organisations that worked closely with national governments to improve access to PMTCT services, PMTCT and the health of mothers remained largely out of the spotlight until 2011. With this renewed commitment, it seems feasible that increasing numbers of countries will add their names to the already growing list of low-and middle-income countries reaching the 80% coverage target of antiretrovirals for PMTCT.61.
Swift progress will depend on strong leadership from national governments, and on the committed support of foreign donors and non-governmental organisations. It will also require sustained advocacy from campaigners and the media.
The programmes that are provided need to ensure that they are reaching as many women as possible. As this article has shown, this means addressing not just practical issues, but also social, cultural and personal factors. People's attitudes towards HIV are central to the success or failure of PMTCT.
UNAIDS Executive Director Michel Sidibé, during a visit to a Millennium Villages Projects (MVP) in Kenya, emphasised that reducing mother-to-child transmission is an achievable goal.
"We have seen that it is possible to virtually eliminate infant HIV infections in high-income countries through HIV testing of pregnant women, contraception, and the use of antiretroviral drugs during and after delivery...Now we must apply the knowledge and tools to create an AIDS-free generation in Africa and the rest of the world." 62
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