1. Scaling up Prevention of Mother to Child Transmission of HIV (PMTCT): What Will it Take to Eliminate MTCT? Jessica Rodrigues Presentation for UNICEF Written Test 04 May 2012 Photograph courtesy of EGPAF and NPR

2. Where We Are: Global Progress to Date More pregnant women counseled and tested for HIV Uptake of PMTCT services improving.... Follow up care for HIV exposed infants is poor 35-42% pregnant women (PW) receive HIV testing and counseling Significant increase in East and Southern Africa 52-61% PW receive most effective regimens BUT ONLY 5 of 22 priority countries reached 80% coverage 42% infants received antiretroviral (ARV) medicine for PMTCT 28% HIV exposed infants diagnosed early 23% children in need receive antiretroviral therapy (ART)

3. Smart Scale-Up Source: Towards Universal Access, WHO, 2011 Focus on Countries With Highest MTCT Burden! High PMTCT Coverage & Low Rates of MTCT CountryAdult HIV Prevalence HIV Prevalence in Pregnancy PMTCT Coverage ART Children Coverage Nigeria3%2.4-4%10%12% South Africa18%29%73%61% US and UK0.3-0.6%0.06%>95% Source: Towards Universal Access, WHO, 2011 and Besser, 2011

5. Where We’re Going: Global Targets MTCT accounts for 90% of new infections 1,000 children infected with HIV everyday 48% of pregnant women received ARV medicine for PMTCT Reduce number of pediatric infections by 90% Reduce number of AIDS related maternal deaths by 50% Today 2015 Effective PMTCT Source: Global Plan for the Elimination of Pediatric HIV and UNDP Reduce HIV incidence among women 15-49 yrs by 50% Reduce unmet family planning need to zero MTCT to 5% 90% of eligible pregnant women ART Primary Infection Unintended Pregnancy ARV prophylaxis Care, Treatment & Support Source: WHO, UNAIDS, UNICEF 2010 AND MDGs 3-6 (Gender Equity, Infant Mortality, Maternal Health, Infectious Diseases)

6. Antenatal Care HIV Counseling and Testing ARV prophylaxis for PMTCT Treatment Eligibility Access to Antiretroviral Treatment if needed Linkages to family planning, ART Labor and Delivery Safe Delivery Infant prophylaxis for PMTCT Early infant diagnosis Safe feeding practices Follow up care and treatment for mother and child until 18 months Why Aren’t We There Yet? Missed Opportunities PMTCT Services We Know What to Do Persistent Gaps MORE THAN HALF OF PREGNANT WOMEN IN NEED: Do not receive ARV medicine for PMTCT Are not assessed for treatment eligibility LESS THAN HALF OF PREGNANT WOMEN IN NEED: Receive antiretroviral therapy for their own health in the 22 priority countries MORE THAN HALF OF INFANTS IN NEED: Do not receive ARV medicine for PMTCT Attend ANC clinic 95% Counseled and Tested for HIV, 74% Receive ARVs (pre and perinatal) 50% Source: Guay, 2011 and P Barker, 2008

7. Challenges to Scaling Up PMTCT Quality Pre and post test, pre-ART, adherence counseling Limited diagnostic capacity Fragmented services Access Poverty (Long distances, transport, opportunity costs) Stigma and discrimination Low or late ANC attendance and home deliveries Health system bottlenecks Stock outs of tests, drugs and consumables Human resource shortages and high turnover Monitoring and evaluation tools and registers HIGH ATTRITION & POOR ADHERENCE COMPROMISED RESPONSE LATE IDENTIFICATION

8. The Many Roads Ahead Hospital Promote service integration (FP, MCH) Increase uptake of more efficacious regimens Improve diagnostic capacity with point of care technology Task shifting for counseling and testing Expand provider initiated testing and counseling Community Expand community based testing Strengthening community support, patient led support groups Encourage male involvement Increase patient voice and feedback Health System Produce, train and retain health workers Innovative financing mechanisms Strengthen supply chain management Improve data quality and use Commitment Ramp up global advocacy & resource mobilization Coordinated technical assistance Promote government accountability to scale up Increase private sector involvement