SCA L I NG UP PR EVENT I ON OF M OT HER-TO-CHI L D T R AN SMI SSI O N O F H I V
Scaling up prevention
of mother-to-child
transmission of HIV
SUMMARY DOCUMENT
This paper should be read with the
detailed research report, Scaling
up prevention of mother-to-child
transmission of HIV, available on
www.tearfund.org
Why is action necessary to
scale-up prevention of mother-tochild transmission of HIV (PMTCT)?
Photo: Layton Thompson / Tearfund
In 2007, 420,000 children were infected with
HIV. Mother-to-child transmission (MTCT) occurs
during pregnancy, delivery or breastfeeding and
is responsible for 90 per cent of paediatric HIV
infection. Of the 2.5 million children living with
HIV, 90 per cent are in sub-Saharan Africa.
However, simple interventions can significantly reduce the risk of
transmission. These are:
■
giving antiretroviral drugs (ARVs) to mothers who are HIV positive
during pregnancy and labour;
■
giving ARVs to mothers and their babies after delivery, and
■
exclusive breastfeeding for six months unless replacement feeding
is acceptable, feasible, affordable, sustainable and safe.
The risk of MTCT can be further reduced by taking a comprehensive
approach to PMTCT, including the engagement of the male partner.
The comprehensive approach includes preventing HIV infection
in women, unintended pregnancy in women living with HIV and
providing follow-up treatment, care and support for women who are
positive, their children and families, in addition to interventions to
prevent transmission during pregnancy, delivery and breastfeeding.
Antiretroviral treatment (ART) for pregnant women living with
advanced HIV can also reduce the risk of MTCT, as well as improve
the health of these women and, hence, of their children.
What has been achieved so far?
Global commitments have highlighted the importance of PMTCT.
The 2001 United Nations General Assembly Special Sessions on
HIV/AIDS (UNGASS) Declaration committed countries to reduce the
proportion of infants infected with HIV by 50 per cent by 2010, by
ensuring that 80 per cent of pregnant women have access to PMTCT
services, including ARVs. This was reinforced by the Call to Action for
the Elimination of HIV infection in Infants and Children, issued by the
Inter-Agency Task Team (IATT) on PMTCT and paediatric HIV High
Level Partners Forum in Abuja, Nigeria in 2005, and the subsequent
PMTCT_summary_08 D2.indd 1
commitment by countries to universal access to HIV prevention,
treatment and care.
The IATT, which brings together UN agencies, donors and
implementing organisations, leads global efforts to reduce HIV
infection in children. These efforts include advocacy with policy
makers, resource mobilisation and support for countries to establish
and scale up PMTCT programmes.
There has been considerable progress. Over 100 low- and middleincome countries have national PMTCT policies and strategies and 52
have a national PMTCT scale-up plan with population-based targets.
All countries in East and Southern Africa and 80 per cent of countries
in West and Central Africa and the Caribbean have set PMTCT
targets. In 2006, Botswana, Namibia, South Africa and Swaziland
were among 17 low- and middle-income countries on track to meet
the 80 per cent coverage target for ARV prophylaxis by 2010.
Globally, between 2005 and 2006, the proportion of pregnant
women tested for HIV increased from 10 per cent to 16 per cent,
and the proportion of pregnant women living with HIV who received
ARVs for PMTCT increased from 11 per cent to 20 per cent. East
and Southern Africa made the most progress, with 31 per cent of
pregnant women living with HIV receiving ARVs for PMTCT in 2006.
Between 2005 and 2006, the proportion of infants born to mothers
living with HIV who were given ARV prophylaxis increased from 10
per cent to 15 per cent, and the number of children living with HIV
receiving ART increased from 71,892 to 127,087, a quarter of the
estimated number in need.
25/6/08 10:36:53 am
S C AL I N G UP P R EV ENTION OF MOTHER-TO- C HILD TRANSM I SSI ON OF HI V
Despite these achievements, there is a long way to go if UNGASS
targets are to be met. While countries such as Botswana, Kenya,
Rwanda, South Africa and Zambia have made significant progress,
others are lagging behind. More must be done to reach the millions
of women and children who do not have access to PMTCT and
paediatric treatment services.
What factors have contributed
to progress?
Countries that have made good progress share a number of
characteristics. Strong political leadership and commitment from
national governments, the development and implementation of
national scale-up plans with population-based targets and the
establishment of effective national management and co-ordination
mechanisms are critical to success.
In Botswana, successful scale-up is attributed to political
support. Zambia, which has made rapid progress, has a strategic
framework with a clear plan for achieving 100 per cent coverage
with PMTCT services over two years. Malawi has established
a co-ordination mechanism led by the Ministry of Health,
incorporated PMTCT into Integrated Management of Childhood
Illness guidelines and developed one reporting system with a
single register for antenatal care (ANC) and PMTCT data.
Factors that can contribute to successful scale-up include:
■
integrating PMTCT services into maternal and child health
(MCH) services
■
decentralised approaches – where regional, provincial or district
health teams plan, implement and monitor PMTCT services
■
action to strengthen health systems – in particular, the role of
MCH services.
To provide services in the face of shortages of health workers, some
countries have used approaches such as task shifting, where lower
level cadres of health workers carry out tasks usually assigned to
nurses or doctors.
In Botswana, PMTCT services are provided by all public sector
MCH and family planning (FP) clinics, which serve almost
100 per cent of pregnant women. In Kenya, PMTCT is a key
component of safe motherhood and integrated with ANC and
other MCH services. Efforts to improve basic ANC services
alongside introducing PMTCT have increased the number of new
ANC clients, acceptance of HIV counselling and testing (CT) and
uptake of ARV prophylaxis. The PMTCT working group in Zambia
requires PMTCT donors to support all elements of ANC.
Adoption of new approaches and technologies, in particular providerinitiated testing and rapid HIV tests, has increased the number of
pregnant women finding out their HIV status, an essential step in
accessing PMTCT interventions. In 2006, 82 countries had introduced
provider-initiated testing, compared to 55 countries in 2005.
PMTCT_summary_08 D2.indd 2
Introduction of dried blood spot (DBS) technology for early diagnosis
of HIV is helping to identify infants who need HIV treatment and care.
Botswana introduced provider-initiated HIV testing in 2004
and within three months the proportion of women tested for
HIV increased from 75 per cent to 90 per cent. Zambia doubled
the number of pregnant women tested in a year by introducing
provider-initiated testing.
Efforts to improve the availability of PMTCT services must be
matched by efforts to increase uptake of MCH services, especially
antenatal and delivery care, and of PMTCT interventions. Increased
access to ART, including for eligible pregnant women, has helped to
reduce HIV-related stigma, a significant barrier to uptake of PMTCT
services.
Countries that have achieved successful scale-up of PMTCT also
attribute progress to the involvement of male partners, for example
through couple CT and the involvement of communities and people
living with HIV in raising awareness, promoting HIV CT and PMTCT,
reducing stigma and linking communities and health facilities.
Efforts in Malawi to encourage couple counselling are reported
to have increased uptake of HIV CT and PMTCT services and the
proportion of women who return for results of their HIV test and
CD4 cell counts. It has reduced stigma and improved dialogue
between men and women, so women are less afraid of disclosing
their status. The fact that HIV testing and ARVs are more widely
available and are free of charge is also reported to be a major
reason for increased uptake of HIV services including PMTCT.
What are the challenges and
obstacles to scale-up?
Some countries have been slow to revise national policy to reflect
global guidance on PMTCT and paediatric treatment and care, in
particular recent guidance that recommends use of a combination of
drugs for ARV prophylaxis in pregnant women.
Policies are not always disseminated well. Health workers at clinic
facilities are often unaware of existing policies and guidelines
and unclear about what advice to give mothers living with HIV
about infant feeding. Failure to promote exclusive breastfeeding,
unless in circumstances where replacement feeding is acceptable,
feasible, affordable, sustainable and safe is putting infants at
increased risk of HIV and of other infections as a result of mixed
feeding or early cessation of breastfeeding. There is often a lack of
standard operational guidelines to support the implementation of
comprehensive PMTCT and ensure that services are integrated.
Weak health systems are a significant challenge, in particular
shortages of key cadres of health workers, inadequate equipment
and poor procurement and supply management, are significant
challenges. Scale-up is difficult when health services lack staff who
can provide HIV CT, administer ARVs and advise women about family
25/6/08 10:37:12 am
In Zambia, constraints to PMTCT scale-up include shortages
of medical staff, in particular staff to provide quality CT, and
inadequate infrastructure in rural areas. There is also a need
for regular in-service training at district level because of rapid
staff turnover and to ensure more accurate and integrated data
collection. In Rwanda, less than a third of PMTCT sites can
provide ARV prophylaxis because of a shortage of trained staff,
CD4 machines and other laboratory equipment. PMTCT and
follow-up services are adversely affected by weak logistics in
Malawi. There is a lack of reporting on availability of HIV test
kits, nevirapine (NVP) tablets and syrup and septrin.
Women living with HIV can only be reached with PMTCT
interventions if they come into contact with health services during
pregnancy and labour. Low uptake of ANC and delivery care, due to
financial, geographical and socio-cultural barriers, is a challenge to
PMTCT scale-up.
In many countries, MCH and HIV services, including PMTCT services,
operate in parallel and links between these services are weak. Vertical
programmes are an obstacle to comprehensive PMTCT, as they
require women to go to several facilities to obtain the range of health
services and they may be lost in the system.
In Zambia, over 92 per cent of women attend ANC at least once
but 60 per cent deliver at home and post-natal care services
are limited. In Uganda, 92 per cent of pregnant women make at
least one visit to an ANC facility but only 40 per cent make four
or more visits. In Malawi, links between MCH, including ANC,
and ART services are weak. While MCH facilities offer HIV CT,
they refer women for ARV prophylaxis and ART, resulting in high
drop-out rates.
Photo: Marcus Perkins / Tearfund
planning or infant feeding, or lack basic commodities such as HIV test
kits or contraceptives.
Follow-up treatment and care for mothers and children is still limited
in many countries. Available data indicates that only seven per cent
of women living with HIV and receiving ARV prophylaxis for PMTCT
in 2006 were assessed for treatment eligibility. Limited follow-up is
due in part to weak referral systems and, for children specifically, to
low availability of technology for early infant diagnosis and lack of
systems to identify and track exposed and infected children.
Pregnant women may be deterred from finding out their HIV status
and accessing PMTCT services in contexts where HIV is highly
stigmatised and male involvement is limited. Women who are tested
for HIV may decide not to come back for the test result or not to
disclose their HIV-positive status if they are fearful of being blamed
for bringing HIV into the family, and of consequences, which may
include divorce or domestic violence.
Inadequate data and weak Monitoring and Evaluation (M&E) systems
are a significant challenge to scale-up. The number of countries
reporting data on PMTCT increased from 71 in 2005 to 108 in 2006.
But data is only collected on coverage, specifically the number of
women receiving CT and receiving ARV prophylaxis. As yet, few
countries systematically collect information on how many pregnant
women are assessed for ART eligibility or on early infant diagnosis.
Indicators to monitor access to primary prevention and FP services in
the context of PMTCT are not included in many PMTCT programmes.
Data on infant feeding choices and the quality of follow-up
treatment, care and support for women and infants is not available
from many of the countries surveyed.
What needs to be done?
To achieve scale-up of MTCT, specific steps needs to be taken at both an international and national level in the following areas: increasing
commitment and leadership; strengthening information gathering, guidance and M&E; improving availability, quality and uptake of PMTCT services.
Increase commitment and leadership
Action at international level by:
Action at national level by:
Ensure that national policy makers give higher priority to the scale-up of PMTCT, in particular to
establish national scale-up plans and targets and effective national co-ordination mechanisms
• UN agencies, e.g. UNICEF, WHO,
UNAIDS
• Donors
• UN agencies
• Governments
• NGOs
Broaden the range of organisations involved in advocacy and support for comprehensive PMTCT
• UN agencies
• NGOs
• UN agencies
• NGOs
Improve tracking of progress, such as reporting on PMTCT and paediatric treatment in
UNAIDS Global Epidemic Update
• UN agencies, e.g. UNAIDS
• Governments
Strengthen government and donor accountability for commitments
• Donors
• NGOs
• Governments
• NGOs
Ensure initiatives to strengthen health systems are used as an opportunity to address
requirements for scale-up of PMTCT and paediatric care
• Donors
• UN agencies
• NGOs
• Governments
• NGOs
PMTCT_summary_08 D2.indd 3
25/6/08 10:37:17 am
S C AL I N G UP P R EV ENTION OF MOTHER-TO- C HILD TRANSM I SSI ON OF HI V
Strengthen information gathering, guidance and M&E
Action at international level by:
Establish an accessible central source of all relevant information about PMTCT and paediatric
treatment and care
• IATT and UN agencies, specifically
UNICEF and WHO
Clarify guidance and recommendations on infant feeding including weaning
• IATT and UN agencies, specifically
UNICEF and WHO
Encourage national policy makers to revise guidance so that it is in line with the latest global
recommendations
• IATT and UN agencies, specifically
UNICEF and WHO
Improve national dissemination and adoption of guidance, such as through pre-service and
in-service training, and through NGOs
Action at national level by:
• Governments
• Governments
Develop operational guidelines to support implementation of integrated service delivery and
of comprehensive PMTCT. These should include issues such as how to diagnose paediatric HIV,
how to provide follow-up treatment and care to mothers, infants and families, how to involve
male partners, and how to link communities and facilities
• IATT and UN agencies, specifically
UNICEF and WHO
Learn and share lessons from countries that have achieved successful scale-up, including
about effective approaches on how to integrate PMTCT into MCH services
• IATT and UN agencies, specifically
UNICEF and WHO
• Implementing agencies
• NGOs
Build the capacity of national M&E systems to capture comprehensive data on PMTCT
coverage, including data on women accessing PMTCT services through the private sector and
vertical programmes, data on how many pregnant women are assessed for ART eligibility and
the proportion of people receiving ART who are pregnant women, and data on infant feeding
and the quality of follow-up treatment, care and support for women and infants
• Donors
• UN agencies
• Governments
Improve availability and quality of PMTCT services
Action at international level by:
Action at national level by:
Accelerate integration of PMTCT into MCH services and provision of comprehensive family
care that includes antenatal, delivery, postnatal, family planning, child health and HIV care in
settings with high HIV prevalence
• Implementing agencies
• NGOs
• Governments
• NGOs
Strengthen human resource planning, and develop and implement innovative solutions to
shortages of human resources for health
• Donors
• UN agencies
• Governments
Increase efforts to improve procurement and supply management to ensure adequate
supplies and equipment, in particular HIV test kits, contraceptives, cotrimoxazole and other
essential drugs
• Donors
• UN agencies
• Implementing agencies
• Governments
Encourage and support countries to switch from single dose nevirapine (sdNVP) to more
efficacious combination regimens for ARV prophylaxis as rapidly as possible
• IATT and UN agencies, specifically
UNICEF and WHO
• Governments
Expand access to ART for eligible pregnant women living with HIV, by ensuring that MCH
services have the capacity to provide HIV CT, assess CD4 count or HIV clinical stage and offer
ART or referral to nearby facilities providing ART
•
•
•
•
• Governments
• NGOs
Promote clear policies and messages about infant feeding, including intensified efforts to train
health providers to provide appropriate infant feeding counselling
• IATT and UN agencies, specifically
UNICEF and WHO
• Implementing agencies
• NGOs
• Governments
• NGOs
Develop and implement strategies to increase provision of comprehensive, quality PMTCT
by the private sector and NGOs, including ensuring that these providers receive guidance
and training
• UN agencies
• Governments
Improve uptake of PMTCT services
Action at international level by:
Action at national level by:
Encourage countries that have yet to do so to implement provider-initiated testing and
couple counselling
• UN agencies
• Implementing agencies
• NGOs
• Governments
• NGOs
Develop and implement strategies to increase uptake of ANC and delivery care and to provide
PMTCT services for women who do not attend ANC or deliver at home
• UN agencies
• Implementing agencies
• NGOs
• Governments
• NGOs
Develop and implement strategies to increase involvement of male partners and communities
• UN agencies
• Implementing agencies
• NGOs
• Governments
• NGOs
Use innovative approaches to increase access to PMTCT within MCH services for marginalised
populations in settings with concentrated epidemics
• Implementing agencies
• NGOs
• Governments
• NGOs
Tackle gender inequalities that prevent women from accessing PMTCT and other services.
Establish and enforce policy and legal frameworks that protect the rights of women living
with HIV
• UN agencies
• NGOs
• Governments
• NGOs
Donors
UN agencies
Implementing agencies
NGOs
© Tearfund July 2008
Tearfund is a Christian relief and
development agency building a
global network of local churches
to help eradicate poverty.
www.tearfund.org
100 Church Road, Teddington, TW11 8QE, UK
Tel: +44 (0)20 8977 9144
Published by Tearfund.
A company limited by guarantee.
Registered in English No. 994339.
Registered Charity No. 265464.
18786a–(0608)
PMTCT_summary_08 D2.indd 4
25/6/08 10:37:27 am