Prevention of mother-to-child transmission (PMTCT) programmes provide antiretroviral treatment to HIV-positive pregnant women to stop their infants from acquiring the virus.
Without treatment, the likelihood of HIV passing from mother-to-child is 15% to 45%. However, antiretroviral treatment and other effective PMTCT interventions can reduce this risk to below 5%.
A comprehensive approach to PMTCT
Effective PMTCT programmes require women and their infants to have access to - and to take up - a cascade of interventions including antenatal services and HIV testing during pregnancy; use of antiretroviral treatment (ART) by pregnant women living with HIV; safe childbirth practices and appropriate infant feeding; uptake of infant HIV testing and other post-natal healthcare services.
The World Health Organization (WHO) promotes a comprehensive approach to PMTCT programmes which includes:
preventing new HIV infections among women of childbearing age
preventing unintended pregnancies among women living with HIV
preventing HIV transmission from a woman living with HIV to her baby
providing appropriate treatment, care and support to mothers living with HIV and their children and families.
World Health Organization PMTCT guidelines
In September 2015, the WHO released new guidelines recommending lifelong antiretroviral treatment for all pregnant and breastfeeding women living with HIV.
Guidelines for pregnant and breastfeeding women living with HIV
The 2015 guidelines recommend Option B+ where lifelong antiretroviral treatment is provided to all pregnant and breastfeeding women living with HIV regardless of CD4 count or WHO clinical stage. Treatment should be maintained after delivery and completion of breastfeeding for life.
Previously, the 2013 guidelines included another choice called Option B, where treatment was only continued after the completion of breastfeeding if the mother was eligible for antiretroviral treatment for her own health. The 2015 guidelines no longer recommend this option.
Guidelines for HIV-exposed infants
All infants born to HIV-positive mothers should receive a course of antiretroviral treatment as soon as possible after birth. The treatment should be linked to the mother's course of antiretroviral drugs and the infant feeding method.
Breastfeeding - the infant should receive once-daily nevirapine from birth for six weeks.
Replacement feeding - the infant should receive once-daily nevirapine (or twice-daily zidovudine) from birth for four to six weeks.
At four to six weeks old, all infants who are born to HIV-positive mothers should be given an early infant diagnosis. Another HIV test should be done at 18 months and/or when breastfeeding ends to provide the final infant diagnosis.
Global PMTCT targets
In 2011, a Global Plan was launched to reduce the number of new HIV infections via mother-to-child transmission by 90% by 2015.
The WHO identified 22 priority countries, with the top 10 (Angola, Botswana, Burundi, Cameroon, Chad, Côte d’Ivoire, Democratic Republic of the Congo, Ethiopia, Ghana and India) accounting for 75% of the global PMTCT service need.
It was estimated that the effective scaling up of interventions in these countries would prevent over 250,000 new infections annually.
Progress in the prevention of mother-to-child transmission
Progress among pregnant and breastfeeding women
The proportion of pregnant women living with HIV receiving antiretroviral treatment more than doubled in 21 of the 22 Global Plan priority countries from 36% in 2009, to 80% in 2015. Perhaps more importantly, 93% of pregnant women receiving treatment, were receiving lifelong treatment, up significantly from 73% in 2014. India does not feature in the latest data.
In 2015, six priority countries (Botswana, Mozambique, Namibia, South Africa, Saziland andUganda) met the Global Plan target of reducing mother-to-child transmission by 90%.Outside of the priority countries, in mid-2015, Cuba became the first country to eliminate the mother-to-child transmission of HIV. In 2016, Belarus and Armenia achieved the same feat while Thailandbecame the first country in the Asia and Pacific region to eliminate MTCT.As PMTCT is not 100% effective, elimination is defined as a reduction of transmission to such low levels that it no longer constitutes a public health problem.
Many point to the implementation of Option B+ as a major reason behind coverage progress. By the end of 2015, all priority countries except Nigeria had rolled out Option B+. Consequently, AIDS-related deaths among women of reproductive age in the Global Plan countries declined by 43% between 2009 and 2015.
Another target of the Global Plan was to reduce the MTCT rate to 5% or less among breastfeeding women, and to 2% or less among non-breastfeeding women. Together, the 21 Global Plan countries reduced the MTCT rate among breastfeeding women from 22.4% to 8.9% between 2009 and 2015. Four countries (South Africa, Uganda, Swaziland and Namibia), achieved the 5% milestone. Botswana, the only non-breastfeeding Global Plan priority country, has a transmission rate of 2.6% - just above the threshold of 2%.
However, countries need to accelerate efforts to reduce new HIV infections among women. The Global Plan aimed to reduce the number of new infections among women of reproductive age by 50% but they declined by just 5% between 2009 and 2015. As a result, there were 4.5 million new infections among this group over this period.
Progress among children
Between 2009 and the end of 2015, there was a 60% decline in new HIV infections among children in the Global Plan priority countries, from 270,000 to 110,000, equating to 1.2 million averted infections. This compares to a fall of just 24% between 2000 and 2008, meaning that the rate of the decline in new infections since the launch of the Global Plan nearly tripled. Without Nigeria, the remaining countries reduced new HIV infections by 69%.
While this progress is encouraging, it is significantly below the 90% target. However, some countries got close to this target including Uganda (86%), South Africa and Burundi (both 84%). Botswana, Burundi, Namibia and Swaziland had fewer than 1,000 new infections in 2015. These are small enough numbers that, with determined efforts, could be reduced dramatically.
Other countries still face significant challenges to rolling out effective PMTCT services. Angola, Cote d’Ivoire and Nigeria have registered a less than 40% reduction in new HIV infections among children since 2009.
Barriers to the uptake of PMTCT programmes
As well as the scale-up of PMTCT, a number of barriers need to be overcome in order to increase access to these services.
Knowledge about HIV, MTCT and PMTCT
A number of studies have identified the link between knowledge of HIV, MTCT and PMTCT and uptake of PMTCT services.
For example, research from Togo reported a 92% HIV testing uptake among participants where:
77% of pregnant women agreed that unprotected sex increased the risk of HIV transmission to their child
61% recognised that the risk of HIV transmission to their child was higher for mixed breastfeeding than for exclusive breastfeeding.
Another study of over 500 pregnant and postnatal women in Botswana with high PMTCT knowledge found that 95% of participants believed that pregnant women should be tested for HIV.
Conversely, other studies have associated high levels of HIV, MTCT and PMTCT knowledge with lower acceptability of PMTCT.
One study from south west Nigeria recorded that while 99.8% of pregnant women were aware of HIV and had very high knowledge of MTCT (92%) and PMTCT (91%) - 71% had negative views towards PMTCT. This was due to factors such as stigma and discrimination.
Knowledge of HIV status
Knowledge of HIV status is vital in order that pregnant women access the appropriate treatment and care for themselves and their unborn infants.
Not knowing one's HIV status acts as a barrier to PMTCT services. For example, a South African study found that voluntary HIV testing and counselling was widely accepted among women already attending antenatal clinics (95%) but low among those who were not (37%).
Confusion over exclusive breastfeeding
One study from Malawi reported that while the majority of mothers chose to exclusively breastfeed because "that's the advice they give to HIV-positive women", most mothers reported mixed feeding in the first six months. A number of reasons were given for this including traditional feeding practices, a poor understanding of what exclusive breastfeeding involves, as well as poor communication about why women should exclusively breastfeed.
Research from Tanzania compared two hospitals that offered different infant feeding options. Hospital A promoted exclusive breastfeeding as the only infant feeding option, while hospital B followed Tanzanian PMTCT infant feeding guidelines which promote patient choice. Women in hospital A trusted the advice given and were confident in their ability to exclusively breastfeed, whereas women in hospital B expressed confusion and uncertainty about how to best feed their infants.
HIV stigma, discrimination and PMTCT
A body of research has highlighted how HIV-related stigma and discrimination affect a pregnant woman's decision to enrol on PMTCT programmes and interrupt adherence to treatment and retention in care.
It has been estimated that over 50% of vertical HIV transmissions from mother-to-child globally can be attributed to the cumulative effect of stigma.
One study has identified a range of HIV-related stigmas experienced by pregnant women:Enacted stigma
In some countries, pregnant women who disclose their HIV status may be physically or verbally abused or socially marginalised.
Research on the provision of HIV testing and counselling across Burkina Faso, Kenya, Malawi and Uganda found that 25% of women reported being made to feel bad because of their HIV status. Other women who disclosed their status experienced rejection or were divorced by their partners.
Anticipated stigma
Pregnant women may not seek PMTCT services because they fear stigma if they are found to be HIV-positive following an HIV test. A focus group participant in Soweto, South Africa reported:
"I didn’t book at an antenatal clinic because I was afraid that they would test me for HIV, so I avoided it as I told myself that I might be found to have this disease."
Perceived community stigma
Pregnant women living with HIV may avoid PMTCT and treatment for their own health if they believe that other HIV-positive pregnant women experience stigma and discrimination when using these services.
Women on a PMTCT programme in Malawi reported involuntary HIV disclosure and negative community reactions; unequal gender relations; difficulties accessing care and treatment; and lack of support from husbands.
Some pregnant women living with HIV internalise negative perceptions about people living with HIV and are therefore less likely to enrol in PMTCT and often suffer from mental health issues. Research on HIV-positive women in Karnataka, India said:
"...self-stigma was in many cases derived from moral judgment of one’s self for not fulfilling traditional gender roles of wife and mother."
Stigma in healthcare settings
Some healthcare workers are hesitant about handling the delivery of babies born to HIV-positive mothers for fear of HIV infection. A study from Ethiopia reported that:
"many health workers don’t have the necessary skill and equipment to confidently handle delivery for an HIV positive woman and given the risk of accidental exposure, most nurses shy away from dealing with such patients."
In more serious cases, women report direct abuse from healthcare workers. An HIV-positive woman from Mexico reported an interaction with her doctor:
"How can you even think about getting pregnant knowing that you will kill your child because you’re positive?!!!’ He threatened not to see me again if I got pregnant. He told me that I was ‘irresponsible’, a bad mother, and that I was certainly running around infecting other people."
Even though HIV testing is not compulsory, the way that some healthcare workers talk about it can lead women to believe that it is. As a result, many delay or avoid antenatal services, risking their health. In a study from South Africa, a woman from KwaZulu-Natal said:
"Testing was not optional, it was compulsory…If you didn’t test you didn’t have antenatal classes, everyone had to go through the tests."
One study has estimated that highly effective stigma reduction programmes leading to greater PMTCT access could reduce new HIV infections among infants by up to 33%.
Country and clinic resources
In resource-poor settings, shortages of PMTCT staff, interruptions in treatment and supplies of medical equipment, as well as a shortfall in counselling services, all act as barriers to PMTCT services.
These factors often mean long waiting times for post-test counselling and many leave without getting their HIV test results.
Research findings show how PMTCT workers can lack proper understanding of programme principles and fail to give adequate counselling to women. Some have put adherence issues around exclusive breastfeeding down to the poor quality of counselling women receive.Another study from Kenya reported that 92% of respondents lacked privacy in their counselling rooms.
Poor monitoring of PMTCT services by healthcare workers also leads to poor retention in care. Research from Ethiopia reported poor follow-up rates in the PMTCT programme because healthcare facilities did not have registered information on HIV-positive mothers.
Option B+ challenges
Though the implementation of Option B+ has been attributed to progress in PMTCT coverage, for some, the immediacy of treatment initiation is a challenge.
A study from Lilongwe, Malawi, noted that some participants needed time, whether it was for discussing their status with their partner or personally accepting their HIV status:.
“I couldn’t accept them [ART] for the reason of my partner…The child’s father, I can say we could have problems…I was scared that he would be mad and also our marriage could be jeopardized.”
“I wanted my relatives to know about my status, I can’t just receive the drugs and take them home while I came here for antenatal services, they would be surprised….”
Side effects were the most commonly reported barrier to adherence and were found to be more significant barriers compared to previous studies on barriers in non-B+ contexts.Another study from the same country revealed that women who started treatment in the context of B+ were five times more likely to be lost to follow-up compared to those who started treatment for their own health.
Cultural beliefs and gender dynamics
In many settings, traditional gender roles and cultural beliefs mean that men often make decisions determining women's participation in HIV testing. One study reported that in some countries, 75% of women said that their husbands alone make health decisions for their families.
In many communities in sub-Saharan Africa, pregnancy is viewed as a 'woman's affair', with a man's role primarily to provide financial support. Even where men view accompanying their partner to antenatal clinics or PMTCT services as good practice, many still feel their main role is to provide financing for registration and delivery fees.
Men also report negative attitudes from community members when escorting their spouses to antenatal clinics. One report from Uganda stated:
"Because of cultural beliefs, most men do not like to accompany their wives to the antenatal clinics. Men who accompany their wives to ANC are perceived to be weaklings by their peers."
Male involvement
Generally, research has highlighted the beneficial impact of male involvement in programmes to prevent the mother-to-child transmission of HIV to tackle new infections among infants.
A study of 15 countries found that supportive male partners who were willing to get an HIV test and communicate with their partner about sexual and reproductive health issues, increased the commitment of pregnant women to PMTCT programmes.
By comparison, women in relationships with unsupportive males who did not discuss reproductive issues have reported violence, abandonment or fear of abandonment. Many studies have reported shock, disbelief, violence and discrimination among male partners of pregnant women who disclose their HIV status.
Inviting men to use voluntary HIV testing and counselling services, offering PMTCT services at sites other than antenatal care ones (such as bars, churches and workplaces), as well as prior knowledge of HIV and HIV testing facilities have all been identified as ways of increasing male involvement.
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