U.S. Leadership in Preventing Mother-to-Child Transmission of HIV

Kevin M. De Cock MD, FRCP (UK), DTM&H is the Director of the Center for Global Health at the U.S. Centers for Disease Control and Prevention (CDC).

From July 22 to 27, Washington, D.C. will host the XIX International AIDS Conference, welcoming more than 20,000 attendees from around the world, representing hundreds of HIV/AIDS organizations and diverse backgrounds. 

The U.S. Centers for Disease Control and Prevention (CDC) and the Elizabeth Glaser Pediatric AIDS Foundation (EGPAF) partner with many of these organizations combatting HIV/AIDS through PEPFAR, the U.S. President’s Emergency Plan for AIDS Relief.

PEPFAR is the largest public health program ever mounted for an individual disease, and is celebrating almost a decade since it was established. Now more than 7 million people worldwide are receiving antiretroviral therapy (ART) for HIV. The conference offers opportunity to assess progress in the fight against HIV/AIDS, review research advances and priorities, and recommit to meeting HIV/AIDS specific targets that we have collectively endorsed.

It was in the late 1980s that research in the U.S. and other countries such as the Democratic Republic of Congo laid the foundation for our understanding of mother-to-child transmission of HIV. Approximately one-quarter of children born to HIV-infected mothers acquired the infection themselves, with other research subsequently showing that prolonged breastfeeding contributed an additional 14% transmission risk.

Overall, up to 40% of children born to and breastfed by mothers living with HIV would become infected. And yet, alternatives to breastfeeding were not realistic options for most African mothers for reasons of poverty, stigma, and the fact that lack of breastfeeding exposed infants to higher risk of malnutrition and other lethal infectious diseases.

The history of research on mother-to-child transmission of HIV and its prevention offers the clearest example of how domestic and global HIV/AIDS work have interacted and benefited from integration, and how research has led to specific program implementation. Communicating this relationship is an overarching contribution of International AIDS Conferences.

In the early 1990s, the groundbreaking ACTG 076 trial showed that prophylactic zidovudine given to the mother during pregnancy and labor and delivery, and postnatally to the infant, prevented HIV transmission by two-thirds. The trial initiated an avalanche of research on prevention of mother-to-child transmission in and tailored to low-income settings, the benefits of which we are reaping today.

Opinion is growing that the World Health Organization’s “Option B+” – under which HIV-infected women start combination ART on detection of pregnancy and stay on it for life – will be an important tool to meet our ambitious goal of virtual elimination of mother-to-child transmission of HIV by 2015.

In 2010, 35% (42% in sub-Saharan Africa) of pregnant women in low- and middle-income countries received HIV testing and counseling, and the estimated coverage of antiretroviral drugs for prevention of mother-to-child transmission of HIV among pregnant women was 48%.  In 2011, 57% of pregnant women living with HIV in low- and middle-income countries received effective antiretroviral drugs to prevent transmission to the child.

Despite this progress, much remains to be done. Only 28% of exposed infants worldwide received an appropriate test for HIV infection in the first two months of life in 2010, with 22% coverage of ART for infected children. In 2011, treatment coverage for ART in infected children rose to 28%, yet treatment coverage among children is still substantially lower than the estimated 57% coverage among adults living with HIV.

The U.S. Administration’s Global Health Initiative has refocused attention on the health of women and children. Now we have unrivalled opportunity for synergy and integration – harmonizing programs for maternal and child health, HIV/AIDS, and family planning for the greater good of women and children’s well-being.

Re-commitment to the worthy goals of an AIDS-free generation would be a good outcome of the XIX International AIDS Conference. The targets are to reduce the number of children newly infected with HIV by 90% by 2015, reduce mother-to-child transmission of HIV to below 5% everywhere, and reduce maternal mortality related to HIV by 50%.

Looking back to the dark days – when AIDS was a death sentence, life expectancy was declining in southern Africa, under-five mortality was rising because of AIDS, and hopelessness prevailed – the 2012 International AIDS Conference should be an occasion of pride, re-engagement, and forceful determination to achieve what was once thought impossible: an AIDS-free generation