Eliminating Mother-to-Child Transmission of HIV
Over two million HIV-positive women give birth annually, and most of these births occur in areas where access to quality comprehensive health services and HIV medication regimens are limited. It is estimated that over 1,000 children become infected with HIV daily and that 90 percent of new infections in children are due to mother-to-child transmission (MTCT). This tragedy leads to a child dying every two minutes. In the developed world – where HIV-positive women can access comprehensive testing, care, and treatment – the rate of MTCT of HIV is less than two percent. In the developing world, however, an inadequate continuum of care leads to MTCT rates as high as 45 percent.
Beginning in 2008, we deployed our distinct “across the cascade” approach to PMTCT in six countries: Cambodia, Ethiopia, Lesotho, Malawi, Tanzania, and Vietnam. The cascade, outlined below, leverages the points of care with the highest impact in saving lives and provides a framework that our partner governments can use to focus their efforts. CHAI has concentrated on increasing access to and uptake of services along the entire PMTCT cascade, but the critical first step is getting pregnant women to seek antenatal care. From there, the results of our initial efforts demonstrate the efficacy of this approach in ultimately leading to reductions in MTCT rates.
Opt-Out HIV Testing for All Women in Antenatal Care
Antenatal care is good for maternal health regardless of a woman’s HIV status. Previously, many women would refuse HIV testing during antenatal care. CHAI helped roll out an opt-out system where all pregnant women are tested unless they opt not to and combined that with communications strategies explaining the benefits of antenatal HIV testing.
Determining the Right Medication
If a woman tests positive for HIV during antenatal care, it is important to conduct a CD4 test and provide a clinical evaluation to determine if she is ready for treatment or if a shorter course of prophylaxis is sufficient to guard the mother’s health during pregnancy and prevent transmission to the child.
Deliver at a Health Facility
Ensuring that the mother and the infant receive the correct prophylaxis during and immediately after delivery is critically important to prevent transmission. Skilled care at birth is also crucial in preventing maternal and infant mortality. We therefore work to ensure that women deliver at facilities staffed by skilled health workers.
The next step is making sure that infants exposed to HIV receive the proper prophylaxis.
Throughout the cascade, counselors offer guidance to the mother on family planning, prevention of transmission to others, safe infant feeding options to prevent transmission through breastfeeding, and testing of other family members.
Early Infant Diagnosis
The final step in the cascade involves testing infants for HIV once in their first two months of life and again after breastfeeding has stopped using Dried Blood DNA technology and rapid HIV testing. These are systems that we rolled out and strengthened as part of our pediatric HIV/AIDS work.
To help drive participation at weak points in the cascade, CHAI often employs a “fast track” process that convenes key local stakeholders to tailor community-specific, 90 day campaigns to keep women involved in every part of the cascade. The fast track programs in Malawi and Ethiopia, for example, have focused on garnering more male partner and community involvement. Anecdotal evidence suggests they have contributed to dramatically increased uptake of PMTCT services within the communities.
Building on Success
CHAI’s “across the cascade” approach has demonstrated phenomenal results in our six target countries. Now that the evidence is clear that this approach works, we need additional resources to take it to scale across the developing world. The world is now pushing for the elimination of MTCT. To reach this goal, we must provide every mother and child with the comprehensive and integrated services they need to survive and thrive.