Global guidance on criteria and processes for validation: elimination of mother-to-child transmission of HIV and syphilis, 2nd edition. Geneva: World Health Organization; 2017. Licence: CC BY-NC-SA 3.0 IGO.
Mother-to-child transmission (MTCT) of HIV is a significant contributor to the HIV pandemic, accounting for 9% of new infections globally. The Joint United Nations Programme on HIV/AIDS (UNAIDS) reported that in 2016 an estimated 160 000 children were newly infected with HIV, and an estimated 3.1 million children were living with HIV globally (1). Although this is still a large number of new infections, at the peak of the HIV epidemic, there were close to 500 000 children infected with HIV through MTCT each year.
MTCT of HIV occurs when HIV is transmitted from a woman living with HIV to her baby during pregnancy, labour or delivery, or after delivery through breastfeeding. Without treatment, approximately 15–30% of infants born to HIV-positive women will become infected with HIV during gestation and delivery, with a further 5–15% becoming infected through breastfeeding. HIV infection of infants results in early mortality for many or creates a lifelong chronic condition that greatly shortens life expectancy and contributes to substantial human, social and economic costs.
Globally, an estimated 1.3 million women living with HIV become pregnant every year (2). Primary prevention of HIV, prevention of unintended pregnancies, effective access to HIV testing and counselling, initiation of lifelong antiretroviral therapy (ART) with support for adherence, retention and viral suppression for mothers living with HIV, safe delivery practices, optimal infant-feeding practices and access to postnatal antiretroviral (ARV) prophylaxis for infants all contribute to the prevention of mother-to-child transmission (PMTCT), thereby reducing maternal and child mortality. With the global shift to highly effective and simplified interventions based on lifelong maternal ART, it is now feasible to virtually eliminate new HIV infections in infants, while assuring the health of the mother (3).
In 2012 (the most recent global data), WHO estimated that over 900 000 pregnant women were infected with syphilis. These maternal infections resulted in more than 350 000 estimated adverse pregnancy outcomes, over 200 000 of which were stillbirths or neonatal deaths (4). Syphilis is caused by the Treponema pallidum bacterium, renowned for its invasiveness. It can be transmitted via sexual exposure or vertically from mother to child early in pregnancy (in utero infection). If the infection remains untreated, adverse pregnancy outcomes are frequent. Indeed, over half of the pregnancies among women with active syphilis will result in stillbirth, early neonatal death, a preterm or low-birth-weight infant, or serious neonatal infection (5). Screening for maternal syphilis early in pregnancy and prompt treatment of seropositive mothers with intramuscular benzathine benzylpenicillin, a long-acting penicillin, cures syphilis in both mother and infant, and prevents most complications associated with MTCT of syphilis (6).
Dual elimination serves to improve a broad range of maternal and child health (MCH) services and outcomes. This achievement directly contributes to Sustainable Development Goals (SDGs) 3, 5 and 10, which aspire to ensure health and well-being for all, achieve gender equality and empower women and girls, and reduce inequalities in access to services and commodities (7). Additionally, the similarity of the control interventions necessary to prevent transmission of HIV and syphilis in pregnancy adds to the feasibility and benefit of such an integrated approach to the elimination of MTCT (EMTCT) of both infections. Indeed, building on an integrated MCH platform, several WHO regions are moving to “triple elimination” by incorporating hepatitis B into the EMTCT framework. The Pan American Health Organization is promoting a strategy of “EMTCT Plus”, which includes the EMTCT of hepatitis B and Chagas disease, in addition to the EMTCT of HIV and syphilis (see Regional websites).
The processes and criteria to validate EMTCT of HIV and syphilis described in this document were developed to apply across a wide range of epidemiological and programmatic contexts. They also seek to ensure that representatives of civil society, including women living with HIV, are involved in the validation effort, and that elimination goals are achieved in a manner that protects and respects the human rights of women, and particularly women living with HIV and/or syphilis.
A harmonized approach to eliminating MTCT of HIV and syphilis is encouraged. However, depending on the progress of national EMTCT efforts, countries may choose to validate the EMTCT of HIV, syphilis or both. Elimination must be achieved while protecting human rights and with the involvement of women and affected communities in all interventions, including in planning and designing programmes, implementation, and monitoring and evaluation (M&E).
This revised document was developed by WHO and the Global Validation Advisory Committee (GVAC) in order to clarify existing guidance, update checklists and tools, and provide new guidance on the Path to Elimination for high-burden countries. The document is intended for use by national and regional validation committees as they prepare or review national submissions for validation of EMTCT of HIV and/or syphilis. In developing this revised document, WHO and the GVAC considered the input of national programmes, regional validation teams and committees, and external experts, including in the area of human rights. Suggestions for topic areas that needed revision were collected by WHO from global validation team members during country validation missions and during face-to-face meetings of the GVAC held in Geneva in June 2016 and June 2017.
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