The webinar on ‘Expanding access to good practices on Elimination of Mother-To-Child Transmission of HIV and syphilis (EMTCT) through South-South Cooperation (SSC)’ took place on 31 of January 2019. The aim of this webinar was to share examples of successful practices and lessons learned by countries working towards achieving EMTCT validation, and to discuss how South-South Cooperation can be used as a vehicle towards global validation by means of knowledge exchange and sharing of best practices. The event was organised by The Community of Practice on South-South Cooperation for Children (CoP-SSC4C), a joint initiative by UNICEF, UNOSSC and IPC-IG.
The presenters in this webinar were Dr. Dorothy Mbori-Ngacha (UNICEF HIV/AIDS, NYHQ), Dr. Sarawut Boonsuk (Director of Health Promotion Regional Center, Department of Health, Ministry of Public Health, Thailand), Dr. Anita Suleiman (Head of HIV/STI/Hepatitis C Sector, Disease Control Division, Ministry of Health, Malaysia) Dr. Mariame Sylla (Chief, Health and Nutrition, Programme Section, UNICEF South Africa) and discussant, Dr. Melanie Taylor (Medical Officer,World Health Organization). The event was moderated by Ms. Laurie Gulaid (Senior Health Specialist, UNICEF ESARO).
The webinar opened with a global overview on trends and main challenges of EMTCT, then moved on to presentations showcasing the experiences of Thailand, Malaysia and South Africa. This was followed by a brief presentation by WHO on MTCT of Syphilis and the success of dual HIV-Syphilis testing. Finally, the presenters addressed questions sent in by participants in a Q&A session.
EMTCT: Global Progress and Guidance
Dr. Dorothy Mbori-Ngacha, UNICEF Headquarters, New York
Dr. Dorothy Mbori-Ngacha presented an overview of EMTCT in 2018:
- 1.4 million of pregnant women are living with HIV;
- 80% of pregnant women living with HIV receiving drugs for prevention of mother-to-child transmission (PMTCT);
- 13% of mother-to-child HIV transmission rate, including perinatal and postnatal infections.
The rate of MTCT of HIV remains high and the prevention of MTCT needs continued efforts. Please see below global trends:
Along with the increase in PMTCT coverage, we see a decrease in the MTCT rate. From 2014, we see a flat line of pregnant women receiving ARVs and therefore there is a need to change the strategies for the 20% remaining without ARVs. These 20% represent those who are most vulnerable, such as: Women living in extreme poverty, marginalised groups in the most remote areas where access to healthcare is poor, ethnic minorities who don’t have good access to care or those who mistrust the health service. Reaching key populations with the marginalised individuals in societies, such as migrant populations and the partners of marginalised individuals, remain crucial challenges to achieving full coverage.
Achieving EMTCT of HIV is a multi-step process, as you can see below:
The criteria for receiving EMTCT validation requires a very high and stringent process of testing, treatment and services access. In terms of impact, it requires less than 50 cases of HIV transmission per thousand births. Beyond the mentioned indicator criteria, there are four additional qualitative requirements for validation:
- Time: Process indicators in place for two years and impact indicators for one year;
- Geography: All areas of the country have to demonstrate effort and success, even low performing sub-national administrative units should show that there are not “unattended” hotspots of transmission.
- Quality: High quality monitoring and evaluation (M&E) and laboratory systems in place (including in the private sector) to capture data and accurately detect cases.
- Equity: Validation criteria have been met in a manner consistent with basic human rights considerations.
Consequently, reaching EMTCT of HIV requires a lot of effort. It needs a sustained commitment from governments and health workers, high levels of coverage of testing, treatment and immunisation services over time. This includes retaining women on antiretroviral therapy (ART) throughout breastfeeding and for life, and robust systems to capture accurate data outcomes. Furthermore, a human rights-based approach to services, which is focused on the mother and her consent and autonomy is an important factor for success.
Countries that have achieved dual EMTCT validation:
- 2015: Cuba;
- 2016: Thailand, Belarus, Moldova and Armenia.
- 2017: Anguilla, Antigua & Barbuda, Bermuda, Cayman Islands, Montserrat, St. Christopher & Nevis.
- 2018: Malaysia.
EMTCT in Thailand
Dr. Sarawut Boonsuk, Ministry of Public Health, Thailand
Dr. Sarawut Boonsuk presented on the epidemic context of EMTCT of HIV and Syphilis in Thailand. He highlighted achievements and progress to date, key lessons learned, and core challenges to maintaining success in the EMTCT of HIV & Syphilis. The key features of Thailand’s progress to date were presented in this virtual cycle:
This highlights four key areas of Thailand’s success in EMTCT, namely: policy, surveillance systems, investigation, and human rights to achieve the EMTCT. This includes strengthening the Maternal and Child Health Bureau (MCHB) at the national and regional level, improving definitions and surveillance systems for reporting data, scaling up early diagnosis, treatment and care for infants and children, and strengthening capacity policy for the migrant population.
Dr. Sarawut Boonsuk highlighted two major challenges to maintain EMTCT in Thailand:
- There is an increasing trend in the congenital syphilis case rate and a prevalence among pregnant women, which calls for an urgent need to implement a national strategy for the prevention and control of sexually transmitted infections (STI). This can be achieved by targeting prioritised provinces with a rising trend in syphilis prevalence as well as strategies to manage high risk and vulnerable pregnant women, including late presenting and young women.
- The number of migrants continues to rise. There is a need for a sustainable system to document and support non-registered migrants for EMTCT of HIV and syphilis.
EMTCT in Malaysia
Dr. Anita Suleiman, Ministry of Health, Malaysia
Dr. Anita Suleiman emphasized that a strong political commitment has been crucial toMalayasia’s success, allowing a National Strategic Plan for Ending AIDS to be implemented. PMTCT is now fully integrated into the public MCH’s services, with more than 300 Family Medicine specialists in more than 1000 government clinics, providing antenatal care (ANC) to 83% of pregnant women. As a result, 97.4% of women in Malaysia received a minimum of four antenatal visits. Lastly, the prevention of unintended pregnancies was achieved through pre-marital HIV testing performed by a platform to educate on pre-planned conception for better outcomes.
To maintain success, the country must cater to high-risk mothers (late presentation, lost follow-up, non-adherence due to stigma) and also migrant women, as the government has imposed a fee for basic ANC consultations (new Fee Act 2014). To overcome this, they are working on combating stigma and discrimination and on community empowerment. For the second challenge, they are giving Free ARV (Option B) and free ART prophylaxis and formula feeds for infants. United Nations High Commissioner for Refugees (UNHCR) card holders receive 50% discount for lifelong ART (Option B+).
EMTCT in South Africa
Dr. Mariame Sylla, UNICEF South Africa
South Africa has the biggest HIV epidemic in the world, with an estimated 7.35 million people living with HIV in 2017 and a prevalence among all ages of 14%. It also has the largest ART programme in the world (serving 4,471,523 people), which underwent further expansion in 2016 with the implementation of a “universal test and treat” policy. At the end of November 2018, 157,644 children under 15 years remained on ART.
Over the past years, there have been significant achievements, as the graph below shows:
Alongside this, the number of new HIV infections among children 0 – 14 years old has decreased, reaching less than 20K in 2017, peaking at 70K in 2002. To achieve these improvements, political leadership and commitment at all levels was crucial for accelerating the national HIV response. Besides that, strong partnerships with development and implementing organisations, academia, and civil society collectively played a pivotal role. To keep improving, they need to work on the integration of services, prevention, innovation for impact, the sustainability of interventions and support, and reaching elimination.
Dual HIV & Syphilis testing
Dr. Melanie Taylor, World Health Organization (WHO)
Discussant, Dr. Melanie Taylor presented some numbers on missed opportunities to prevent adverse birth outcomes due to syphilis and the current state of adoption for the dual HIV-syphilis rapid diagnostic test (RDT). She detailed cost-effective interventions to prevent MTCT of syphilis.
Moderated by Ms. Laurie Gulaid
The webinar closed with an interesting Q&A, which you can access here. If you have any thoughts on the topic discussed, we would love to hear them. Please join the Online Community of Practice on South-South Cooperation for Children (CoP-SSC4C) if you are interested in following the most recent discussions on the topic and add your comments below!