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HIV Prevention Knowledge Base

A Collection of Research and Tools to Help You Find What Works in Prevention

Biomedical Interventions: Prevention of Mother-to-Child Transmission of HIV (PMTCT)

I. Definition of the Prevention Area

Prevention of mother-to-child transmission (PMTCT; also known as prevention of vertical transmission) refers to interventions to prevent transmission of HIV from a mother living with HIV to her infant during pregnancy, labor and delivery, or during breastfeeding.

II. Epidemiological Justification for the Prevention Area

Approximately one-third of children born to mothers living with HIV will acquire HIV infection in the absence of preventive measures. Although only 14 percent of children who breastfeed up to 2 years will acquire the infection during breastfeeding, they account for 40 to 64 percent of children infected with the virus. The risk of transmission is particularly high if the mother herself acquires her HIV infection during pregnancy or breastfeeding because viral load tends to be highest during the early stages of infection. Mixed infant feeding in the first six months is also associated with an increased rate of mother-to-child transmission (MTCT).
Under ideal conditions, comprehensive prevention programs can reduce MTCT rates to about 1 to 2 percent. Antiretroviral therapy (ART) given to medically eligible women living with HIV during pregnancy reduces transmission by at least 75 percent. Ensuring that treatment eligible women receive treatment is critical not only to prevent MTCT but to protect women’s own health and survival.

UNAIDS estimates that in 2008, 2.1 million children under 15 years of age were living with HIV; 430,000 were newly infected; and 280,000 died from AIDS-related causes. MTCT still accounts for a substantial, although decreasing, portion of new HIV infections in many African countries. Optimal PMTCT coverage has not yet been achieved. United Nations agencies report that in 2008, in low- and middle-income countries:

•    Twenty-one percent of pregnant women were tested for HIV
•    Forty-five percent of pregnant women living with HIV received antiretroviral drug (ARV) regimens or ART
•    Thirty-two percent of infants born to mothers living with HIV received ARV prophylaxis at birth.

III. Core Programmatic Components

The World Health Organization (WHO) recommends a four-pronged approach to a comprehensive PMTCT strategy:

1. Primary prevention of HIV infection among women of childbearing age
2. Preventing unintended pregnancies among women living with HIV
3. Preventing HIV transmission from women living with HIV to their infants
4. Providing appropriate treatment, care, and support to mothers living with HIV and their children and families.

This resource describes the third strategy: PMTCT. Preventive interventions consist of a cascade of services, including HIV testing and counseling; ARV prophylaxis or ART; safe delivery; safer infant feeding and postpartum interventions such as cotrimoxazole prophylaxis; early infant diagnosis for HIV-exposed infants; and links to treatment and care, as well as standard postpartum child survival interventions. To achieve maximum impact of PMTCT, acceptable levels of coverage, access, utilization, and in some cases, adherence must be attained across the entire continuum of care.

The 2010 WHO recommendations for PMTCT are based on recent program experience and scientific findings. Highlights include lowering the eligibility threshold for ART for pregnant women to 350; immediate initiation of ART (regardless of gestational age) for treatment eligible women; and provision of ARVs to non-treatment eligible women and/or their infants in the postnatal period to prevent breastfeeding transmission. It is now recommended that mothers known to be HIV-infected (and whose infants are not infected or whose status is unknown) exclusively breastfeed their infants for the first six months of life, introducing appropriate complementary foods thereafter, and continue breastfeeding until the infant is at least a year old.

IV. Current Status of Implementation Experience

Eastern and Southern Africa, the most affected regions, have made progress in PMTCT. In 2008, 21 percent of pregnant women in low- and middle-income countries were tested for HIV. However, in South Africa 78 percent of pregnant women were tested and in Namibia, 90 percent of pregnant women were tested. Among pregnant women living with HIV, 45 percent received ARV or ART and 40 percent of HIV-exposed infants received ARV prophylaxis.

National guidelines and policies warrant revision in order to effectively implement the 2010 WHO PMTCT recommendations. This would include the scale-up of CD4 testing for pregnant women infected with HIV; the revision of training curricula; the retraining of health workers; the improvement of follow-up of mother/baby pairs; and the enhancement of access to ARVs.

Eliminating pediatric HIV/AIDS is now regarded as achievable, and PMTCT is considered an essential part of maternal, newborn, and child health care. PMTCT programs not only reduce transmission of HIV, but if well implemented as part of a full continuum of care, they can result in HIV-free survival, meaning that infants are protected from other causes of death as well.