Fig. 7.2 shows the estimated number of children who acquired HIV infection from mother-to-child transmission between 2000 and 2009.
The Global Plan (4) target is to reduce the number of children acquiring HIV infection by 90%, from 429 000 in 2009 (the baseline) to 43 000 in 2015.
Mathematical modelling shows that eliminating mother-to-child transmission requires simultaneously implementing all four prongs of the United Nations comprehensive approach to preventing mother-to-child transmission (19).
Number of children acquiring HIV infection
600 000 500 000 400 000 300 000 200 000
0
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2014 2015
Fig. 7.2 Estimated number of children newly infected with HIV in low- and middle-income countries, 2000–2015
100 000
2013
7.2.1 Strategies for primary prevention of HIV infection among women of reproductive age Programmes to prevent the mother-to-child transmission of HIV, delivered in the context of maternal, newborn and child health services, represent an important entry point to provide information on HIV prevention to women of reproductive age. Provider-initiated testing and counselling and testing and counselling for couples delivered through programmes for preventing mother-to-child transmission contribute significantly to primary prevention by increasing knowledge of HIV status in the general population of women of reproductive age and, increasingly, among male partners (23). Based on the evidence of high rates of HIV seroconversion during pregnancy and the early postpartum period (24), HIV prevention counselling for HIV-negative pregnant women in early pregnancy is particularly important. Other evidence-informed HIV prevention interventions include: social and behaviour change communication; abstinence from sex and injecting drug use; condom use; medical male circumcision; harm reduction; and the emerging area of antiretroviral therapy (22).
Ensuring comprehensive, correct knowledge about how to prevent HIV transmission is a critical fi rst step towards reducing the number of people acquiring HIV infection. In sub-Saharan Africa, the region that accounted for 74% of the people 15–24 years old acquiring HIV infection globally in 2010, only 26% (22) of young women had comprehensive, correct knowledge
about HIV prevention versus 33% of young men. Within sub-Saharan Africa, the proportion is higher in eastern and southern Africa (34%) and lower in western and central Africa (20%).
Although comprehensive knowledge about HIV prevention is still generally low throughout the region, several priority countries for preventing mother-to-child transmission have made important progress towards improving this among women 15–24 years old.
Improvements have been observed in Mozambique, from 20% (2003) to 36% (2009); in Kenya, from 34%
(2003) to 48% (2008–2009); and in Lesotho, from 26% (2004) to 39% (2009) (25). Fewer young women have comprehensive knowledge of HIV prevention in Asia (17% in South Asia and 24% in East Asia and the Pacifi c) than in sub-Saharan Africa.
HIV testing
Antenatal care is a critical opportunity for both pregnant women and their partners to receive HIV testing and counselling. This is particularly important in sub-Saharan Africa, where about half the people living with HIV are in a long-term sexual relationship with an HIV-negative partner (26). Couples testing and counselling in settings for preventing mother-to-child transmission is an important strategy for reaching male partners with HIV testing and counselling, helping HIV-negative women and men remain HIV-negative and reducing the risk of transmission in serodiscordant couples.
Couples testing and counselling may also improve
Box 7.6
Involving male partners is central to Rwanda’s strategy for eliminating the mother-to-child transmission of HIV
By embracing a family-centred approach to comprehensive servicesfor preventing mother-to-child transmission, Rwanda has been able to substantially improve the participation of male partners in preventing mother-to-child transmission as part of a gender-sensitive transformation of its health system. National strategies encouraging male partners to participate in HIV counselling and testing in antenatal care services have been supported by high-level political commitment and are bearing fruit. In 2010, 81% of pregnant women who were tested for HIV through the national programme for preventing mother-to-child transmission had male partners who also tested for HIV within the past 12 months, many of whom were tested with their partner as part of antenatal care (Fig. 7.3).
It is also essential to consider how HIV testing strategies in antenatal care services can best address the needs of young people who, although sexually active, are often not in stable relationships. Data on antenatal care are currently not disaggregated by age in many countries, thereby limiting the ability to determine the proportions of young people accessing HIV testing and counselling in antenatal care services.
Fig. 7.3 HIV testing and counselling of male partners
during antenatal care, Rwanda, 2003–2010
100
adherence to antiretroviral therapy and to interventions for preventing mother-to-child transmission (see Chapter 4) (27).
Though couples testing in antenatal care is often encouraged, uptake among male partners is still generally limited; among 37 countries providing data on the uptake of HIV testing and counselling among male partners of women attending antenatal care, 20 countries reported uptake levels of less than 5%, although it reached 81% in Rwanda (Box 7.6).
Select primary prevention methods
Condom use among women 15–24 years old who had more than one sexual partner in the past year has increased in some countries with high HIV prevalence (Fig. 7.4). However, the rates of condom use among
young people are still generally low across regions, with young men reporting higher rates of condom use than young women.
New studies published in 2010 and 2011 (Table 3.4) have added two important new tools to the array of effective prevention technologies. Antiretroviral therapy has been shown to greatly reduce the risk of HIV transmission, and topical and oral antiretroviral pre-exposure prophylaxis, including an antiretroviral-based microbicide for women, can lower the risk of acquiring HIV among HIV-negative individuals. These methods (see Chapter 3) are expected to be able to considerably strengthen the primary prevention of HIV infection among women of reproductive age and can help further reduce the number of these women who are newly infected with HIV.
100
Fig. 7.4 Percentage of people 15–24 years old who had more than one sexual partner in the past 12 months reporting the use
of a condom during their last sexual intercourse, by selected countries that had trend data for men and women in the same survey, 1998–2010
z Women z Men
Percentage (%)
Sources: MEASURE DHS: all surveys by country [web site] (25). Demographic and Health Surveys: Côte d’Ivoire 1998–1999; Kenya, 2003 and 2008–2009; Lesotho, 2004 and 2009; Malawi, 2000; Swaziland, 2006–2007. AIDS Indicator Surveys: Côte d’Ivoire, 2005.
Multiple Cluster Indicator Survey [web site] (28). Multiple Cluster Indicator Surveys: Malawi, 2006; Swaziland, 2010.
a The data for women in Swaziland from the 2006–2007 Demographic and Health Survey (25) are based on small denominators (typically 25–49 unweighted cases).
26%
Box 7.7