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Prevention of Mother-to-Child Transmission (PMTCT) of HIV
The mother-to-child transmission (MTCT) of HIV refers to the transmission of HIV from an HIV-positive woman to her child during pregnancy, labour, delivery or breastfeeding. MTCT is by far the most common way that children become infected with HIV (90 percent). 1
Without treatment, the likelihood of HIV passing from mother-to-child is 15-45 percent. However, antiretroviral treatment (ART) and other effective interventions for the prevention of mother-to-child transmission (PMTCT) can reduce this risk to below 5 percent. 2
A comprehensive approach to PMTCT
Effective PMTCT programmes require women and their infants to receive a cascade of interventions including uptake of antenatal services and HIV testing during pregnancy, use of antiretroviral treatment (ART) by pregnant women living with HIV, safe childbirth practices and appropriate infant feeding, uptake of infant HIV testing and other post-natal healthcare services. 3
The World Health Organisation (WHO) promotes a comprehensive approach to PMTCT programmes which includes:
- Prevention of new HIV infections among women of childbearing age
- Preventing unintended pregnancies among women living with HIV
- Preventing HIV transmission from a woman living with HIV to her baby
- Providing appropriate treatment, care and support to mothers living with HIV and their children and families 4
Global PMTCT targets
In 2011, a Global Plan was launched to reduce the number of new HIV infections via MTCT by 90 percent by 2015. 6
WHO identified 22 priority countries, with the top 10 (Angola, Botswana, Burundi, Cameroon, Chad, Côte d’Ivoire, Democratic Republic of the Congo, Ethiopia, Ghana and India) accounting for 75 percent of the global PMTCT service need. It was estimated that the effective scaling up of PMTCT interventions in these countries would prevent over 250,000 new infections annually. 7
Progress in the prevention of mother-to-child transmission
Progress among pregnant women
In 2012, over 900,000 pregnant women living with HIV globally accessed PMTCT services - a coverage of 62 percent. Four priority countries ( Botswana, Ghana, Namibia and Zambia), had achieved 90 percent PMTCT coverage. 8
In the same year, 58 percent of pregnant women living with HIV received ART for their own health, compared with 64 percent of all adults. In many countries, less than half of HIV-positive pregnant women with a CD4 count under 350 (the threshold for ART initiation under the 2010 WHO treatment guidelines), received ART for their own health. Indeed, HIV prevention for pregnant women varies greatly between regions with over 90 percent accessing these services in Eastern and Central Europe and the Caribbean compared to less than 20 percent in Asia and the Middle East and North Africa (MENA). 9
However, the global gap in ART provision between pregnant women and all adults is closing. 10
Progress among children
Between 2001 and 2012, new HIV infections among children fell by 52 percent. However, in 2012, there were still an estimated 260,000 new HIV infections among this group. 11
Moreover, there is an even bigger gap in ART provision for children living with HIV. In 2012, only 34 percent of under 15s living with HIV received ART - nearly half adult ART coverage. In priority countries, only 30 percent of children received HIV treatment. Low ART coverage among children is due mainly to shortfalls in early infant diagnosis (EID) with three priority countries reporting EID coverage of less than 5 percent. 12
PMTCT programmes need to be expanded significantly in order to meet the target of reducing new HIV infections among children by 90 percent by 2015. 13
Factors determining the effectiveness of PMTCT programmes
As well as the scale-up of PMTCT, a number of barriers need to be overcome in order to increase access to PMTCT services.
Knowledge about HIV, MTCT and PMTCT
A number of studies have identified the link between knowledge of HIV, MTCT and PMTCT and uptake of PMTCT services.
For example, research from Togo reported a 92 percent HIV testing uptake among participants where:
- 77 percent of pregnant women agreed that unprotected sex increased the risk of HIV transmission to their child
- 61 percent recognised that the risk of HIV transmission to their child was higher for mixed breastfeeding than for exclusive breastfeeding. 14
Another study of over 500 pregnant and postnatal women in Botswana found that 95 percent of participants believed that pregnant women should be tested for HIV. All participants had high PMTCT knowledge. 15
Conversely, other studies have associated high levels of HIV, MTCT and PMTCT knowledge with lower acceptability of PMTCT.
For example, one study from south-west Nigeria recorded that while 99.8 percent of pregnant women were aware of HIV, had very high knowledge of MTCT (92 percent) and PMTCT (91 percent) - 71 percent had negative views towards the PMTCT of HIV. This was due to other factors such as stigma and discrimination faced by HIV-positive pregnant women. 16
Knowledge of HIV status
Not knowing HIV status acts as a barrier to PMTCT services. For example, a South African study found that voluntary HIV testing and counselling (VCT) was widely accepted among women already attending antenatal clinics (95 percent), and low among those who were not (37 percent). 18
A mother's knowledge of her infant's HIV status has also been found to determine whether infants are tested for HIV in PMTCT programmes. Indeed, one study from South Africa found that higher levels of PMTCT knowledge among mothers, infant treatment adherence and exclusive breastfeeding was associated with greater early infant diagnosis. 19
HIV stigma and discrimination & PMTCT
A body of research has highlighted how HIV-related stigma and discrimination affect a pregnant woman's decision to enrol in PMTCT programmes and interrupt adherence to treatment and retention in care. 20 It has been estimated that over 50 percent of vertical HIV transmissions from mother-to-child globally, can be attributed to the cumulative effect of stigma when accessing PMTCT services. 21
One study has identified a range of HIV-related stigmas experienced by pregnant women: 22
- Enacted stigma
In some countries, pregnant women who disclose their HIV status may be physically or verbally abused or socially marginalised. For example, one study on the provision of HIV testing and counselling across Burkina Faso, Kenya, Malawi and Uganda found that 25 percent women reported being made to feel bad because of their HIV status. Other women who disclosed their status experienced rejection or were divorced by their partners. 23
- Anticipated stigma
Pregnant women may not seek PMTCT services because they fear stigma if they are found to be HIV-positive following an HIV test. A focus group participant in Soweto, South Africa reported:
"I didn’t book at an antenatal clinic because I was afraid that they would test me for HIV, so I avoided it as I told myself that I might be found to have this disease." 24
- Perceived community stigma
Pregnant women living with HIV may avoid PMTCT and ART for their own health if they believe that other HIV-positive pregnant women experience stigma and discrimination when using PMTCT services. Women on a PMTCT programme in Malawi reported:
"involuntary HIV disclosure and negative community reactions, unequal gender relations, difficulties accessing care and treatment, and lack of support from husbands." 25
Some pregnant women living with HIV internalise negative perceptions about people living with HIV and therefore are less likely to enrol in PMTCT and often suffer from mental health issues. Research on HIV-positive women in Karnataka, India said:
"...self-stigma was in many cases derived from moral judgment of one’s self for not fulfilling traditional gender roles of wife and mother." 26
Stigma in healthcare settings
Some healthcare workers are hesitant about handling the delivery of babies born to HIV-positive mothers for fear of HIV infection. A study from Ethiopia reported that:
"many health workers don’t have the necessary skill and equipment to confidently handle delivery for an HIV positive woman and given the risk of accidental exposure, most nurses shy away from dealing with such patients." 27
In more serious cases, women report direct abuse from healthcare workers. An HIV-positive woman from Mexico reported an interaction with her doctor:
"How can you even think about getting pregnant knowing that you will kill your child because you’re positive?!!!’ He threatened not to see me again if I got pregnant. He told me that I was ‘irresponsible,’ a bad mother, and that I was certainly running around infecting other people." 28
One study has estimated that highly effective stigma reduction programmes leading to greater PMTCT access could reduce new HIV infections among infants by up to 33 percent. 29
Cultural beliefs, gender dynamics and PMTCT
In many settings, traditional gender roles and cultural beliefs mean that men often make decisions determining women's participation in HIV testing. 30 One study reported that in some countries, 75 percent of women said that their husbands alone make health decisions for their families. 31
Men also report negative attitudes from community members when escorting their spouses to antenatal clinics. One report from Uganda stated:
"Because of cultural beliefs, most men do not like to accompany their wives to the antenatal clinics. Men who accompany their wives to ANC are perceived to be weaklings by their peers" 32
Male involvement in PMTCT
One study of 15 countries in sub-Saharan Africa identified male partners as either supportive or non-supportive. Supportive male partners were willing to get an HIV test and communicate with their partner about sexual and reproductive health issues increasing the commitment of pregnant women to PMTCT programmes. 33 By comparison, non-supportive males did not discuss reproductive issues openly with their partners, with many women reporting violence, abandonment or fear of abandonment. 34 Many studies have reported shock, disbelief, violence and discrimination among male partners of pregnant women who disclose their HIV status. 35 36
Generally, research has highlighted the beneficial impact of male involvement in programmes to prevent the mother-to-child transmission of HIV to tackle new infections among infants. 37 In Kenya, male involvement in PMTCT has been found to reduce the vertical transmission of HIV from pregnant women to their infants by 40 percent. 38
Inviting men to use voluntary HIV testing and counselling services, offering PMTCT services at sites other than antenatal care ones (such as bars, churches and workplaces), as well as prior knowledge of HIV and HIV testing facilities have all been identified as ways of increasing male PMTCT involvement. 39
Confusion over exclusive breastfeeding
WHO guidelines give different advice to mothers in resource-rich and resource-poor countries leading to confusion among mothers who choose to breastfeed their babies rather than replacement feed.
For example, one study from Malawi reported that while the majority of mothers chose to exclusively breastfeed because "that's the advice they give to HIV-positive women", most mothers reported mixed feeding in the first 6 months. A number of reasons were given for this including traditional feeding practices, a poor understanding of what exclusive breastfeeding involves, as well as poor communication about why women should exclusively breastfeed. 40
By contrast, research from Tanzania compared two hospitals that offered different infant feeding options. Hospital A promoted exclusive breastfeeding as the only infant feeding option, while hospital B followed Tanzanian PMTCT infant feeding guidelines which promote patient choice. Women in hospital A trusted the advice given and were confident in their ability to exclusively breastfeed, whereas women in hospital B expressed confusion and uncertainty about how to best feed their infants. 41
Country and clinic resources
In resource-poor settings, shortages of PMTCT staff, interruptions in treatment and supplies of medical equipment, as well as a shortfall in counselling services, all act as barriers to PMTCT services. These factors often mean long waiting times for post-test counselling and many leave without getting their HIV test results. 42 43 One study from Kenya reported that 92 percent of respondents lacked privacy in their counselling rooms. 44
Poor monitoring of PMTCT services by healthcare workers also leads to poor retention in care. One study from Ethiopia reported poor follow-up rates in the PMTCT programme because healthcare facilities did not have registered information on HIV-positive mothers. 45
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- 5. WHO (2013) ' Consolidated guidelines on the use of antiretroviral drugs'
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31. WHO (2009) '
Integrating Gender into HIV/AIDS Programmes in the Health Sector'[/fn]
In many communities in sub-Saharan Africa, pregnancy is viewed as a "woman's affair", with a man's role primarily to provide financial support. Even where men view accompanying their partner to antenatal clinics (ANC) or PMTCT services as good practice, many still feel their main role is to provide financing for ANC registration and delivery fees.
Nkuoh, G.N. et al (2010) ' Barriers to men's participation in antenatal and prevention of mother-to-child HIV transmission care in Cameroon, Africa' Journal of Midwifery and Womens Health 55(4):363-369
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- 33. Auvinen, J. et al (2010) ' Male participation and prevention of human immunodeficiency virus (HIV) mother-to-child transmission in Africa' Psychology, Health & Medicine 15(3):288-313
- 34. Auvinen, J. et al (2010) ' Male participation and prevention of human immunodeficiency virus (HIV) mother-to-child transmission in Africa' Psychology, Health & Medicine 15(3):288-313
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- 38. IRIN Africa (16 January, 2012) ' KENYA: The downside of male involvement in PMTCT'
- 39. Morfaw, F. et al (2013) ' Male involvement in prevention programs of mother to child transmission of HIV: a systematic review to identify barriers and facilitators' Systematic Reviews 2(5)
- 40. Levy, J. et al (2010) ' "On our own, we can't manage": experiences with infant feeding recommendations among Malawian mothers living with HIV' International Breastfeeding Journal 5:15
- 41. Vaga, B.B. et al (2014) ' Reflections on informed choice in resource-poor settings: the case of infant feeding counselling in PMTCT programmes in Tanzania' Social Science & Medicine 105:22-29
- 42. Mutel, T. et al (2011) ' The prevention of mother-to-child transmission of HIV in Mali: HIV-positive pregnant women and loss to follow-up in the Segou region' 6th IAS Conference on HIV Pathogenesis and Treatment Abstract no. MOPE480
- 43. Nuwagaba-Biribonwoha, H. (2007) ' Challenges faced by health workers in implementing the prevention of mother-to-child HIV transmission (PMTCT) programme in Uganda' Journal of Public Health 29(3):269-274
- 44. Kalembo, F.W. and Zgambo, M. (2012) ' Loss to Followup: A Major Challenge to Successful Implementation of Prevention of Mother-to-Child Transmission of HIV-1 Programs in Sub-Saharan Africa' ISRN AIDS Article ID 589817
- 45. Merdekios, B. and Adedimeji, A.A. (2011) ' Effectiveness of interventions to prevent mother-to-child transmission of HIV in Southern Ethiopia' International Journal of Women's Health 3:359-366
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