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, childbirth or breastfeeding. MTCT is by far the most common way that children become infected with HIV (90%).1
Without treatment, the likelihood of HIV passing from mother-to-child is 15 to 45%. However, antiretroviral treatment (ART) and other effective interventions for the prevention of mother-to-child transmission (PMTCT) can reduce this risk to below 5%.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:
- preventing 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
World Health Organisation PMTCT guidelines
In September 2015, the WHO released new guidelines recommending lifelong antiretroviral treatment (ART) for all pregnant and breastfeeding women living with HIV.5
Guidelines for pregnant and breastfeeding women living with HIV
The 2015 guidelines recommend Option B+ where lifelong ART is provided to all pregnant and breastfeeding women living with HIV regardless of CD4 count or WHO clinical stage. ART should be maintained after delivery and completion of breastfeeding for life.
Previously, the 2013 guidelines included another choice called Option B, where treatment was only continued after the completion of breastfeeding if the mother was eligible for ART for her own health. The 2015 guidelines no longer recommend this option.
Guidelines for HIV-exposed infants
All infants born to HIV-positive mothers should receive a course of treatment as soon as possible after birth. The treatment should be linked to the ARV drug regimen that the mother is taking and the infant feeding method.
- Breastfeeding - the infant should receive once-daily nevirapine (NVP) from birth for six weeks.
- Replacement feeding - the infant should receive once-daily NVP (or twice-daily zidovudine (AZT)) from birth for four to six weeks.
At four to six weeks old, all infants who are born to HIV-positive mothers should be given an early infant diagnosis. Another HIV test should be done at 18 months and/or when breastfeeding ends to provide the final infant diagnosis.5
Global PMTCT targets
In 2011, a Global Plan was launched to reduce the number of new HIV infections via MTCT by 90% 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% 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
The proportion of pregnant women living with HIV receiving ART more than doubled in 21 of the 22 Global Plan priority countries from 37% in 2009, to 77% in 2014. In 2014, seven priority countries (Botswana, Mozambique, Namibia, South Africa, Swaziland, Uganda and Tanzania) met the Global Plan target that at least 90% of pregnant women living with HIV receive ART.8 India does not feature in the latest data.
Many point to the implementation of Option B+ as a major reason behind PMTCT coverage progress. During 2014, many countries phased out approaches for preventing new HIV infections among children that were no longer recommended by the WHO (such as Option A), instead rapidly expanding access to Option B+. As of 2015, all but three countries (Côte d’Ivoire, Ghana and Nigeria) had rolled out Option B+.8
Of the 77% of pregnant women (946,000) receiving ART in 2014, 86% (812,000) were receiving lifelong ART. This means that 66% of all pregnant women living with HIV, were started on, or were already receiving, lifelong treatment. This shows how successful Option B+ is at enabling pregnant women to get treatment. As a result, treatment coverage for pregnant women is now higher among pregnant women than among all adults.8
However, PMTCT need remains high due to the continuing high number of HIV infections among women. In 2014, 1.2 million women in 21 priority countries required PMTCT services. The Global Plan aimed to reduce the number of new HIV infections by 50%. However, new infections among this group declined by just 15% between 2009 and 2014, from 670,000 to 570,000.8
Progress among children
Between 2009 and 2014, there was a 48% decline in new HIV infections among children in 21 Global Plan priority countries, from 330,000 to 170,000. By comparison, from 2000 to 2008, the number of new HIV infections fell by just 13%. This means that since the launch of the Global Plan, the rate of the decline in new infections nearly quadrupled.8
While this progress is encouraging, it is unlikely that the 90% reduction by 2015 will be met, however, some countries may get close to this target. For example, South Africa has experienced a decline of 76% since 2009, while six other countries (Ethiopia, Mozambique, Namibia, Swaziland, Uganda and Tanzania), have recorded a fall of at least 60%.8
However, other countries still face significant challenges to rolling out effect PMTCT services. This includes Nigeria that has the second largest number of new HIV infections among children. Since 2009, new paediatric HIV infections in the country have declined by only 15%.8
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% HIV testing uptake among participants where:
- 77% of pregnant women agreed that unprotected sex increased the risk of HIV transmission to their child
- 61% recognised that the risk of HIV transmission to their child was higher for mixed breastfeeding than for exclusive breastfeeding.9
Another study of over 500 pregnant and postnatal women in Botswana found that 95% of participants believed that pregnant women should be tested for HIV. All participants had high PMTCT knowledge.10
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% of pregnant women were aware of HIV, had very high knowledge of MTCT (92%) and PMTCT (91%) - 71% 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.11
Knowledge of HIV status
Knowledge of HIV status is vital in order that pregnant women access the appropriate treatment and care for themselves and their unborn infants.12
Not knowing one's 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%), and low among those who were not (37%).13
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.15
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.16
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.17 It has been estimated that over 50% of vertical HIV transmissions from mother-to-child globally, can be attributed to the cumulative effect of stigma when accessing PMTCT services.18
- 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% of 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.20
- 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." 21
- 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." 22
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." 23
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." 24
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." 25
Even though HIV testing is not compulsory, the way that some healthcare workers talk about it can lead women to believe that it is. As a result, many delay or avoid antenatal services, risking their health. In a study from South Africa, a woman from KwaZulu-Natal said:
"Testing was not optional, it was compulsory…If you didn’t test you didn’t have antenatal classes, everyone had to go through the tests." 26
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%.27
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.28 29 One study from Kenya reported that 92% of respondents lacked privacy in their counselling rooms.30
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.31
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.32 One study reported that in some countries, 75% of women said that their husbands alone make health decisions for their families.33
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.34
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." 35
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.36
By comparison, non-supportive males did not discuss reproductive issues openly with their partners, with many women reporting violence, abandonment or fear of abandonment.36 Many studies have reported shock, disbelief, violence and discrimination among male partners of pregnant women who disclose their HIV status.37 38
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.39 In Kenya, male involvement in PMTCT has been found to reduce the vertical transmission of HIV from pregnant women to their infants by 40%.40
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.41
Photo credit: Photo by World Bank Photo Collection/ CC BY. Photos are used for illustrative purposes. They do not imply any health status or behaviour on the part of the people in the photo.
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