Prevention of Mother-to-Child Transmission of HIV and Syphilis

Excerpt

The past decade has yielded enormous progress in the prevention of mother-to-child transmission (PMTCT) of the human immunodeficiency virus (HIV) (UNAIDS 2015). Interventions that decrease mother-to-child transmission (MTCT) of HIV from more than 30 percent to 1 percent have been identified. Decentralized point-of-care (POC) approaches for detecting maternal HIV and immediate provision of comprehensive antiretroviral treatment (ART) have resulted in rapid decreases in the number of HIV-infected infants. Indeed, PMTCT has been credited with driving observed decreases in HIV incidence overall.

The guidelines for PMTCT of HIV have been dynamic: the World Health Organization (WHO) and Joint United Nations Programme on AIDS (UNAIDS) have revised their recommendations every two to five years, most recently to recommend combination lifelong ART for all pregnant HIV-infected women (WHO 2014a). The term elimination of mother-to-child transmission (EMTCT) was used to further spur global efforts to virtually eliminate pediatric HIV by 2015 (UNAIDS 2011; WHO 2014a).

PMTCT of syphilis (Treponema pallidum) has not received the same amount of attention as PMTCT of HIV, although syphilis is estimated to affect more children globally than HIV. PMTCT of syphilis requires less costly and less intensive interventions than HIV, making its elimination potentially more feasible. The rollout of PMTCT of syphilis may be hampered by less political will to implement it than PMTCT of HIV, lack of accountability for monitoring PMTCT of syphilis, inconsistent availability of diagnostic tests, and use of tests that are not POC (WHO 2006). PMTCT of syphilis could readily leverage advances in PMTCT of HIV by using these programs to enhance the supply chain, lab testing, and accountability for prompt syphilis diagnosis and treatment.

The current momentum in PMTCT of HIV offers a unique opportunity to accelerate PMTCT of HIV and syphilis concurrently. Combining interventions for PMTCT of HIV and syphilis adds minimal cost while potentially benefiting twice as many mother-infant pairs as interventions focused solely on either HIV or syphilis. Health systems improvements for rapid diagnosis and treatment, partner engagement, and follow-up of mothers and infants can enhance both types of PMTCT programs. Combined PMTCT of HIV and syphilis will yield sustained and important benefits for women and children worldwide.

This chapter reviews the rates, burden, and consequences of mother-to-child transmission of HIV and syphilis; the effectiveness of interventions to decrease transmission; the estimated cost-effectiveness of these interventions; and several successful PMTCT programmatic approaches. The chapter also highlights opportunities for integrated programming to efficiently decrease the number of infants infected with these chronically debilitating pathogens. Because syphilis testing is already currently recommended by WHO for all pregnant women (WHO 2006) and is at least partially implemented in most antenatal clinics, new costs for improving the program may be minimal: adapting programs to incorporate dual POC tests to diagnose syphilis, providing training to improve adherence to guidelines, and increasing accountability for tracking outcomes in PMTCT of syphilis within clinics can be added to existing programs with limited additional investment.

In 2015, Cuba became the first country to eliminate perinatal HIV and syphilis (WHO 2015). This experience demonstrates that the goal of dual elimination is attainable and feasible with effective integration of PMTCT of HIV and syphilis. Children do not need to suffer from the consequences of either of these devastating infections when these PMTCT programs function synergistically.