Missed opportunities despite availability of safe, effective, and affordable interventions
Over 1.5 million babies are infected by human immunodeficiency virus (HIV), syphilis, and hepatitis B virus (HBV) each year globally. About 80 percent of these infections occur in low- and middle-income countries (LMICs). Pregnant women living with HIV, syphilis, or HBV can pass these infections on to their infants during pregnancy, delivery, or post-partum. This is known as vertical transmission. Without access to preventive measures, infants at risk of these infections can progress to chronic disease and early death.
Safe, effective, and affordable tools exist to prevent transmission of these deadly infections from mothers to babies. Expanding access to prevention measures, including stopping new infections among people of reproductive age, timely screening, treatment, and HBV vaccination, all delivered through a common reproductive, maternal and child health (RMCH) platform can increase the survival of babies significantly. However, implementation of these measures in LMICs differ dramatically across the three diseases, reflects uneven investment levels, and political will.
Converging planning and service delivery across the three infections can save more lives
Shared touchpoints between pregnant mothers and newborns within healthcare systems, as well as the common routes of transmission for HIV, syphilis and HBV present an opportunity to bundle the delivery of lifesaving interventions, enabling a more person-centered care. This approach is known as “triple elimination.” Many governments are establishing triple elimination strategies; however, domestic resource constraints and limited international catalytic support impedes implementation and scale up. Of the countries that have initiated their triple elimination programs, coordination among multiple departments to ensure timely and appropriate interventions are delivered is proving to be challenging, leading to low coverage and poor access.
India and Uganda demonstrate that triple elimination of HIV, syphilis, and HBV is within reach
Countries such as India and Uganda are demonstrating that these challenges are not insurmountable through visionary approaches, resolve, optimal resource utilization, and careful planning.
India has a robust reproductive, maternal, newborn, child health, and adolescent health program, along with established disease-specific programs like the National AIDS Control Program (NACP) and the National Viral Hepatitis Control Program (NVHCP). Despite an annual birth cohort of nearly 25 million, coverage of antenatal services exceeds 95 percent in India, demonstrating the country’s commitment to improving access to quality maternal and child healthcare. In April 2022, India launched the ‘Elimination of vertical transmission of HIV and syphilis’ guidance note to facilitate the integration of elimination efforts for these two diseases. Despite high antenatal care coverage, gaps in screening, testing, and treatment among pregnant women persist, highlighting the need to strengthen coordination across programs.
India is starting to address these gaps by promoting inter-sectoral coordination and convergent service delivery approaches that offer a path for effective integration and improved outcomes in vertical elimination efforts. To achieve triple elimination, several priorities have been identified. These encompass revising guidelines for HBV prevention, incorporating HBV into the HIV and syphilis guidance note, and promoting integrated service delivery.
Further, CHAI is undertaking a service gap assessment in states with high disease burden and initiating a demonstration pilot in the state of West Bengal to converge and strengthen service delivery, with the intent to leverage learnings to enable rapid scale up across the country.
“Elimination of the vertical transmission of HIV, Syphilis and HBV is a unique opportunity that needs to be capitalized to ensure our next generation of young are free of the three infections by 2030 – India has taken on the challenge using its existing infrastructure and investments in health to achieve these elimination goals.”
Dr. Po-Lin Chan, Team Lead – Communicable Diseases, World Health Organisation, India Country Office
Uganda has made remarkable strides in leveraging its achievements in HIV programming to advance comprehensive maternal and newborn health services through expansion of HIV, syphilis, and HBV testing and treatment. These services include combined HIV and syphilis screening with dual kits detecting both infections, and upcoming expansion in HBV screening for all pregnant women during antenatal care, linking eligible pregnant women to treatment, and administering HBV vaccine to infants, including newborns.
Currently, 95 percent of pregnant women receive HIV testing at least once and 86 percent undergo syphilis testing during antenatal care. Moreover, 94 percent and 82 percent of those who tested positive for HIV and syphilis, respectively, receive timely treatment. Despite this progress, women and children are still falling through the cracks in care. At least 5,000 newborns tested positive for HIV in 2022 and an even larger number of stillbirths, defined as loss of a baby after 28 weeks of pregnancy, were caused by syphilis infection. There are also significant service delivery gaps for HBV, with only a fraction of pregnant women screened during antenatal care, fewer linked to confirmatory testing, and less than two percent of those eligible receiving treatment.
Uganda is working to address these gaps by strengthening HBV screening among pregnant women, ensuring they are quickly linked to care, and launching the introduction of a timely HBV birth dose vaccine for newborns. Uganda is also strengthening counseling and follow-up for pregnant women on HIV treatment, increasing retesting during pregnancy and breastfeeding.
To amplify these efforts in Uganda, CHAI is supporting the government to close the resource gap in the delivery of triple elimination services. As part of Uganda’s 2023 grant application to the Global Fund for AIDS, Tuberculosis, and Malaria (GFATM), CHAI advocated for and supported the inclusion of these lifechanging interventions into the funding proposal. Beyond funding advocacy, CHAI partners with Uganda’s Ministry of Health to enhance initiatives in preventing vertical transmission of HIV, syphilis, and HBV.
“A future, where all children are born free from hepatitis B, syphilis, and HIV, is well within our grasp, all it needs is for us to all come together, combine effort and investments, as well as work with and in the communities.”
Dr. Linda Kisaakye, Prevention of Mother-to-child Transmission (PMTCT) Lead, Ministry of Health, Uganda
Product access and innovation is enabling integrated, patient centered care
Advances in technology and improved market accessibility for drugs and diagnostics present an opportunity for countries to rapidly scale and integrate optimal products and services for triple elimination.
Through partnerships with MedAccess and World Health Organization pre-qualified suppliers, CHAI has facilitated access to a competitive market for dual HIV/Syphilis rapid diagnostic tests (RDTs) and HIV self-tests for LMICs. CHAI is supporting countries to introduce and scale up dual RDTs and efforts to address the implementation barriers that hinder syphilis testing and treatment in pregnant women.
CHAI is paving the way for an integrated screening approach for HIV, syphilis, and HBV, including demonstration models in Nigeria, Rwanda, and Ethiopia and advocating for development of a triple combination RDT to simplify service delivery, save testing costs and time, and streamline supply chain barriers. Leveraging experiences from the introduction of the dual RDT, a collaborative effort across key stakeholders can promote an enabling environment for new product introduction of a triple RDT. This includes ensuring policy makers and governments adapt policies for triple elimination, suppliers develop quality-assured and affordable products, governments and donors provide financial commitments for strategic plans, and health programs establish a roadmap for sustainable implementation.
CHAI is also increasing access to treatment for syphilis and hepatitis B. Earlier this year, an agreement with suppliers has led to hepatitis B treatment being offered at a ceiling price of US$2.40, bringing it in line with pricing for HIV programs. As countries increase efforts to eliminate congenital syphilis, a reliable supply of affordable and quality assured benzathine penicillin G (BPG), a long-acting, injectable antibiotic, is essential. CHAI in collaboration with BMGF, the World Health Organization and other partners continue to support activities that mitigate risks for shortages such as improved monitoring and information sharing, and deployment of resources in support of activities that drive the adoption of quality-assured products. These opportunities, combined with increasing catalytic funding and political will, indicate that triple elimination of HIV, syphilis and HBV is within reach.
With increased strategic investment and an “all hands-on deck” push globally and within countries, we can ensure that no child will be born with HIV, syphilis or HBV.
Umesh Chawla, Lead, Key and Priority Population, Viral Hepatitis Team; Stephanie Dowling, Associate Director, Pediatric HIV, Global HIV Access Team; Obiageli Alintan, Senior Associate, Global MNH, SRMNCH, and Robia Islam, Associate, Global Laboratory Services, Hepatitis, Global Diagnostics Team