More photos »

Prevention of mother-to-child transmission (PMTCT): Establishing standards of care

HIV-positive children largely become infected from their mothers, either during pregnancy, delivery, or the breastfeeding period. In developed countries, pediatric HIV infection has been nearly eliminated through successful prevention of mother-to-child transmission (PMTCT). Transmission rates in developed countries are typically below 2%. , However, in developing countries, PMTCT interventions have not been as successful, with an estimated 420,000 new pediatric (<15 years old) infections globally in 2007. In the US, fewer than 250 infected infants are born each year according to current estimates. Today nearly 90% of all HIV-positive children live in sub-Saharan Africa.

Treatment providers, including MSF, continue to struggle to prevent newborn infections, grappling with complex protocols and high numbers lost to follow-up. PMTCT is an increasingly important component of MSF’s projects, and from our field experience the need for simplified protocols is clear. MSF currently offers PMTCT interventions in 54 projects, with >10,000 women having started in a PMTCT intervention in 2007. Major emphasis is placed on integrating PMTCT into routine antenatal care (ANC) and maternal and child health (MCH) services, such as in Arua, Uganda; Chiradzulu and Thyolo, Malawi; and Nairobi (Mathare and Kibera), Homa Bay, and Busia, Kenya; as well as in Lesotho, Burkina Faso, and Liberia. Collection and analysis of data in MSF’s PMTCT programs are in the early stages.

In many developing countries, women have little access to ANC. All mothers should be informed of the need for HIV testing, so that if positive they can receive both treatment for themselves and interventions for preventing HIV transmission to their children. Today only an estimated 20% of HIV-positive pregnant women are receiving ARVs for PMTCT. Although reasons for this low coverage rate include financial barriers, human resource shortages, and weak health systems for MCH, one neglected but crucial factor is that of the protocols and formulations available. The protocols are complicated, and adapted ARV packaging, such as single-dose nevirapine (NVP) syrup or zidovudine (AZT) syrup for one week, are unavailable.

Also, protocols applied to developing countries differ from those used in developed countries. In developed countries, any pregnant woman who is HIV-positive has the option to receive full ART throughout pregnancy, followed by formula feeding for the infant. In most resource-limited contexts, this is not an option. To protect infants from infection, interventions are being explored to simplify the PMTCT protocol in resource-limited settings, including HAART for all HIV-positive pregnant women throughout pregnancy and the breastfeeding period. Preliminary studies under trial environments have shown some success, with HIV transmission rates as low as nearly 1%. Access to triple therapy for all pregnant women regardless of immunological status (CD4 count) has been shown to be the best way to prevent HIV transmission to the child. MSF is currently looking at implementing triple therapy in the last trimester of pregnancy and throughout breastfeeding in some pilot projects. Discussions continue on how best to approach the breastfeeding period.

Rolling out and implementing PMTCT interventions on a large scale would require the identification of the most appropriate ARV combination and the development of an adaptable FDC that is easy to administer, has favorable toxicity, and has minimal risk of resistance. Some national frameworks have already adapted simplified protocols for their PMTCT programs, and international and national guidelines should be adapted to reflect these realities. The need is evident for the international community to expediently examine new strategies for implementing simplified PMTCT protocols in resource-limited settings, all so that child HIV infections can be significantly reduced.

Optimizing pediatric HIV care in resource-limited settings requires:

• Earlier and improved access to at-risk infants, with active follow-up of PMTCT-born newborns and testing of enrolled patients’ children
• Integration of PMTCT into MCH services, including antenatal and postnatal care
• In high prevalence contexts, the offer of early infant diagnosis at vaccination sites
• Pediatric and PMTCT FDC drug regimens
• Reliable, easy-to-use, inexpensive, point-of-care diagnostic tools adapted for pediatric use, and routine diagnostic facilities in high-risk populations, such as malnourished children
• Proper management of opportunistic infections, such as TB in pediatric cohorts
• Improvement of adherence through patient and peer support measures for both mothers and their children, including support tools according to age group

Continue reading: HIV-TB co-infection »