Elimination of mother-to-child transmission – the necessary steps to be made

June 29, 2015

Globally, the mother-to-child HIV transmission rate dropped from 31% in 2005 to 13% in 2013. While this is a good development, still 240,000 children became newly infected with HIV in 2013. These new infections can be avoided! What can you do to contribute to complete elimination of new HIV infections in children and keeping mothers alive?

"I am too weak to walk 6 hours to the nearest clinic as I am seven months pregnant. I asked my husband for money for transport but he refused. I have no options for a health check. The rumour goes around in my village that my husband is HIV positive. I am scared for the health of my baby and myself." – Betty (20)

New treatment guidelines for pregnant and breastfeeding women

In 2013 the World Health Organization (WHO) introduced the new HIV treatment guidelines. The guidelines include recommendations for providing life-long antiretroviral treatment (ART) to pregnant and breastfeeding women living with HIV for the prevention of mother-to-child transmission (PMTCT). The preferred option is option B+, that recommends providing lifelong ART to all pregnant and breastfeeding women living with HIV regardless of CD4 count or WHO clinical stage. Moreover, ART should be maintained after delivery and completion of breastfeeding for life.

Paediatric HIV cascade of children lost in care

The number of pregnant women taking ART to prevent mother-to-child transmission has increased tremendously to 67% in 2013. However, there are still a lot of mothers to be reached, and thus new HIV infections to be avoided. The figure below shows the example of the many losses in the treatment cascade for women and children in Uganda.

Why are still so many mothers not accessing the life-saving treatment?

Many barriers to be overtaken by pregnant women

In the past years, the focus seems to have been on addressing the barriers at the supply side, where a lot of progress has been made on availability and quality of care. Barriers at the demand side are still many. Transport is by far the most frequently mentioned barrier for women; the distance to the clinic and the transport costs are hindering women from accessing services. With regard to social norms and knowledge, non-disclosure, stigma and partner relations are the most commonly cited barriers.

Recent studies in the Towards an AIDS Free Generation (TAFU) and the Access, Services, Knowledge (ASK) projects in Uganda, further identified inadequate knowledge of early infant diagnosis and lack of psychosocial support as important barriers and explain the difficult situation many women are in in their marriage related to their (potential) HIV status:

Some men are difficult and control their wives. One of the men told his wife ‘if you go and get those drugs, don’t come back’. The woman feared to lose her marriage so she did not go. - 
(FGD with men in Serere, Uganda, May 2015)

Most women after testing HIV positive, they keep quiet because they know if they tell their husbands, they will be beaten and accused of bringing HIV in the family - (FGD with women in Mubende, Uganda, May 2015)

It is easy to understand that women in these situations drop-out of treatment. 

Working at different levels to reach zero new infections among infants

  • Household level: Before an intervention can be designed a study into the barriers needs to be done. Also facilitators need to be investigated, as these can help in addressing the barriers. For instance in the TAFU study area some men were found to be supportive to their wives; they could be asked to be peer educators for other men. This is also an approach of ASK partner Mama’s Club in Uganda, that works with mentor mothers and fathers to provide the necessary support. In one area a voucher system was available for transport to the clinic. The TAFU program is going to build on the lessons of this voucher system to help the women deal with the transport issue. But also economic strengthening through Village Savings and Loan Groups, is part of the approach. 
  • Community level: Interventions at community level will increase the knowledge on HIV and PMTCT and create support groups for  women living with HIV.
  • Health facility level: Outreach services can be strengthened, bringing the services closer to the women, and linkages with other (health) programmes  need to be made or strengthened. 

Only if all stakeholders at the different levels work together and address the many barriers to PMTCT in an integrated way, we can reach the goal of zero new infections among infants!

Please read more about our PMTCT related projects here:
- TAFU: Towards and AIDS Free Generation in Uganda
- ASK: Access, Services and Knowledge – what young people want, what young people need
- Link Up: Reaching and engaging young people most affected by HIV
- Quality improvement of HIV and Reproductive Maternal and Neonatal health (RMNH) services for (young) women in Africa

This article was published in the STOP AIDS NOW! e-news June 2015: Elimination of HIV infections in children and keeping mothers alive