Date Published: June 27, 2017
Publisher: Public Library of Science
Author(s): Melanie Taylor, Lori Newman, Naoko Ishikawa, Maura Laverty, Chika Hayashi, Massimo Ghidinelli, Razia Pendse, Lali Khotenashvili, Shaffiq Essajee
Abstract: Melanie Taylor and colleagues discuss progress towards eliminating vertical transmission of HIV and syphilis.
Partial Text: Nearly 1 million syphilis infections occur among pregnant women globally each year. These syphilis-affected pregnancies resulted in an estimated 350,000 adverse birth outcomes due to congenital syphilis in 2012 . More than 1.4 million pregnant women are infected with HIV, and mother-to-child transmission (MTCT) of HIV is estimated to have resulted in over 150,000 infant cases in 2015 . Untreated maternal syphilis results in congenital syphilis in over half of affected pregnancies and can lead to early fetal loss, premature birth, stillbirth, low birth weight, complications from infection, and neonatal death . Over half of infants vertically infected with HIV die before the age of 2 years . Antenatal screening for syphilis and HIV, and treatment for pregnant women infected, prevents MTCT and aligns with the Sustainable Development Goal (SDG) targets of ending preventable deaths of newborns and children under 5 years of age, ensuring universal access to sexual and reproductive healthcare services, and achieving universal health coverage (UHC)  as well as the Joint United Nations Start Free-Stay Free-AIDS Free initiative . In May 2016, the World Health Assembly endorsed 3 new global health strategies (2016–2021) on HIV, sexually transmitted infections (STIs), and hepatitis. These strategies call for member states and WHO to work together towards goals of 0 new HIV infections in infants by 2020, the elimination of congenital syphilis as a public health threat by 2030, and achieving a 0.1% prevalence of hepatitis B surface antigen (HBsAg) among children by 2030 [6–8].
WHO, in collaboration with the Joint United Nations Programme on HIV/AIDS (UNAIDS), UNICEF, and the United Nations Population Fund (UNFPA), has developed standardized processes and criteria to validate EMTCT of HIV and syphilis that emphasize country-led accountability, analytic and programmatic rigour, and multilevel collaboration . This global guidance outlines the process, indicator targets, and available support for programmatic advancement towards achieving the benchmarks required for validation. The validation process consists of a series of national-, regional-, and global-level program and data reviews (Fig 1, S1 Fig). Regional and global validation committee secretariat functions are performed by WHO Regional Offices and Headquarters, in partnership with UNAIDS, UNFPA, and UNICEF. Subsequently, WHO headquarters monitors maintenance of EMTCT of HIV and syphilis annually through routine global reporting mechanisms already in place and with additional reports from validated countries.
WHO has established global EMTCT impact and service delivery (process) targets (Box 1). Impact targets must be met for at least 1 year prior to EMTCT validation assessment. Coverage of antiretroviral treatment in HIV-infected pregnant women is set at 90% in current EMTCT validation guidance. This criterion for maternal HIV treatment coverage will be increased from ≥90% to ≥95% in the forthcoming revised EMTCT validation guidance expected later in 2017. All of the countries that have achieved validation thus far reached the ≥95% target. Process targets must have been achieved for the 2 consecutive years prior to validation. Countries must ensure that validation criteria have been met in a manner consistent with human rights .
During the validation process, a country must demonstrate that all pregnant women and infants exposed to HIV or syphilis have universal access to essential interventions to prevent MTCT (population coverage and service coverage). Quality of interventions including laboratory services is also assessed. Financial barriers, out-of-pocket payment, and financial support for vulnerable populations are evaluated to ensure equitable access (S2 Fig). These criteria must be sufficiently fulfilled for the country to be validated for EMTCT. A selection of EMTCT program attributes from the 5 validated countries is presented in Table 1. Validation teams working within countries identified challenges encountered by countries within the 4 EMTCT areas of program services, data and surveillance, laboratory services, and human rights and community engagement. Some of these are highlighted in this paper. Overall, syphilis surveillance and laboratory services were less developed than those of HIV. Additional challenges encountered when delivering EMTCT services among special populations are described.
Dual EMTCT of syphilis and HIV has been identified as a global public health priority and a priority in the context of the rights of a child to be born free of HIV and syphilis . Criteria for validation of EMTCT include high levels of ANC access and HIV and syphilis testing and treatment for pregnant women and their infants. EMTCT priorities require integrated and universal access to these services within ANC and monitoring of coverage and health outcomes. The sentinel health system accomplishment of EMTCT validation demonstrates the political will by countries to improve the quality of, and access to, ANC and to reduce maternal and infant morbidity and mortality. While recognition of the efforts of the 5 countries described here is due, renewed support is needed for initiatives to achieve validation targets in many countries with high prevalence of HIV and syphilis, particularly those in sub-Saharan Africa.