What is mother-to-child transmission?

Mother-to-child transmission (MTCT) is when an HIV-positive mother passes the virus to her child during pregnancy, delivery and breast feeding. Each year around 1.5 million women living with HIV become pregnant, and without antiretroviral drugs (ARVs), there is a 15 to 45 percent chance that their child will also become infected.  However, among mothers that take a regimen of ARVs for the prevention of mother-to-child transmission (PMTCT), the risk of HIV transmission can be reduced to less than 5 percent.

How common is mother-to-child transmission today?

Providing PMTCT information to mothers

In 2011, around 330,000 children under the age of 15 became infected with HIV and an estimated 230,000 died from AIDS.  Almost all of these infections were as a result of mother-to-child transmission and among children living in sub-Saharan Africa.

However, mother-to-child transmission can be averted, and in high-income countries mother-to-child transmission has been almost completely eliminated as a result of effective voluntary testing and counselling services, access to antiretroviral therapy, safe delivery practices, and the widespread availability and safe use of breast-milk substitutes. Globally, since 1995, more than 350,000 children have avoided HIV infection due to these interventions.  If these interventions were available and accessible to women worldwide, they could prevent thousands of children from becoming infected with HIV each year.

Preventing mother-to-child transmission

UNAIDS advocate four key strategies for preventing mother-to-child transmission:

1. Keeping women of reproductive age and their partners HIV-negative through reproductive health and HIV prevention services.
2. Avoiding unwanted pregnancies among HIV-infected women and women at risk of HIV, through family planning and HIV testing and counseling services.
3. Ensuring HIV testing of pregnant women and timely access to effective antiretroviral therapy, both for the health of HIV-infected mothers and for PMTCT, during pregnancy, delivery and breastfeeding.
4. Better integration of HIV care, treatment and support for HIV-infected women and their families.

The challenges facing PMTCT

There are a number of barriers and challenges facing the prevention of mother-to-child transmission. Many countries still do not have enough PMTCT services and too many women live a long way from their nearest health clinic. The cost or unavailability of transport, as well as heavy workloads and other responsibilities, such as the care of children or other dependents, can further inhibit women from accessing PMTCT services.

In many low- and middle-income countries health systems are often poorly staffed and resourced; clinics struggle to provide existing services, let alone new ones. As a result of this limited capacity, many countries are unable to adapt their existing health systems according to World Health Organization (WHO) PMTCT guidelines, which are amended as new evidence becomes available and more cost-effective in the long-term. Therefore, many clinics are not providing HIV-infected women with the most effective drugs. One example of this is the use of single-dose nevirapine, an antiretroviral drug which, despite no longer being recommended by the WHO, in 2011 was still being used in many developing countries for PMTCT.

Even where quality PMTCT services are locally available, there may be social, cultural or personal reasons why women do not access PMTCT services. The fear of stigma and discrimination, particularly if a woman is economically dependent on her partner, for example, may prevent her from getting tested, from disclosing her status to a partner or healthcare provider, or from accessing anti-retroviral treatment for her own health and for PMTCT. Fear of disclosure is a common reason why women are reluctant to return to their HIV clinic. In the words of a woman:

“My husband might see me with the medicines, and he will want to know what they are for. That way he will find out about my [HIV positive test] result. Even the location bothers me, because everyone who comes to the clinic knows what goes on [at the programme]. As soon as a pregnant woman is seen coming here, it’s known right away that she is seropositive” –

Consequently, around two out of three women in low- and middle-income countries do not know their HIV status  and the proportion of women, in low- and middle-income countries, accessing effective treatment for PMTCT stands at just over half.

Other challenges that inhibit the prevention of mother-to-child transmission include poor adherence to anti-retroviral drugs; not being offered an HIV test; failure to attend follow-up appointments, either for results or treatment monitoring; poor social support; the risk of becoming infected with HIV later in pregnancy; lack of adequate HIV counseling; and difficulties with replacement feeding due to the price of formula and lack of access to clean water.