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Elimination of mother-to-child transmission of HIV, syphilis and viral hepatitis B: A call for renewed global focus

Open AccessPublished:November 26, 2022DOI:https://doi.org/10.1016/j.ijid.2022.11.031

      Keywords

      In 2021, there were an estimated 160 000 new HIV infections globally among children aged < 15 years, a remarkable reduction from >400 000 cases in 2000 [
      Joint United Nations Programme on HIV/AIDS
      Danger: global AIDS update 2022.
      ]. This accomplishment was the result of increasing the global coverage of mother-to-child transmission (MTCT) prevention of HIV from 1% in 2000 to 81% in 2021 [
      Joint United Nations Programme on HIV/AIDS
      Danger: global AIDS update 2022.
      ]. However, the percentage of pregnant women living with HIV (WLWH) receiving antiretroviral therapy (ART) has stalled since 2015. ART coverage has been quite varied, with 43% of all pregnant WLWH living in western and central Africa not on ART in 2021 [
      Joint United Nations Programme on HIV/AIDS
      Danger: global AIDS update 2022.
      ]. Moreover, only 28% of pregnant WLWH in the Middle East and North Africa received ART during pregnancy in 2021 [

      United Nations Children's Fund. Elimination of mother-to-child transmission. New York: UNICEF; 200 https://data.unicef.org/topic/hivaids/emtct/. Accessed 13 November 2022.

      ].
      Progress with the prevention of MTCT of HIV has given an impetus to the prevention of perinatal transmission of syphilis and hepatitis B virus (HBV). MTCT of syphilis during pregnancy can lead to serious outcomes including stillbirth, neonatal death and congenital infections [
      • Gomez G.B.
      • Kamb M.L.
      • Newman L.M.
      • Mark J.
      • Broutet N.
      • Hawkes S.J.
      Untreated maternal syphilis and adverse outcomes of pregnancy: a systematic review and meta-analysis.
      ]. Recent estimates showed that global maternal syphilis in 2016 resulted in 661,000 congenital syphilis, including 355,000 adverse birth outcomes [
      • Korenromp E.L.
      • Rowley J.
      • Alonso M.
      • Mello M.B.
      • Wijesooriya N.S.
      • Mahiane´ S.G.
      • et al.
      Global burden of maternal and congenital syphilis and associated adverse birth outcomes—Estimates for 2016 and progress since 2012.
      ]. Likewise, chronic HBV infection is an important cause of morbidity and mortality. In 2019, 296 million people were living with chronic HBV infection, with 1.5 million new infections occurring each year [

      World Health Organization. Hepatitis B fact sheets. Available from https://www.who.int/news-room/fact-sheets/detail/hepatitis-b. Accessed 12 November 2022.

      ]. The estimated number of deaths related to HBV was 820 000 in 2019 [

      World Health Organization. Hepatitis B fact sheets. Available from https://www.who.int/news-room/fact-sheets/detail/hepatitis-b. Accessed 12 November 2022.

      ]. Moreover, most of the disease burden of HBV results from infections acquired in infancy through perinatal or early childhood exposure to HBV [
      • Van Damme P.
      • Ward J.W.
      • Shouval D.
      • Zanetti A.
      Hepatitis B Vaccines.
      ].
      Given the significant morbidity of these conditions, the triple elimination of MTCT (EMTCT) of HIV, syphilis and HBV has been identified by the World Health Organization (WHO) as a global public health priority. Effective tools for the prevention of MTCT of these infections are already available [
      • Connor E.M.
      • Sperling R.S.
      • Gelber R.
      • Kiselev P.
      • Scott G.
      • O'Sullivan M.J.
      • et al.
      Reduction of maternal-infant transmission of human immunodeficiency virus type 1 with zidovudine treatment. Pediatric AIDS Clinical Trials Group Protocol 076 Study Group.
      ,
      • Cooper E.R.
      • Charurat M.
      • Mofenson L.
      • Hanson I.C.
      • Pitt J.
      • Diaz C.
      • et al.
      Combination antiretroviral strategies for the treatment of pregnant HIV-1-infected women and prevention of perinatal HIV-1 transmission.
      ,
      • Darville T.
      Syphilis.
      ,
      • Wiesen E.
      • et al.
      Progress towards hepatitis B prevention through vaccination in the Western Pacific, 1990–2014.
      ]. As HIV, syphilis and HBV share common transmission dynamics and determinants, a joint approach towards triple elimination could maximise impact and efficiency. Triple EMTCT services could be integrated in maternal and child health programmes and be part of a universal health coverage package. EMTCT services should be affordable, comprehensive, non-discriminatory and accessible by all, including vulnerable women such as migrants and key populations. Core EMTCT services include primary prevention of HIV, syphilis and HBV among women of childbearing age; antenatal screening for HIV, syphilis and HBV; prompt linkage to care for pregnant women who test positive; safe delivery; treatment and follow up of exposed infants; and optimal infant-feeding.
      To drive these EMTCT initiatives, WHO released the first edition of its global guidance on the criteria and processes for validating EMTCT of HIV and syphilis in 2014 [
      World Health Organization
      Elimination of mother-to-child transmission (EMTCT) of HIV and syphilis. Global guidance on criteria and processes for validation.
      ]. This was subsequently followed by the establishment of the Global Validation Advisory Committee in 2015 to objectively evaluate if countries had achieved EMTCT. In 2017, the Path to Elimination concept was introduced to recognise countries with a high burden of HIV and/or syphilis that have made significant progress in lowering MTCT rates [
      World Health Organization
      Global guidance on criteria and processes for validation: elimination of mother-to-child transmission of HIV and syphilis.
      ]. In 2021, the third version of the global guidance included criteria and processes for validation of triple EMTCT [
      World Health Organization
      Global guidance on criteria and processes for validation: elimination of mother-to-child transmission of HIV, syphilis and hepatitis B virus.
      ]; process and impact indictors are shown in Fig. 1 [
      World Health Organization
      Global guidance on criteria and processes for validation: elimination of mother-to-child transmission of HIV, syphilis and hepatitis B virus.
      ].
      Fig. 1
      Fig. 1Impact and process targets for global validation of EMTCT of HIV, syphilis and hepatitis B
      Note. Adapted from World Health Organization. Governance for the validation of elimination of mother-to-child transmission of HIV, syphilis and hepatitis B virus: an overview of validation structures and responsibilities at national, regional and global levels. Geneva: WHO; 2022 https://www.aidsdatahub.org/resource/governance-validation-elimination-mother-child-transmission-hiv-syphilis-and-hepatitis-b. Accessed 12 November 2022.
      The triple validation process is a perfect illustration of public health and human rights convergence. A key requirement for validation of a country for triple EMTCT is that interventions to reach the specified targets have been implemented in a manner consistent with international, regional and national human rights standards and have taken gender equality into consideration. Given the many challenges of translating principles into practice, global progress towards validation has been slow. In 2015, Cuba became the first country in the world to be validated for having achieved EMTCT of HIV and syphilis [
      World Health Organization
      Press release: WHO validates elimination of mother-to-child transmission of HIV and syphilis in Cuba.
      ]. To date, only 16 countries (Table 1) have been validated for EMTCT of HIV and/or syphilis []. In September 2022, WHO certified Oman for EMTCT of HIV and syphilis, becoming the first country in the WHO Eastern Mediterranean Region to achieve this [
      World Health Organization
      Press release: Oman first country in the Eastern Mediterranean Region to eliminate mother-to-child transmission of HIV and syphilis.
      ].
      Table 1Countries which have received WHO validation for HIV and/or syphilis
      CountryValidated forYearWHO region
      CubaHIV & Syphilis2015PAHO
      ThailandHIV & Syphilis2016SEARO
      BelarusHIV & Syphilis2016EURO
      ArmeniaHIV only2016EURO
      MoldovaSyphilis only2016EURO
      AnguillaHIV & Syphilis2017PAHO
      MontserratHIV & Syphilis2017PAHO
      BermudaHIV & Syphilis2017PAHO
      Cayman IslandsHIV & Syphilis2017PAHO
      St. Kitts and NevisHIV & Syphilis2017PAHO
      Antigua and BarbudaHIV & Syphilis2017PAHO
      MalaysiaHIV & Syphilis2018SEARO
      MaldivesHIV & Syphilis2019SEARO
      Sri LankaHIV & Syphilis2019SEARO
      DominicaHIV & Syphilis2020PAHO
      OmanHIV & Syphilis2022EMRO
      PAHO, Pan American Health Organization; EURO, WHO region of Europe; SEARO, South-East Asia Region of WHO; EMRO, Regional Office for Eastern Mediterranean.
      Note. Adapted from World Health Organization. Countries which have received WHO validation. Geneva: WHO; 2022 https://www.who.int/initiatives/triple-elimination-initiative-of-mother-to-child-transmission-of-hiv-syphilis-and-hepatitis-b/validation. Accessed 13 November 2022.
      What can we learn from countries that have been validated for EMTCT of HIV and/or syphilis? The success of many of these countries should be seen more as the culmination of many decades of progress in implementing public health policies than as a targeted approach with a narrow objective. The common denominator has been the recognition of the importance of equity of access. This is especially relevant as we commemorate World AIDS Day 2022 (theme: Achieving Equity to End HIV), with UNAIDS urging us to address the inequalities holding back progress in ending AIDS. In the early stages of policy development for EMTCT, these countries have addressed inequalities that existed among key populations and migrant workers facing major legal barriers including criminalisation, stigma and discrimination. These inequalities were not just barriers to achieving EMTCT but could perpetuate public health risk arising from concealment of HIV status/risk and non-engagement with healthcare professionals.
      The countries that are yet to be validated for EMTCT represent a wide spectrum. At one end, many developed countries with robust health systems have already provided routine antenatal screening for HIV, syphilis and HBV and treatment for women who test positive and their exposed infants. These countries may have met the validation process and impact targets, but lack surveillance systems to capture appropriate data. A further challenge would be providing evidence for equitable access to healthcare for vulnerable populations, including migrants and ethnic minorities. At the other end of the spectrum are developing countries that might lack political will and leadership towards EMTCT due to limited resources and competing public health priorities [
      • Taylor M.
      • Newman L.
      • Ishikawa N.
      • Laverty M.
      • Hayashi C.
      • Ghidinelli M.
      • et al.
      Elimination of mother-to-child transmission of HIV and Syphilis (EMTCT): Process, progress, and program integration.
      ]. Moreover, weaker health and surveillance systems could hinder progress with meeting the validation targets. Furthermore, some of these countries have punitive laws that constitute a barrier to access to healthcare. A further challenge is the higher HIV prevalence and rates of breastfeeding; despite their concerted efforts, these countries would struggle to achieve the targets for MTCT of HIV rates. On the other hand, countries with lower HIV prevalence might not have policies for universal HIV, syphilis and HBV in pregnancy.
      To conclude, MTCT of HIV, syphilis and HBV remains a global public health problem causing significant morbidity and mortality. Since the launch of the EMTCT initiative by WHO in 2014.The number of countries that have been validated for HIV and/or syphilis remained small. However, the global community has revitalised its commitment to triple EMTCT. Indeed, the Global Health Sector Strategies on HIV, viral hepatitis and sexually transmitted infections for the period 2022-2030 sets challenging targets for the number of countries validated for the EMTCT of either HIV, HBV, or syphilis of 50 and 100 by 2025 and 2030, respectively [
      World Health Organization
      Global health sector strategies on, respectively, HIV, viral hepatitis and sexually transmitted infections for the period 2022-2030.
      ]. To achieve these ambitious targets, WHO and their other UN partners should continue their advocacy, political diplomacy and technical support towards triple EMTCT. Implementation research could add to the scientific knowledge base of triple EMTCT. Countries considering to achieve triple EMTCT could learn from validated countries with efforts for strengthening health systems so as to provide sustainable and equitable EMTCT services that meet the stringent validation standards.
      Author declarations: All authors declare no conflicts of interest.

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