PMTCT Strategic Vision

20102015
Preventing mother-to-child transmission of HIV
to reach the UNGASS and
Millennium Development Goals

Moving towards the elimination of paediatric HIV

WHO Library Cataloguing-in-Publication Data

PMTCT strategic vision 20102015 : preventing mother-to-child transmission of HIV to reach the UNGASS and Millennium Development Goals.

1.HIV infections - prevention and control. 2.Disease transmission, Vertical - prevention and control. 3.Strategic planning. 4.International cooperation. 5.World health. 6.Millennium
development goals. 7.Pregnant women. 8.Child. I.World Health Organization.

ISBN 978 92 4 159903 0 (NLM Classification: WC 503.2)

World Health Organization 2010

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PMTCT Strategic Vision
20102015
Preventing mother-to-child transmission of HIV
to reach the UNGASS and
Millennium Development Goals

Moving towards the elimination of paediatric HIV

Preface

This publication, PMTCT strategic vision 20102015: preventing mother-to-

child transmission of HIV to reach the UNGASS and Millennium Development
Goals, reflects an important part of the World Health Organizations
(WHOs) health sector response to HIV/AIDS and will contribute directly
to the new Outcome framework of the Joint United Nations Programme on
HIV/AIDS (UNAIDS).

The purpose of this document is to define WHOs commitment to global

and country support to scale up access to prevention of mother-to-child
transmission (PMTCT) of HIV services and integrate these services with
maternal, newborn and child and reproductive health programmes. The
objectives included in this PMTCT strategic vision 20102015 illustrate WHOs
ongoing commitment to the United Nations General Assembly Special
Session (UNGASS) goals on PMTCT and strengthening support for PMTCT
within the context of the Millennium Development Goals (MDGs).

As the co-lead for PMTCT within the United Nations, WHO will use this
strategic vision to accelerate support for PMTCT with the United Nations
Childrens Fund (UNICEF), UNAIDS and the expanded Interagency Task
Team (IATT) on Prevention of HIV Infection in Pregnant Women, Mothers
and their Children. WHO will work to enhance global collaboration among
key partners, increase its capacity at the regional and country levels for
providing technical assistance and support, strengthen strategic partner-
ships with key funding and implementing agencies such as the Global Fund
to Fight AIDS, Tuberculosis and Malaria and US Presidents Emergency
Plan for AIDS Relief (PEPFAR), and help develop and lead the UNAIDS
Outcome framework.
Contents

2 Preface

4 Abbreviations

5 Foreword

6 Executive summary

8 Background

11 Vision, goal, objectives and targets

12 Strategic directions

13 Strategic direction 1: Commitment

14 Strategic direction 2: Technical guidance

15 Strategic direction 3: Integration

17 Strategic direction 4: Equitable access

18 Strategic direction 5: Health systems

19 Strategic direction 6: Measurement

20 Strategic direction 7: Collaboration

21 Implementation approach

24 WHOs role

25 References

26 Appendix A. Key indicators in the twenty highest-burden countries

27 Appendix B. Major initiatives in the twenty highest-burden countries

28 Appendix C. Elements and activities

 Abbreviations

AIDS acquired immune deficiency syndrome

ANC antenatal care

ARV antiretroviral

ART antiretroviral therapy

Global Fund The Global Fund to Fight AIDS, Tuberculosis and Malaria

HIV human immunodeficiency virus

IATT interagency task team

IMAI integrated management of adolescent and adult illness

IMCI integrated management of childhood illness

IMPAC integrated management of pregnancy and childbirth

IHP+ International Health Partnership and related initiatives

MCH maternal and child health

MDG Millennium Development Goal

MMR maternal mortality ratio

MNCH maternal, newborn and child health

MTCT mother-to-child transmission (of HIV)

NGO nongovernmental organization

PEPFAR US Presidents Emergency Plan for AIDS Relief

PMTCT prevention of mother-to-child transmission (of HIV)

RH reproductive health

SRH sexual and reproductive health

STI sexually transmitted infection

UN United Nations

UNAIDS Joint United Nations Programme on HIV/AIDS

UNFPA United Nations Population Fund

UNGASS United Nations General Assembly Special Session

UNICEF United Nations Childrens Fund

WHO World Health Organization

4 PMTCT Strategic vision 20102015

Foreword

Prevention of mother-to-child transmission (PMTCT) of HIV has been at the forefront

of global HIV prevention activities since 1998, following the success of the short-course
zidovudine and single-dose nevirapine clinical trials. These offered the promise of a
relatively simple, low-cost intervention that could substantially reduce the risk of HIV
transmission from mother to baby. Research and programme experience over the past
ten years has demonstrated newer and more effective ways to prevent new paediatric
infections, particularly in high-burden, low-resource settings.

In the context of the 2010 UNGASS HIV/AIDS goals and 2015 Millennium Development
Goals, this is a critical time for the global public health community to assess current
progress towards and needs for PMTCT, and to recommit to help achieve national and
international scale-up of effective PMTCT services.

According to the latest data, significant progress has been made in delivering PMTCT
services in low- and middle-income countries. However, much work remains to be done.
An estimated 430000 children were newly infected with HIV in 2008, the vast majority
of them through mother-to-child transmission. Even in countries with strong PMTCT
programmes, there is no room for complacency. In many developed countries, paediatric
HIV has been virtually eliminated. The revised 2009 WHO recommendations for HIV
treatment, PMTCT and HIV and infant feeding provide an important new opportunity to
implement highly effective interventions in resource-limited settings, and promote the
health of mother and child.

We are pleased to present this PMTCT strategic vision 20102015. WHO is committed to
developing norms and standards for effective interventions, and supporting countries to
scale up quality PMTCT services integrated within maternal, newborn and child health
programmes and with sexual and reproductive health programmes. The activities included in
this strategic vision have the potential to save lives, help eliminate paediatric HIV, and greatly
improve the health of women and children.

Dr Hiro Nakatani Daisy Mafubelu

WHO Assistant Director-General WHO Assistant Director-General
for HIV/AIDS, Tuberculosis and Malaria for Family and Community Health

5
 Executive summary

An estimated 430000 children were newly infected with As the lead United Nations (UN) agency in the health sector
HIV in 2008, over 90% of them through mother-to-child and the only UN agency with the technical and programmatic
transmission (MTCT). Without treatment, about half of these mandate to address all four components of the comprehensive
infected children will die before their second birthday. Without approach to prevention of mother-to-child transmission
intervention, the risk of MTCT ranges from 20% to 45%. With (PMTCT) of HIV, WHO is in a unique position to help support
specific interventions in non-breastfeeding populations, the risk global PMTCT efforts.
of MTCT can be reduced to less than 2%, and to 5% or less in
breastfeeding populations. In many developed countries, paediatric HIV has been virtually
eliminated. The newly revised 2009 WHO recommendations
To prevent the transmission of HIV from mother to baby, the for HIV treatment, PMTCT and infant feeding provide an impor-
World Health Organization (WHO) promotes a comprehensive tant new opportunity to implement highly effective interven-
approach, which includes the following four components: tions globally, and particularly in resource-limited settings, and
promote the health of mother and child.
Primary prevention of HIV infection among women of
childbearing age; This PMTCT strategic vision 20102015 defines WHOs com-
mitment to help countries achieve agreed international goals
Preventing unintended pregnancies among women living on PMTCT, increase access to quality PMTCT services and
with HIV; integrate these services with maternal, newborn and child
health and sexual and reproductive health programmes. The
Preventing HIV transmission from a woman living with HIV objectives of the strategic vision illustrate WHOs ongoing
to her infant; and commitment to the PMTCT-related goals of the United Nations
General Assembly Special Session (UNGASS) and to strength-
Providing appropriate treatment, care and support to en support for PMTCT within the context of the Millennium
mothers living with HIV and their children and families. Development Goals.

6 PMTCT Strategic vision 20102015: preventing mother-to-child transmission of HIV

Recent data indicate that reaching these goals demands a WHOs global, regional and country support efforts in the
renewed commitment, and a comprehensive and sustained next few years will focus on responding to the needs of the
approach to scaling up quality and effective PMTCT services, ten countries with the highest number of pregnant women
especially in high-burden countries. To this end, WHO will focus with HIV. It is in these countries, where 75% of the need for
on the following seven strategic directions: PMTCT is found, that WHO can have the greatest impact on
paediatric infections averted and lives saved. In addition, WHO
1. Commitment: Strengthen commitment and leadership for will also intensify its support to accelerate regional approaches
achieving full coverage of PMTCT services. to eliminate paediatric HIV, particularly in low-prevalence and
concentrated epidemic settings.
2. Technical guidance: Provide technical guidance to optimize
HIV prevention, care and treatment services for women
and children.

3. Integration: Promote and support integration of HIV

prevention, care and treatment services with maternal,
newborn and child health and reproductive health
programmes.

4. Equitable access: Ensure reliable and equitable access for

all women, including the most vulnerable.

5. Health systems: Promote and support health systems

interventions to improve the delivery of HIV prevention,
care and treatment services for women and children.

6. Measurement: Track programme performance and impact

on MTCT rates and on maternal and child health outcomes.

7. Collaboration: Strengthen global, regional and country

partnerships for providing HIV prevention, care and treat-
ment for women, infants and young children, and advocate
for increased resources.

7
 Background

HIV infection transmitted from an HIV-infected mother to her the highest rates of infection, coverage with ARVs jumped to
child during pregnancy, labour, delivery or breastfeeding is 58% in 2008 from 46% in 2007 due to increased national
known as mother-to-child transmission (MTCT). The prevention commitment and focused international support. In fact, several
of mother-to-child transmission (PMTCT) is a highly effective countries in sub-Saharan Africa, including Botswana, Namibia
intervention and has huge potential to improve both maternal and Swaziland, have now achieved the United Nations General
and child health. In 2001, the United Nations General Assembly Assembly Special Session (UNGASS) goal of 80% coverage
set a target for 80% of pregnant women and their children to with significant reductions in new infant infections. Several
have access to essential prevention, treatment and care by 2010 other large countries with a high HIV prevalence, including
to reduce the proportion of infants infected by HIV by 50%. South Africa, Kenya and Zambia, are accelerating progress
towards this goal, demonstrating that national scale-up of
According to the 2009 report, Towards universal access: scaling PMTCT services in resource-limited settings can be achieved.
up priority HIV/AIDS interventions in the health sector, significant
progress in the area of PMTCT has been made during the past Significant improvements have also been demonstrated in other
several years. In 2008, 45% of the estimated HIV-infected regions. The percentage of pregnant women with HIV receiving
pregnant women in low- and middle-income countries received at least some ARVs for PMTCT in Latin America increased from
at least some antiretroviral (ARV) drugs to prevent HIV 47% in 2007 to 54% in 2008, and in the Caribbean from 29%
transmission to their child, up from 35% in 2007 and 10% in to 52%. In Europe and Central Asia, coverage jumped from 74%
2004. In Eastern and Southern African nations, which have in 2007 to 94% in 2008.

Percentage of pregnant women with HIV receiving antiretrovirals for preventing mother-to-child transmission of HIV
in low- and middle-income countries by region, 20042008
100%
94
2004 2005 2006 2007 2008
90%

80%
74
70%
65 66

60% 58
54
50%
45 45
43 42
41
40%
35 35 35

30%
24 24 25 24
20%
15 16 15
9 9 9 10
10%

0%
Sub-Saharan Latin America and Europe and East, South and Total low- and middle-
Africa the Caribbean Central Asia South-East Asia income countries

The bar indicates the uncertainty range around the estimate.

Source: WHO, UNAIDS, UNICEF. Towards universal access: scaling up priority HIV/AIDS interventions in the health sector. Progress report 2009. p 99.

8 PMTCT Strategic vision 20102015: preventing mother-to-child transmission of HIV

One important reason for the improving coverage is that HIV interventions, including the provision of antiretroviral treatment
testing among pregnant women is increasing with the expan- (ART) for pregnant women and mothers eligible for treatment,
sion of provider-initiated testing and counselling in antenatal and to demonstrate the impact of these interventions by
clinics, labour and delivery centres, and other health-care a decrease in paediatric infections, HIV-free survival, and
settings. In 2008, an estimated 21% of pregnant women giving improved maternal and child health.
birth in low- and middle-income countries were tested for HIV,
up from 15% in 2007. In sub-Saharan Africa, the corresponding To prevent the transmission of HIV from mother to baby, WHO
percentage rose from 17% to 28%, with particularly high rates promotes a comprehensive strategic approach that includes the
of increase in countries in Eastern and Southern Africa. following four components:

Yet, despite recent progress, much work remains to be done. In Primary prevention of HIV infection among women of
2008, an estimated 430 000 children were newly infected with childbearing age;
HIV, nearly all of them through MTCT. Globally, HIV/AIDS is Preventing unintended pregnancies among women living
now the leading cause of mortality among women of reproduc- with HIV;
tive age and, in several high-burden countries such as South Preventing HIV transmission from a woman living with HIV
Africa and Zimbabwe, HIV is the leading cause of maternal to her infant; and
mortality. Even in countries that are rapidly scaling up PMTCT Providing appropriate treatment, care and support to
services, the major challenge is to provide more effective ARV mothers living with HIV and their children and families.

Percentage of pregnant women who received an HIV test in low- and middle income countries by region, 20042008

100%

2004 2005 2006 2007 2008

90%

80%

70%

65 65
60%

57
50%

46 45
40%
40 40
38
30%
28 29

20% 21
19
17
14 15
10% 12 13
9
6 7 8 7 7
0% 3 2
Sub-Saharan Latin America and Europe and East, South and Total low- and middle-
Africa the Caribbean Central Asia South-East Asia income countries

Source: WHO, UNAIDS, UNICEF. Towards universal access: scaling up priority HIV/AIDS interventions in the health sector. Progress report 2009. p 98.

9
 As the UNs lead agency for the health sector and co-lead Because many of the countries with the highest burden of HIV
for PMTCT with UNICEF, WHOs role is to provide normative also face the greatest challenges in making progress in maternal
guidance on standards and approaches for PMTCT interventions, and child health, more effective linkages are required between
and technical, evidence-based support to help Member States the services addressing HIV and those addressing other major
deliver effective PMTCT services and monitor progress. causes of maternal and child mortality. The overlapping HIV,
tuberculosis and malaria epidemics, and the continuing high
Priority actions differ between and within regions depending burden of maternal and neonatal deaths illustrate not just the
on the nature of the local epidemic. For instance, efforts in three necessity for joint responses but also the synergies that might
WHO regions (Western Pacific Region, South-East Asia Region be achieved if such planning can be successfully converted into
and Americas Region) focus on the dual elimination of MTCT effective implementation. Achieving equitable and universal
of HIV and congenital syphilis, primarily in low-prevalence and access to primary health care demands all of these components
concentrated epidemic settings. In Eastern Europe, improving to come together. As part of this strategic vision, WHO will
PMTCT services for affected high-risk populations, such as play an active role in promoting linkages between PMTCT and
injecting drug users and their partners, is a priority. In sub- maternal and child health (MCH) and sexual and reproductive
Saharan Africa, which includes 90% of PMTCT need and where health (SRH) services.
many countries have very high prevalence, emphasis is on rapid
scale-up of effective interventions and national programmes to The vision, goal, objectives and targets outlined in this strategic
significantly reduce new paediatric infections. vision, as well as the strategic directions, elements and activi-
ties, will serve as a framework for WHO to support countries to
focus on and prioritize the accelerated scale-up of effective and
comprehensive PMTCT services, demonstrate the public health
impact of PMTCT interventions, and integrate HIV and PMTCT
with other key programmes.

10 PMTCT Strategic vision 20102015: preventing mother-to-child transmission of HIV

Vision, goal, objectives and targets

VISION: Women and children alive and free of HIV

GOAL: To eliminate paediatric HIV infections and improve maternal, newborn and child health and survival in the context of HIV

OBJECTIVES: 1. Accelerate global and national scale-up of effective and comprehensive PMTCT services.
2. Improve the quality and demonstrate the public health impact of PMTCT services.
3. Strengthen linkages between maternal, newborn and child health services, reproductive health services and
HIV-related services to reduce overall maternal and child mortality.

TARGETS:
At present, there are a number of important international targets related to PMTCT. The Millenium Development Goals (MDGs)
adopted by the UN General Assembly in 2000 committed the international community to reducing child mortality, improving
maternal health, and combating HIV/AIDS, malaria and other diseases by 2015. At the UN General Assembly Special Session
(UNGASS) in 2001, governments further committed to reduce by 50% the proportion of infants infected by HIV by 2010 by ensuring
that 80% of pregnant women accessing antenatal care receive PMTCT services.

However, the PMTCT UNGASS targets were for 2010 and were developed before the concept of universal access and the new, more
effective PMTCT interventions. In addition, the MDGs do not provide specificity with regard to what needs to be achieved in the areas
of the prevention of MTCT and paediatric HIV.

In light of encouraging progress on PMTCT (see Towards universal access, 2009), more effective interventions, and a new global focus
on PMTCT, new PMTCT targets are needed for 2015. At global level, WHO will work with UNAIDS, co-sponsors and key stakeholders
to put in place an inclusive process through which more ambitious targets for 2015 can be appropriately reviewed and endorsed. At
country level, drawing on global agreements, WHO will work with national authorities and partners to set targets that reflect the new
PMTCT recommendations and promote progress towards the elimination of paediatric HIV.

Millennium Development Goals (MDGs) UNGASS Target 54

and targets

MDG 4: Reduce child mortality By 2010, reduce by 50% the proportion of infants
Target 4.A: Reduce by two-thirds, between 1990 and infected by HIV by ensuring that:
2015, the under-five mortality rate.
Eighty per cent of pregnant women accessing antenatal
MDG 5: Improve maternal health care have HIV information, counselling and other HIV-
Target 5.A: Reduce by three quarters, between 1990 prevention services available to them.
and 2015, the maternal mortality ratio.
Target 5.B: Achieve, by 2015, universal access to
reproductive health.
MDG 6: Combat HIV/AIDS, malaria and other diseases
Target 6.A: Have halved by 2015 and begun to reverse
the spread of HIV/AIDS.
Target 6.B: Achieve, by 2010, universal access to
treatment for HIV/AIDS for all who need it.

11
 Strategic directions

The WHO strategy to accelerate the scale-up of HIV prevention, care and treatment for women and children comprises seven principal
strategic directions (see Appendix C for elements and activities in support of the strategic directions):

Commitment
one

Strengthen commitment and leadership for achieving full coverage

of PMTCT services.

Technical guidance
TWO

Provide technical guidance to optimize HIV prevention, care and treatment services
for women and children.

Integration
THREE

Promote and support integration of HIV prevention, care and treatment services
within maternal, newborn and child health and reproductive health programmes.

Equitable access
FOUR

Ensure reliable and equitable access for all women, including

the most vulnerable.

Health systems
Five

Promote and support health systems interventions to improve the delivery of HIV
prevention, care and treatment services for women and children.

Measurement
SIX

Track programme performance and impact on mother-to-child HIV transmission rates

and on maternal and child health outcomes.

Collaboration
SEVEN

Strengthen global, regional and country partnerships for providing HIV prevention, care and
treatment for women, infants and young children and advocate for increased resources.

12 PMTCT Strategic vision 20102015: preventing mother-to-child transmission of HIV

Strategic direction 1: Commitment

Strengthen commitment and leadership for achieving full coverage

of PMTCT services

Experience indicates the importance of strong commitment health sector planning processes, especially in high-burden
and leadership to achieve rapid scale-up of PMTCT services. countries. Support will also be provided for conducting in-depth
WHO will work with partners at the global, regional and assessments of programme needs and gaps, and for setting
country levels to advocate for scaling up comprehensive health targets for rapid programme scale-up towards full geographical
services for women and children in the context of HIV. WHO and population-based coverage. WHOs basic approach in
will also promote and support regular monitoring of progress this regard is to reach every district with a core package of
towards PMTCT-related goals and targets, and strengthen essential health interventions for all women and children, which
accountability mechanisms. The new regional initiative to includes HIV prevention, care and treatment.
eliminate MTCT of HIV in Latin America is an example of this
strong leadership and commitment (See Box A). WHO will work within the UNAIDS Outcome framework to
develop new PMTCT targets for 2015 to support universal
WHO will provide active support for national policy and access and the elimination of paediatric HIV.
strategy development related to PMTCT within national

Box A: Regional initiative for the elimination of mother-to-child transmission of HIV and
congenital syphilis in Latin America and the Caribbean*

HIV and syphilis are major public health problems affecting women and their newborn infants in Latin America and the
Caribbean. It is estimated that, every year, approximately 6000 children are newly infected with HIV in the region, and
there are more than 450000 cases of gestational syphilis.

The Pan American Health Organization (WHOs Regional Office for the Americas) and the United Nations Childrens
Fund (UNICEF) have defined the elimination of MTCT of HIV and congenital syphilis as a top priority for the region.
Together with key partners and stakeholders, they have recently launched an elimination campaign to be achieved by
the year 2015. The strategy focuses on four strategic lines of action:

Enhancing the capacity of MNCH services for the early detection, care and treatment of HIV and syphilis among
pregnant women, their partners and infants;
Strengthening the surveillance of HIV and syphilis in MCH services and health information systems;
Integrating interventions for managing HIV and sexually transmitted infections (STIs) with services for sexual and
reproductive health (SRH) and other relevant services; and
Strengthening health systems.

At present, WHO is working with countries in the region to develop national acceleration plans, including identifying
opportunities for integration with existing MCH services, setting national elimination targets and strengthening the
capacity of the health workforce. Importantly, WHO has developed a regional monitoring and evaluation framework that
presents a common set of indicators and establishes reporting and communication channels, proposes quality control
mechanisms and outlines suggested analysis for case reporting.
* For more information, visit the WHO Regional Office for the Americas website:
http://new.paho.org/hq/index.php?option=com_content&task=blogcategory&id=987&Itemid=904&lang=e

13
 Strategic direction 2: Quality

Improve the quality of HIV prevention, care and treatment services

for women and children

WHO will continue to develop and support evidence-based WHO will assist countries with the rapid adoption, adaptation
normative guidance to assure quality PMTCT interventions and implementation of new recommendations, including
and services with maximum public health benefit (see BoxB). support to update national guidelines, and to develop or
Regular reviews of emerging evidence will be carried out, improve operational guidance and tools.
and global guidelines and recommendations will be updated
as required. Given the dynamic nature of the field, with
frequently emerging new evidence, evolving programme
experience, and significant advances in the development of
drugs and technologies, guidelines are expected to be revised
approximately every three years.

Box B: Revisions to WHO guidelines for antiretroviral drugs for treating pregnant women
and preventing HIV infection in infants; and infant feeding in the context of HIV (2009)*

One of WHOs most important roles is to provide evidence-based normative guidance on programme standards and
interventions. The PMTCT guidelines have been revised several times since 2000, in response to rapidly changing
evidence and programme experience.

The newly revised guidelines on ARVs for PMTCT and on HIV and infant feeding provide updated normative guidance
for providing highly effective ARV interventions to significantly reduce the risk of MTCT and ensure safe infant-feeding
strategies. These new guidelines represent a major shift towards more effective interventions.

Key recommendations and principles of the guidelines include:

Provide lifelong antiretroviral treatment (ART) for all pregnant women with CD4 350 cells/mm3 or advanced
clinical disease
Pregnant women in need of ART for their own health should receive ART
CD4 testing is critical for determining ART eligibility and should be widely available
For women not eligible for ART, provide combination ARV prophylaxis (with either AZT or triple ARV prophylaxis)
beginning in 2nd trimester and linked with postpartum prophylaxis
In settings where breastfeeding is the preferred infant feeding option, provide prophylaxis to either the mother or
infant during breastfeeding

Once implemented, these recommendations can help reduce the risk of MTCT to less than 5% in breastfeeding
populations, and even lower in non-breastfeeding settings, and can dramatically improve maternal and child health and
survival. These new, more effective interventions make it possible for high-burden and resource-limited countries to
target the virtual elimination of paediatric HIV, a goal which has already been achieved in many developed countries.
* At the time of this printing, the revised guidelines are being finalized; Rapid advice summaries of the key recommendations were posted online,
November 2009 (see references).

14 PMTCT Strategic vision 20102015: preventing mother-to-child transmission of HIV

Strategic direction 3: Integration

Promote and support integration of HIV prevention, care and treatment

services within maternal, newborn and child health and reproductive
health programmes
PMTCT services have sometimes been established as stand- expand the most current HIV prevention, treatment and care
alone vertical programmes, lacking sufficient integration with guidance into local district management plans, including
MNCH programmes, which share the same goals and provide linkages with services for the management of syphilis, family
the basic platform and infrastructure for effective and sustain- planning, immunization and other interventions. A package of
able delivery of HIV services. core interventions for improving PMTCT and MNCH integration
in high-burden settings will be further developed, as necessary,
WHO will continue its efforts to support increased collaboration and promoted. High priority will be given to strengthening
and, where appropriate, service integration between programme linkages between PMTCT and HIV care and treatment services
sectors. A framework will be developed and promoted to align for women, their children and other family members in order to
targets, activities, and monitoring and evaluation processes support an effective continuum of care.
across programme areas. Countries will be supported to link
different programmes by formalizing a management structure Finally, WHO will promote increased community participation
that facilitates coordination at the national and district levels. (including male partners and community health workers) for
support and delivery of PMTCT services.
WHO will also support model district operational plans and
adaptation guides to help countries to rapidly integrate and

Box C: Linking HIV/STI services with reproductive, adolescent, maternal, newborn and
child health services in Asia

Jointly with other United Nations agencies, WHOs Regional Office for the Western Pacific has developed an Asia
Pacific operational framework for linking HIV/STI services with reproductive, adolescent, maternal, newborn and child
health services. Known as the Guilin Framework, this regional document has served as a practical reference for national
and subnational actions.

Four countriesCambodia, China, Papua New Guinea and Viet Namhave adapted and piloted the framework. Among
these countries, Cambodia has expanded operationalization of linkages at all levels. Through this pioneering linked response,
Cambodia has demonstrated that links between services are possible and suitable in resource-constrained settings.

In WHOs South-East Asia Region, India, which has the highest burden of new paediatric HIV infections in the Region,
has committed to implementing more effective interventions and integrating PMTCT (known in India as PPTCT) with
reproductive and child health services within the governments general health system.

The AsiaPacific PMTCT Task Force recently convened their seventh regional meeting in Chennai, India with a broad
theme of Making the most of PMTCT in low and concentrated epidemic settings. Twenty countries from the region
shared best practices and challenges in implementing PMTCT services, and noted the vital importance of improving
linkages with MCH services in order to achieve the elimination of paediatric HIV.

15
 Box D: Involving male partners and communities in scaling up PMTCT services
successes from sub-Saharan Africa

To be successful, PMTCT programmes for HIV must include strategies to reduce stigma by engaging opinion leaders at
the community level, normalize HIV and facilitate access to services by women living with HIV. Programmes must also
strengthen the relationship between the formal health system and community organizations to expand HIV prevention
services and treatment literacy and preparedness.

In this context, community health workers play an important role in increasing the uptake of PMTCT services by
providing information on access to services, expanding treatment literacy related to the use of ARVs, supporting
treatment preparedness and adherence, and encouraging positive prevention and disclosure of HIV status. In Kenya,
for instance, community health workers successfully provide follow-up services for people receiving ART.

Male partners play an equally important role in the scale-up of PMTCT services. In Botswana and Zambia, where
disclosure of HIV status among pregnant women is relatively high, families and male partners are involved in decisions
around ART and infant feeding. Rwanda has embarked on a strong programme promoting male partner testing in
antenatal clinics and has achieved remarkable success78% of male partners were reported tested for HIV in 2008.

16 PMTCT Strategic vision 20102015: preventing mother-to-child transmission of HIV

Strategic direction 4: Equitable access

ENSURE RELIABLE AND EQUITABLE ACCESS FOR ALL WOMEN, INCLUDING

THE MOST VULNERABLE

Considerable inequities are observed in access to PMTCT WHO will support countries to provide HIV services for all
services, based on location, income and other socioeconomic people by advocating for access to a comprehensive and
factors. For instance, in countries with generalized epidemics, integrated package of services for women and children in the
rural and/or poor women often have difficulty in accessing context of HIV. Such services should be provided free at the
services. In areas with concentrated epidemics, there are often point of service delivery.
considerable barriers to access, especially for high-risk and
vulnerable women such as sex workers, drug users and their WHO will support countries to provide HIV services for
partners. In these settings, female drug users and sex workers vulnerable populations, including sex workers and drug users
may perceive HIV testing and counselling during pregnancy as and their partners.
a potential risk for stigmatization, discrimination, prosecution
or losing custody of their children. National programmes should In humanitarian settings, WHO will work with partners to
ensure that antenatal care, labour and delivery, and postpartum ensure that the response to HIV is mainstreamed into the
services provide a user-friendly environment for women living workplan of the health sector and that agreed standards for
with HIV who are drug users or sex workers. HIV and RH services are met during complex emergencies.

17
 Strategic direction 5: Health systems

PROMOTE AND SUPPORT HEALTH SYSTEMS INTERVENTIONS TO IMPROVE THE delivery OF

HIV PREVENTION, CARE AND TREATMENT SERVICES FOR WOMEN AND CHILDREN

Achieving universal access to PMTCT services rests on the WHO will also assist countries to strengthen their health
capacity of national and local health systems to deliver these information systems through a range of activities, including
services. Weaknesses in human resource capacity, supply support for strengthening in-country capacity for improved
chain, programme management, health financing and informa- data management and the design and implementation of
tion systems have hampered the scale-up of services. In integrated management information systems.
particular, WHO will provide technical support to countries for
strengthening health systems to address these weaknesses. Quality improvement methods will be developed and promoted
to strengthen regional and district-level health systems, and
WHO will promote and support health systems interventions to improve the quality and reliability of HIV prevention, care and
improve the quality and reliability of PMTCT services, inluding treatment services for women and children.
systems to improve procurement and supply management of
essential medicines and diagnostics. Finally, WHO will help improve human resource capacity by
assisting countries to ensure that maternal, newborn, child
and reproductive health services are adequately addressed
in national human resources development, management and
training plans.

18 PMTCT Strategic vision 20102015: preventing mother-to-child transmission of HIV

Strategic direction 6: Measurement

TRACK PROGRAMME PERFORMANCE AND IMPACT ON MTCT RATES AND ON MATERNAL

AND CHILD HEALTH OUTCOMES

WHO, in collaboration with UNICEF and UNAIDS, regularly given to improving estimates of disease burden, populations
provides updates on country progress in scaling up HIV preven- needing key interventions, cost of interventions, and impact
tion, care and treatment services for women and children, of interventions on transmission rates, survival, and progress
including links to the MDG and UNGASS goals. Global progress towards MDGs 4, 5 and 6. At the country level, WHO will
in scaling up HIV prevention, care and treatment services for provide support to expand and strengthen health information
women and children will continue to be summarized in the systems to provide effective geographical and population-
annual progress report Towards universal access: scaling up based monitoring of coverage.
priority HIV/AIDS interventions in the health sector. In addition,
more detailed reports will be produced, which assess progress To improve the quality, interpretation and use of data, WHO
in scaling up HIV interventions towards achieving MDGs 4, 5 will support countries to undertake data quality assessments,
and 6, with an emphasis on the health sector. These reports critical reviews of performance indicators, and special surveys
will be published in 2010, 2012 and 2015, as part of WHOs and updated modelling.
contribution to monitoring and reporting on the UNGASS
targets and MDGs. Finally, WHO will play a convening role for the determination
of global priorities for research, including operational and
International guidance on monitoring and evaluating national impact evaluation research intended to improve programmes
programme performance and health outcomes will be and policies.
regularly reviewed and updated. Special attention will be

19
 Strategic direction 7: Collaboration

Strengthen global and regional partnerships on HIV prevention, care

and treatment for women, infants and young children and advocate
for increased resources

For more than a decade, a wide range of bilateral donors, Women, Mothers and their Children, which has proven to be an
nongovernmental organizations (NGOs), foundations, the important strategic and collaborative framework for coordinat-
private sector, people living with HIV, faith-based organizations, ing PMTCT support activities between the UN and an expanded
multilateral agencies and national governments have been range of partners, funders and implementers.
engaged in scaling up access to PMTCT services. As interest
in and commitment to PMTCT scale-up continues to grow, it To support the mobilization of adequate resources for PMTCT
is important to optimize synergies between partner inputs and scale-up, WHO and partners will estimate global and regional
avoid duplication. WHO will use this strategic vision to continue resource gaps. WHO will encourage international solidarity to
to work closely with a wide range of partners, both inside and secure and sustain financing for scale-up, including long-term
outside of the UN system. commitments by existing public and private funding entities,
and new financial mechanisms.
Within the UNAIDS division of labour, WHO is the lead techni-
cal agency for PMTCT in the health sector and co-convener of Increased technical support will be provided to the Global
PMTCT programme support with UNICEF. WHO will continue Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund)
to help lead the development and regular review of joint plans to promote more effective, comprehensive and integrated
at the global and regional levels within the UNAIDS mechanism. PMTCT services, and to strengthen health systems. Specific
Similarly, WHO will strengthen the well-established Interagency support will be provided to countries for PMTCT-related grant
Task Team (IATT) on Prevention of HIV Infection in Pregnant reprogramming and new proposal development.

Box E: Working together to accelerate progress in maternal and newborn health (H4)*

WHO is working closely with three UN agencies, the United Nations Population Fund (UNFPA), UNICEF and the World
Bank, to accelerate progress in saving the lives of women and newborns. During the coming years, the four agencies
will harmonize their support to countries with the highest maternal mortality, starting with six, scaling up
to 25 and later covering 60 countries. This initiative provides an important opportunity to integrate PMTCT with
maternal and newborn services.

The agencies will work with governments and civil society to strengthen health systems so that they can reduce the
maternal mortality ratio (MMR) by 75% and achieve universal access to reproductive health, as called for by MDG 5.
These joint efforts will also contribute to reducing child mortality, as called for by MDG 4. The focus will be on scaling
up quality and comprehensive RH services, including strong linkages with HIV prevention, care and treatment for
women and newborns.

In-country activities will be coordinated with and build upon other harmonization and support processes, including the
International Health Partnership (IHP+).
*  H4 Initiative Intensified joint efforts by WHO, UNICEF, UNFPA and World Bank to support countries to improve maternal and newborn health and
save the lives of mothers and babies.

20 PMTCT Strategic vision 20102015: preventing mother-to-child transmission of HIV

Implementation approach

Focus on 10 highest-burden countries provide support to all regions and all high-burden countries as
In 2008, an estimated 1.4 million pregnant women in low- needed, WHOs global efforts in the next few years will focus
and middle-income countries were living with HIV, of whom on responding to the needs of the 10 countries with the highest
90% were from just 20 countries; all but one (India) are in sub- number of pregnant women with HIV and coordinating support
Saharan Africa (see figure below and Appendix A). It is in these for related initiatives focusing on these countries (see top 10
countries that WHO can have the greatest impact on infections high-burden countries in Appendix A and B).
averted and lives saved, especially the 10 countries with the
highest number of pregnant women with HIV, where 75% of WHOs approach to implementation will follow the strategic
the need for PMTCT services is found. In these 10 countries directions and activities outlined in this PMTCT strategic vision.
alone, successful scale-up of effective interventions to achieve Within this vision, several key approaches will be highlighted,
MTCT rates of less than 5% would prevent more than 250000 including active support for: the national programme, including
infant infections annually. More effective, integrated PMTCT management, updating of guidelines, target-setting, and annual
interventions at the regional and country levels in these high- reviews and monitoring; the joint UN programme framework;
burden countries will help advance the global PMTCT effort and expanded and strategic partnerships with international and
towards elimination of paediatric HIV, and make significant bilateral funding and implementing agencies (see Box F).
progress towards the MDGs. While WHO will continue to

Percentage of pregnant women living with HIV receiving antiretrovirals to prevent the mother-to-child transmission of HIV in 20
countries with the highest HIV disease burden among pregnant women (in descending order), 2008

Estimated number of pregnant women living with HIV Percentage of pregnant women living with HIV receiving antiretrovirals
to reduce the risk of mother-to-child transmission of HIV
250 000 100%

90%

United Nations General Assembly Special Session on HIV/AIDS target for 2010
200 000 80%

70%

150 000 60%

50%

100 000 40%

30%

50 000 20%

10%

0 0%
ria
rica ya
ue lic da bia wi we ndia ia on lic ire di ola ad ho na na
ige Af K en pub ania gan
biq a m ala ab I h iop ero pub ngo Ivo urun ng Ch so
t
ha wa
N h m R e z U Z M b E t m e o d B A Le G ts
u t
oz
a d a n
Zi
m
Ca tic R e C te Bo
So M ite f T ra f th C
Un o oc o
m
De
The bar indicates the uncertainty range around the estimate.
Source: WHO, UNAIDS, UNICEF. Towards universal access: scaling up priority HIV/AIDS interventions in the health sector. Progress report 2009. p 101.

21
 Regional support for elimination of paediatric HIV in countries Revised WHO PMTCT ARV and infant feeding guidelines
with low and concentrated epidemics (2009)
WHO regional and country offices are actively supporting WHO is revising its guidelines on the Use of antiretroviral
PMTCT scale-up efforts to eliminate paediatric HIV in countries drugs for treating pregnant women and preventing HIV infection
with predominantly low and concentrated epidemics. There in infants (2009) and related guidelines on ART and infant
is increased country commitment and momentum in many feeding in the context of HIV. With these revised guidelines,
of these countries to move towards elimination of paediatric there are now highly effective recommended strategies
HIV. Efforts in three WHO regions (Western Pacific Region, for treating mothers who need ART for their own health,
South-East Asia Region and Americas Region) will continue and providing extended prophylaxis during pregnancy and
to focus on integration of PMTCT and MCH services, and the breastfeeding (in settings where breastfeeding is the preferred
dual elimination of MTCT of HIV and congenital syphilis. In option) to significantly reduce the risk of MTCT (see Box B).
countries with concentrated epidemics among most-at-risk Once implemented, these recommendations can help reduce
populations, such as in Eastern Europe, improving access the risk of MTCT to less than 5% in breastfeeding populations,
to PMTCT services by sex workers and injecting drug users and even lower in non-breastfeeding settings, and can
continues to be an important priority. Finally, in humanitarian dramatically improve maternal and child health and survival.
settings, WHO will work with partners to ensure that the HIV These new, more effective interventions make it possible
and reproductive health needs of women and children are met for high-burden and resource-limited countries to target the
during complex emergencies. virtual elimination of paediatric HIV, a goal which has already
been achieved in many developed countries.

WHO will work actively with UN and other implementing

partners, including PEPFAR, to plan for rapid dissemination
of these revised guidelines. Much experience has been
gained from dissemination of previous guidelines, and WHO
will develop adaptation tools and provide active support for
guideline revision and evaluation at regional and country level.

22 PMTCT Strategic vision 20102015: preventing mother-to-child transmission of HIV

 Box F: WHOs approach to implementation in high-burden countries

While WHO will continue to provide support to all countries through its regional offices and programmes, and all high-
burden countries as needed, in the next few years WHOs global efforts will focus on responding to the needs of the 10
countries with the highest number of pregnant women with HIV (see Appendix A and B).

In these 10 countries, WHO will work with the Ministry of Health and partners to:
Define the current baseline for PMTCT programme coverage and need;
Set annual targets for programme scale-up to 2015;
Support updated policies and guidance;
Support rapid implementation of new policies and guidance;
Strengthen national technical working groups and national management of PMTCT;
Promote a harmonized, strategic approach to donor and implementation support;
Provide technical assistance to key funders, implementers and initiatives (e.g. Global Fund and PEPFAR);
Convene annual, national PMTCT meetings to review progress and challenges, and define key goals and decisions
for the coming year;
Support improved programme data monitoring and modelling of coverage, need and impact;
Support integration of PMTCT with MCH and RH programmes;
Promote joint planning and accountability; and
Support health systems strengthening and sustainability.

Coverage of antiretrovirals to prevent the mother-to-child transmission of HIV, 2008

80100%
5080%
2550%
1025%
Less than 10%
Data not available/
high income country

Source: WHO, UNAIDS, UNICEF. Towards universal access: scaling up priority HIV/AIDS interventions in the health sector. Progress report 2009. p 102.

23
 WHOs role

According to the UNAIDS Division of Labour, WHO is the co-lead with

UNICEF for PMTCT and will be helping to lead the new UNAIDS Outcome
framework for PMTCT (under development). As the lead UN agency in the
health sector and the only UN agency with the technical and programmatic
mandate to address all four components of the comprehensive approach to
PMTCT, WHO is in a unique position to guide the acceleration of PMTCT.
WHO has the mandate to provide normative global guidelines and recom-
mendations for best practices and programme standards for PMTCT service
delivery and for broader MCH programmes, and to support the adaptation
and implementation of new guidelines and best practices at regional and
country levels. In addition, WHO has the technical expertise and capacity
to support the availability of essential drugs, key health technologies and
laboratory testing, health systems strengthening, and monitoring and
evaluation across both PMTCT and MCH programmes. Above all, WHO has
a unique relationship with national governments and ministries of health,
and an important role to play in supporting programme development and
management at the country level.

24 PMTCT Strategic vision 20102015: preventing mother-to-child transmission of HIV

References

Countdown Coverage Writing Group. Countdown to 2015 for maternal, newborn and child survival: the 2008 report on tracking
coverage of interventions. The Lancet, 2008 Apr 12, 371:1247-58.

UNAIDS, WHO. 2009 AIDS epidemic update. Geneva, UNAIDS, 2009. http://data.unaids.org/pub/Report/2009/2009_epidemic_
update_en.pdf (accessed on 24 November 2009.)

UNICEF. Countdown to 2015 MNCH: the 2008 Report: tracking progress in maternal, newborn and child survival. New York, UNICEF, 2008.
http://www.countdown2015mnch.org/index.php?option=com_content&view=article&id=68&Itemid=61 (accessed on
10 November 2009).

UNICEF, WHO, UNAIDS, UNFPA. Children and HIV/AIDS: third stocktaking report. New York, UNICEF, 2008. http://www.who.int/hiv/
pub/paediatric/ca_stocktaking/en/index.html (accessed on 10 November 2009).

United Nations General Assembly Special Session. Declaration of Commitment on HIV/AIDS. New York, UN, 2001. http://data.unaids.
org/publications/irc-pub03/aidsdeclaration_en.pdf (accessed on 10 November 2009).

WHO. Antiretroviral drugs for treating pregnant women and preventing HIV infection in infants: towards universal access: recommendations
for a public health approach. Geneva, World Health Organization, 2006.
http://www.who.int/hiv/pub/mtct/antiretroviral/en/index.html (accessed on 10 November 2009).

WHO. Rapid advice: antiretroviral therapy for HIV infection in adults and adolescents. Geneva, World Health Organization, 2009.
http://www.who.int/hiv/pub/arv/advice (accessed on 30 November 2009)

WHO. Rapid advice: infant feeding in the context of HIV. Geneva, World Health Organization, 2009.
http://www.who.int/hiv/pub/paediatric/advice (accessed on 30 November 2009)

WHO. Rapid advice: use of antiretroviral drugs for treating pregnant women and preventing HIV infection in infants. Geneva, World Health
Organization, 2009. http://www.who.int/hiv/pub/mtct/advice (accessed on 30 November 2009)

WHO. WHO Statistical Information System (WHOSIS), 2009 database. http://www.who.int/whosis/en (accessed on
22November 2009).

WHO, UNAIDS, UNICEF. Towards universal access: scaling up priority HIV/AIDS interventions in the health sector. Progress report 2009.
Geneva, World Health Organization, 2009. http://www.who.int/entity/hiv/pub/tuapr_2009_en.pdf (accessed on 10
November 2009).

WHO, UNICEF, with the Interagency Task Team (IATT) on Prevention of HIV Infection in Pregnant Women, Mothers and their Children.
Guidance on global scale-up of the prevention of mother-to-child transmission of HIV: towards universal access for women,
infants and young children and eliminating HIV and AIDS among children. Geneva, World Health Organization, 2007.
http://whqlibdoc.who.int/publications/2007/9789241596015_eng.pdf (accessed on 10 November 2009).

WHO, UNICEF, UNAIDS, UNFPA. HIV and infant feeding: framework for priority action. Geneva, World Health Organization, 2007.
http://www.who.int/hiv/pub/mtct/infant_feeding/en/index.html (accessed on 10 November 2009).

25
 Appendix A. Key indicators in the twenty highest-burden countries

PMTCT need MDG 5: MDG 4: ANC

Maternal Infant
(Estimated Improve Reduce coverage
Country mortality mortality
number of HIV+ maternal child 1visit
ratio rate
pregnant women) health mortality (4 visits)

Per Per 1000

Level of On track? Estimated
Point estimate, 100000 live births
maternal Based on percent
2008 live births, both sexes,
mortality U5MR** 200006
2005 2007

1 Nigeria 210 000 1100 Very high 97 Insufficient 58 (47)

2 South Africa 200 000 400 High 46 Progress 92 (73)

Top 10 high-burden countries

3 Mozambique 110 000 520 Very high 115 Insufficient 85 (53)

4 Kenya 110 000 560 Very high 80 No progress 88 (52)

5 Tanzania 100 000* 950 Very high 73 Insufficient 78 (62)

6 Uganda 82 000 550 Very high 82 Insufficient 94 (47)

7 Zambia 70 000 830 Very high 103 No progress 94 (72)

8 Malawi *73 000 1100 Very high 71 Insufficient 92 (57)

9 Zimbabwe 53 000 880 Very high 59 No progress 94 (71)

10 India 49 000 450 High 54 Insufficient 74 (37)

11 Ethiopia 36 000 720 Very high 75 Insufficient 28 (12)

12 Cameroon 36 000 1000 Very high 87 No progress 82 (60)

13 Democratic Republic 32 000 1100 Very high 108 No progress 85 (47)

of the Congo

14 Cte dIvoire 22 000 810 Very high 89 Insufficient 85 (45)

15 Burundi 16 000 1100 Very high 108 No progress 92 (79)

16 Angola 16 000 1400 Very high 116 Insufficient 80 (?)

17 Chad 15 000 1500 Very high 124 No progress 39 (18)

18 Lesotho 14 000 960 Very high 68 Progress 90 (70)

19 Ghana 13 000 560 Very high 73 No progress 92 (69)

20 Botswana 12 000 380 High 33 Progress 97 (97)

* point estimate for 2008 not available; 2007 point estimate used
** U5MR = Under-five mortality rate

26 PMTCT Strategic vision 20102015: preventing mother-to-child transmission of HIV

 Appendix B. Major initiatives in the twenty highest-burden countries (as of 2009)

Global Fund PMTCT

Country H4 IHP+ PEPFAR focus country
prioritisation

1 Nigeria

2 South Africa
Top 10 high-burden countries

3 Mozambique

4 Kenya

5 Tanzania

6 Uganda

7 Zambia

8 Malawi

9 Zimbabwe

10 India

11 Ethiopia

12 Cameroon

13 Democratic Republic
of the Congo

14 Cte dIvoire

15 Burundi

16 Angola

17 Chad

18 Lesotho

19 Ghana

20 Botswana

H4 Initial countries for intensified joint efforts by WHO, UNICEF, UNFPA and World Bank to support countries to improve maternal and newborn health
and save the lives of mothers and babies
IHP+ Initial countries for international Health Partnership and related initiatives
PEPFAR Initial PEPFAR focus countries; intensified support for PMTCT is now being planned for some of the same and additional countries
Global Fund Initial countries for PMTCT reprogramming support; additional phases for reprogramming and new support for PMTCT are planned.

27
 Appendix C. Elements and activities

Strategic direction 1: Commitment

Strengthen commitment and leadership for achieving full coverage of PMTCT services

Element Activities

1.1 Advocate for strengthened Advocate at the global, regional and country levels for continued commitment to scaling up
commitment to scale up health comprehensive health services for women and children in the context of HIV, especially in high-
services for women and children burden countries.
in the context of HIV.

1.2: Develop and support Work with partners to define appropriate targets for PMTCT in 2015
methods to determine need,
set targets and identify Support the analysis of gaps in PMTCT coverage and support countries to work towards full coverage.
programme gaps at the global,
national and local levels, and Support the ongoing use of targets and active monitoring to help countries achieve PMTCT-related goals.
promote approaches to improve
coverage and ensure the Promote the implementation of an approach to reach every district with health services for women
continuum of care. and children in the context of HIV.

1.3: Support health sector Support national policy and strategy development for scale-up of services within national health sector
planning processes to scale up planning processes.
health services for women and
children in the context of HIV. Support countries to formulate (or update) and implement annual workplans to scale up health services
for women and children in the context of HIV.

28 PMTCT Strategic vision 20102015: preventing mother-to-child transmission of HIV

Strategic direction 2: technical guidance
Provide technical guidance to optimize HIV prevention, care and treatment services
for women and children

Element Activities

2.1: Develop and update global normative Regularly review and update normative global guidelines and recommendations on critical
guidance to ensure quality programmes issues such as HIV testing, ARV prophylaxis and treatment, and infant feeding, based on new
and services with maximum public health evidence, programme experience, changing drugs and technologies, and changing costs.
benefit.
Regularly update operational and implementation guidance to promote rapid and efficient
dissemination, adaptation and implementation of new guidelines at the regional and
country levels.

2.2: Support countries to adopt, adapt and Promote and support the adaptation and implementation of the revised guidelines at
implement the revised guidelines, based on country level, with particular emphasis on:
current WHO recommendations. ART for women in need;
more effective combination prophylactic ARV regimens for reducing vertical
transmission of HIV;
safe infant feeding (including ARV prophylaxis during breastfeeding);
care of exposed infants;
early treatment of infected infants;
sexual and reproductive health services (including family planning) for HIV-infected
women.

Support evaluations of point-of-care HIV and CD4 testing, including algorithms for use in
high- and low-prevalence settings, and provide updated guidance.

Promote and support the rapid scale-up of provider-initiated testing and counselling in
antenatal, delivery, postnatal and family planning services, as key entry points to HIV
services, including:
Re-testing;
Male partner testing.

Promote, support and evaluate the rapid scale-up of early HIV diagnosis among
HIV-exposed infants and young children.

2.3: Support countries to monitor and Help monitor progress on the implementation of new guidelines.
evaluate the implementation of new
guidelines. Assess barriers and programmatic issues related to implementation of new guidelines.

Assess the impact of new guidelines.

29
 Strategic direction 3: Integration
Promote and support integration of HIV prevention, care and treatment services within maternal,
newborn and child health and reproductive health programmes

Element Activities

3.1: Promote and support Develop and support use of a framework to align programme targets, activities and monitoring and evaluation
increased collaboration processes across programme areas.
and, where appropriate,
service integration Support countries to link different programmes by formalizing a management structure that facilitates
between programme coordination at the national and district levels.
sectors.
Promote global coordination between PMTCT and HIV care and treatment programmes, especially as related
to guidance, forecasting, procurement and supply management of drugs and diagnostics, and monitoring
and evaluation.

Develop and support key linkages between PMTCT and other programmes which focus on service delivery to
pregnant women and children, such as MCH, SRH, malaria, TB, syphilis, IMCI interventions and immunization.

3.2: Accelerate the Further develop (as necessary) and promote a package of core interventions for maternal and child health in
implementation of the context of HIV, and a comprehensive, integrated approach to service delivery.
a comprehensive,
integrated package of Support countries to integrate the Integrated Management of Pregnancy and Childbirth (IMPAC), Integrated
maternal, newborn and Management of Childhood Illness (IMCI), Integrated Management of Adolescent and Adult Illness (IMAI)
child health services approaches into their national health services.
within the context of HIV.
Support locally relevant approaches to ensure a districtwide continuum of care for HIV within maternal,
newborn and child health and sexual and reproductive health services.

3.3: Promote increased Support countries to strengthen the capacity of community health workers to help deliver PMTCT services.
community participation
to support and deliver Promote policies and programmatic approaches to increase the involvement of male partners in PMTCT
PMTCT services. services (eg. couples counselling, partner testing).

Support countries to strengthen the relationship between the formal health system and community
organizations to expand HIV prevention services and treatment literacy and preparedness.

30 PMTCT Strategic vision 20102015: preventing mother-to-child transmission of HIV

Strategic direction 4: Equitable access
Ensure reliable and equitable access for all women, including the most vulnerable

Element Activities

4.1 Support countries to Advocate for access for all to a comprehensive and integrated package of health services for women and
provide PMTCT services children in the context of HIV which is free at point of service delivery.
that are free at point of
service for all. Identify major gaps in access to services by socioeconomic, geographical and other criteria and advocate for
addressing equity in approaches to scaling up.

4.2: Increase access Support countries to address the needs of marginalized and most at-risk populations, including drug users and
to PMTCT services for sex workers.
vulnerable populations.

4.3: Promote access Promote the provision of an integrated package of HIV and reproductive health services for women and
to PMTCT services in children in humanitarian settings, based on interagency standards.
complex emergencies.

31
 Strategic direction 5: Health systems
Promote and support health systems interventions to improve the delivery of HIV prevention, care
and treatment services for women and children

Element Activities

5.1: Manage processes for Develop global standards and apply methods for improving and expanding the selection and testing
improving the selection, quality, the quality of essential medicines (including medicines for children) and relevant technologies
pricing, procurement and supply (including HIV diagnostics and CD4 tests).
of essential medicines and
diagnostics. Work with partners to secure an adequate supply of affordable medicines and diagnostics of assured
quality and other commodities such as condoms.

Strengthen national capacity for regulatory activities and procurement and supply processes.

5.2: Strengthen health information Regularly review and update international guidance for monitoring and evaluating national
systems. programme performance and health outcomes related to HIV and maternal and child health, and
sexual and reproductive health.

Support country-level capacity for the design and implementation of integrated management
information systems and for improved data management.

Support countries to improve the quality and use of data through data quality assessments, critical
reviews of performance indicators and surveys and disease modelling to interpret data collected and
set future targets.

5.3: Support countries to adopt Develop and promote quality improvement methods to strengthen regional and district-level health
methods to improve quality of systems, and improve the quality and reliability of HIV prevention, care and treatment services for
service delivery. women and children.

5.4: Improve human resource Assist countries to ensure that maternal, newborn and child health services, as well as sexual and
capacity for PMTCT. reproductive health services, are adequately addressed in national human resource development
and management plans.

Strengthen country capacity to train skilled health care workers, including those needed for PMTCT
and maternal and newborn health services.

32 PMTCT Strategic vision 20102015: preventing mother-to-child transmission of HIV

Strategic direction 6: Measurement
Track programme performance and impact on mother-to-child HIV transmission rates and on
maternal and child health outcomes

Element Activities

6.1: Provide regular Summarize global progress in HIV prevention, care and treatment for women and children, in the annual
updates on global, progress report Towards universal access: scaling up priority HIV/AIDS interventions in the health sector.
regional and country
progress. Develop more detailed reports assessing progress in scaling up HIV interventions in the context of maternal
and child health and sexual and reproductive health, towards achieving MDGs 4, 5 and 6 in 2010, 2012 and
2015.

Contribute to UNGASS and MDG monitoring, analysis and reporting.

6.2: Support innovative Support better use and analysis of antenatal surveys.
surveillance methods
to assess PMTCT Review and update key modelling tools, such as EPP and Spectrum.
programme needs and
coverage. Include key PMTCT indicators in population-based HIV and DHS surveys and MCH surveys

Promote the use of facility surveys.

6.3: Support impact Develop guidance and support the measurement and evaluation of national-level impact of programmes on
evaluations. HIV transmission, maternal and child survival and other key outcomes.

Facilitate special studies by providing systematic methodologies to gather evidence useful for programme
reviews in areas such as:
the costs of various components of HIV interventions in local settings;
CD4 or clinical stage distribution of pregnant women (ART eligibility) receiving an HIV test over time;
the effect of PMTCT services on maternal and child health programmes;
repeat HIV testing in relation to HIV incidence during pregnancy and postpartum; and
improved approaches to modelling of the coverage and impact of PMTCT services and their impact on
MDG goals.

6.4: Support the Set global priorities for operational and impact evaluation research to facilitate the generation of evidence to
identification of global improve programmes and policy.
priorities for research
and develop appropriate Complete the analysis and publication of the Kesho-Bora multicountry study on the safety and effectiveness of
study methodologies. using combination ARV drugs to reduce the risk of HIV transmission during late pregnancy and breastfeeding.

33
 Strategic direction 7: Collaboration
Strengthen global, regional and country partnerships for providing HIV prevention, care and treatment
for women, infants and young children, and advocate for increased resources

Element Activities

7.1: Promote partner Co-lead the development and regular review of joint plans at global and regional levels within the UNAIDS division
coordination. of labour.

Co-lead the expanded Interagency Task Team (IATT) on Prevention of HIV Infection in Pregnant Women, Mothers
and their Children to promote global advocacy and coordinate strategic approaches to scale-up of services.

7.2: Support Develop, with partners, global and regional resource gap estimates for programme scale-up.
global and
regional resource Work with partners to mobilize international solidarity to secure and sustain financing for PMTCT scale-up,
mobilization. including long-term commitments by existing public and private funding entities and new financial mechanisms.

7.3: Collaborate Engage with PEPFAR and other key partners in joint planning and review of support to countries.
with global funding
mechanisms and Actively support the Global Fund on reprogramming current funds and provide support to countries to develop
provide technical proposals prioritizing PMTCT.
assistance to
countries to access
funding.

34 PMTCT Strategic vision 20102015: preventing mother-to-child transmission of HIV

 35
36 PMTCT Strategic vision 20102015: preventing mother-to-child transmission of HIV
 37
World Health Organization
HIV/AIDS Department
hiv-aids@who.int
www.who.int/hiv
20, Avenue Appia
1211 Geneva 27
Switzerland
hiv-aids@who.int