We can cross the finish line when it comes to prevention of mother-to-child transmission (PMTCT) of HIV, but much depends on continued political will, effective integration of PMTCT within broader health care services, and real movement toward universal health coverage (UHC) regardless of means or location.
Global discussions about preventing mother-to-child transmission of HIV accelerated in 2000 when the World Health Organization issued the first global guidelines for treating pregnant women and preventing HIV infection in infants. However, actual work in countries with a heavy HIV burden did not begin until years later when the global health community embraced it as a challenge that could produce significant results in the fight against HIV/AIDS.
Unlike other prevention programs, the world knew how to prevent the transmission of HIV to babies, and the importance of treatment for children and adults to sustain good health and prevent morbidity and mortality. It was clear that PMTCT was cost effective, prevented infections, and saved lives. However, what was lacking was the political will within countries to prioritize PMTCT efforts. A voice for advocacy and a focus on women and children impacted by HIV was missing in the developing world, even as countries began to scale up their national responses to HIV with support from the Global Fund to Fight AIDS, Tuberculosis, and Malaria (Global Fund) and bilateral assistance from the US President's Emergency Plan for AIDS Relief (PEPFAR). For example, early evidence from South Africa and Botswana pointed to initial progress in saving the lives of many children.
Furthermore, the clear imperative to do something about large numbers of children being born and dying of HIV infection when there were clear and proven and effective interventions at hand gained traction and support in 2010. Political leadership and vision, combined with clear clinical guidelines and willing partners, led to the creation of the Global Plan Towards the Elimination of New HIV Infections among Children by 2015 and Keeping Their Mothers Alive (Global Plan) in 2011. The Plan placed clear accountability with goals, targets, and a set of indicators to measure progress at the country level, together with strategies to reduce HIV transmission to children and ensure that mothers could stay in good health for themselves and their families. Launched by PEPFAR and the Joint United Nations Programme on HIV/AIDS (UNAIDS), resources committed to PMTCT were complemented by countries choosing to reprogram Global Fund grants and increase domestic investments to accelerate progress.
Valuable lessons have been learned and reinforced in scaling up this public health intervention. These lessons have implications for the design and delivery of care that is both effective and reaches those who will benefit from it. As with many health services, an environment that fosters a demand for health-seeking behavior is critical. This has been the case with PMTCT, where attention to the nonmedical aspects of care directly impacts the ability and desire to access available services. For example, stigma, with pregnant women fearing to get an HIV test or avoiding care altogether, remains a powerful barrier to stopping HIV transmission and receiving lifesaving treatment. Until stigma in all its forms is called out by the global health community, political and civic leaders, and overcome in settings of care, the full promise of PMTCT will not be realized.
In addition, the root causes of gender inequality that contribute to poor health outcomes and greater vulnerability to HIV must be addressed. This is essential work with a direct bearing on protecting women's health and ending vertical transmission. The local availability of antenatal care with the capability to offer HIV testing must be matched with ensuring that fees for HIV testing and services are not barriers to accessing essential care.
INTEGRATION OF CARE
The early lessons of PMTCT quickly highlighted the necessity of integrating HIV testing, counseling, and access to nevirapine and azidothymidine in antenatal care settings overseen by maternal and child health programs. Under the Global Plan, the pressure to rapidly scale up services accelerated the expansion of services from specialized clinics and hospitals down to the periphery of primary maternal child health care. Departments within Ministries of Health for maternal child health, not traditionally in a dialog with HIV programs, were called on to identify and care for HIV+ pregnant women and their HIV-exposed children throughout the window period for vertical transmission and beyond. The demand for integrated services was increasingly driven by limited health facilities and trained personnel. Moreover, the multiple needs of patients for family planning, HIV testing for male partners, and systems to ensure that mothers and their babies get necessary care made integration of care critical.
As PMTCT programs matured, it became increasingly clear that integration of care did not just mean ensuring that all elements of care for mother, partner, and child were provided. It meant that the health care system itself had to be strengthened. From investing in laboratory capacity to innovating training and expanding the cadre of providers through task shifting, to ensuring that drugs were available and distributed across the care cascade, to making sure that providers understand the need for and use of retention strategies for more difficult populations, significant steps were needed to make PMTCT efforts successful. Notable accomplishments were seen in integrating HIV testing and antiretroviral treatments (ARTs) into the antenatal setting, whereas achieving integration into postpartum and early childhood care have taken longer to operationalize. Lessons learned from the scale up of ART programs, such as the introduction of appointment systems and efforts to track patients in care, were also increasingly drawn on to perform better delivery of services for pregnant women, mothers, and their children.
PMTCT programs also learned quickly that service delivery models must be tailored to country needs and community environments. Moreover, to increase accessibility for women, we must place the right level of expertise at the primary care level with the ability to refer to higher levels of care at district or tertiary level as needed. Moreover, the reach of the health system must be envisioned to come down to the level of the community, as caretaking takes place outside the walls of facilities and clinics. The ability to follow and support women in their communities has been especially important in the cascade of care for PMTCT. Peer support of mentor mothers helps keep pregnant women, new mothers, and their children engaged in continuing treatment and care. Improving adherence to ART, achieving high tuberculosis cure rates, strong immunization programs, child nutrition and health education programs among many others rely on and benefit from community-level health workers and local associations. It is time to formally acknowledge and embrace community-level care as an essential component in achieving strong health systems.
THE WAY FORWARD
The horizon for ending vertical transmission and new HIV infections in children continues to expand, with test and treatment recommendations for all women of childbearing age, renewed attention to primary prevention of HIV acquisition among adolescent girls and young women, and focus on care for the HIV+ woman for her own treatment throughout her lifespan. Particular attention must be given to adolescent girls and young women, as social, cultural, and economic factors can each contribute to increasing vulnerability to acquiring HIV, as well as poorer health outcomes for vertical transmission, retention in care, and adherence to ART among HIV+ women in this age group.
Improved linkages that follow women and their children and retain them in appropriate services and care are critical to protecting positive health outcomes, with particular attention to the barriers of stigma and poverty that may be deterrents to access. Proactive planning for community-level supportive services should be considered. Innovations in point-of-care diagnostics for early infant diagnosis hold promise for ensuring timely identification of HIV+ children for immediate treatment. They also serve as an indicator that gaps in the care cascade for HIV positive pregnant women and breastfeeding mothers may exist. Ongoing investment in implementation science is needed to continually improve practice and the related health outcomes as service delivery models evolve and advances in science and technologies are translated into practice.
It is critical that we also invest in providers by offering supportive supervision after training, and nurturing good judgment and confidence as questions arise in patient care. In addition, respectful of the systems of care already in place, we must give providers and district health officials the tools they need to capture and use health information to identify problems and gaps in services and implement a corrective response, which will improve overall health.
Finally, a sustainable response must be integrated with a comprehensive health system that meets all of a person's diverse health needs. To ensure continuing progress toward elimination of vertical transmission as part of an effective national AIDS response, sustainable financing for health is essential. And, ultimately, the goal must be making progress toward UHC in both fiscal and programmatic terms.
User fees and charges for care rendered remain a barrier to accessing care in many countries, leading to preventable HIV infections and loss of life and delaying the goals of achieving elimination of vertical transmission. The need to integrate PMTCT and other services in each service site demands that the medical system accommodates the expanded service portfolio and link it with the broader primary care needs for women and children and family planning. It is through this integration that we will achieve sustainable services and move toward UHC. Individuals living with HIV also need access to comprehensive health care that addresses noncommunicable diseases which now are leading causes of death and disability in an increasing number of low and middle income countries. It is indeed possible that the mother or child we save from AIDS will die of diabetes or heart disease without integrated and accessible systems of care.
Crossing the finish line on PMTCT is not easy, but it is more achievable today than ever before. We can now envision a world where babies are born HIV-free and can grow up to live happy and healthy lives, a world where women do not fear of dying in childbirth, and a world where women can choose how many children they want to bear. We have benefited from lessons learned and the example of what can be achieved through ambitious efforts such as the Global Plan. Now, let us work to ensure that we have the political will necessary to keep moving forward.