Toward Eliminating Pediatric HIV Infection

Improving Retention in the PMTCT Care Cascade

Holly E. Rawizza, MD

Disclosures

May 30, 2012

In This Article

Background: Global PMTCT Service Delivery

With currently available antiretroviral regimens for the prevention of mother-to-child transmission (PMTCT) of HIV, perinatal transmission may be reduced from 20%-45% without intervention to less than 2%.[1,2] Given the considerable progress in the expansion of antiretroviral therapy (ART) and PMTCT services globally, as well as implementation of more efficacious PMTCT regimens as outlined in the 2010 World Health Organization (WHO) guidelines,[3] the prospect of eliminating pediatric HIV is closer than ever.

The "Countdown to Zero" initiative announced by the Joint United Nations Programme on HIV/AIDS ambitiously aims to eliminate pediatric HIV infection by 2015.[4] However, despite improved access to antiretrovirals, PMTCT service utilization remains suboptimal. In 2010, only 48% of HIV-infected pregnant women received antiretrovirals to reduce mother-to-child transmission, and only 28% of infants born to HIV-infected mothers had HIV testing in the first 2 months of life.[5] As a result, the estimated mother-to-child transmission rate in 2010 was 26%, and nearly 390,000 infants were born with HIV infection[5] -- a rate that falls far short of what can be achieved with available biomedical interventions.

Successful delivery of PMTCT services requires an integrated continuum of care across multiple healthcare settings. This cascade of services includes maternal HIV counseling and testing, CD4+ cell count determination for ART eligibility, initiation of antiretroviral prophylaxis, antiretroviral monitoring, delivery care, infant antiretroviral and cotrimoxazole prophylaxis, early infant diagnosis of HIV, and ART for HIV-infected infants. Any breakdown along the sequential steps required for optimal care may result in cumulative maternal/infant loss from prevention programs and increased risk for HIV transmission. System inefficiencies, poor service integration, lack of knowledge on the part of patients and care providers, and economic or social factors may result in patient attrition and diminished efficacy of PMTCT.[6,7]

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