Elimination of mother-to-child transmission

Fast facts:

• About 160,000 [confidence bounds: 110,000–230,000] new HIV infections among children under five occurred in 2021, dramatically declining from 320,000 [220,000–480,000] in 2010 and representing a 50 per cent decline.
• Among the 35 UNICEF HIV priority countries, about 130,000 [1100,000–230,000] new HIV infections among children under five occurred in 2021 from 230,000 [220,000–480,000] in 2010, representing a 54 per cent decline.

Progress in reducing mother-to-child transmission of HIV has been dramatic since the introduction in 2011 of the ‘Global Plan towards the Elimination of New HIV Infections among Children and Keeping their Mothers Alive’ – largely because of increased access to PMTCT-related services and increased number of pregnant women living with HIV being initiated on lifelong antiretroviral medicines. But it was not fast enough to reach the 2020 targets set by UNAIDS and partners as part of the Super-Fast-Track Framework to end AIDS. Acceleration of treatment for all pregnant and breastfeeding women living with HIV is still needed to achieve elimination of new infections among children and halve HIV-related deaths among pregnant women and new mothers.

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Of the approximately 900,000 paediatric AIDS-related deaths averted between 2000 and 2021 by Antiretroviral Therapy (ART) and cotrimoxazole, the impact was more pronounced in the last 11 years of the response. Eastern and Southern Africa Region (ESAR: 74 per cent) and West and Central Africa Region (WCAR: 14 per cent) accounted for 88 per cent of the averted paediatric AIDS-related deaths.

Between 2000 and 2021, about 2.8 million children born from HIV infected mothers were prevented from maternal transmission of HIV as a result of the implementation and acceleration of the PMTCT programme mainly through the Super-Fast-Track Framework to end AIDS. For instance, in 2021, without the implementation of the PMTCT programme globally, new child HIV infections would have been nearly two and half times (380,000) higher than the current number of 160,000. Of the new child HIV infections averted in over two decades, ESAR (76 per cent) and WCAR (17 per cent) accounted for 93 per cent.

Three has been a slight decrease in the number of pregnant women receiving treatment to stop HIV transmission to their children

Fast facts:

• As a result of higher testing coverage in high HIV burden countries, an increasing number of pregnant women in low- and middle-income countries know their HIV status – either by receiving HIV testing during antenatal care or by knowing their HIV positive status prior to their pregnancy.
• In 2021, 81 per cent [68–>95 per cent] of pregnant women living with HIV globally were receiving effective antiretroviral medicines for prevention of mother-to-child transmission (PMTCT), up from 46 per cent [38–59 per cent] in 2010. Almost 100 per cent of pregnant women receiving ARVs were receiving lifelong antiretroviral therapy (ART).
• Among the 35 HIV priority countries set out in the UNICEF Strategic Plan, 84 [70–>95] per cent of pregnant women living with HIV were receiving effective antiretroviral medicines for PMTCT in 2021.

Regional variations exist in access to antiretroviral treatment for pregnant and breastfeeding women

Fast facts:

• Access to antiretroviral medicines for pregnant women ranges from 89 per cent [75–>95 per cent] in Eastern and Southern Africa to 28 per cent [30–47 per cent] in Middle East and North Africa
• Antiretroviral treatment coverage dropped drastically in East Asia and the Pacific in the last year from 55 per cent [36–57 per cent] to 41 per cent [46–72 per cent] perhaps due to impact of COVID-19.
• Among the 35 UNICEF HIV priority countries, antiretroviral treatment coverage for prevention of mother-to-child transmission was 84 per cent [70–>95 per cent] in 2021.

Expanding HIV testing and counselling services among pregnant women is critical for identifying those in need of follow-up care and increasing coverage of subsequent interventions that can prevent mother-to-child transmission, as well as for providing care and treatment to the mother for their own health.

As per current guidance from the World Health Organization (WHO), transmission of the virus from mother to child can be significantly reduced if lifelong antiretroviral treatment is administered.

Without any intervention, between 15 per cent and 45 per cent of babies born to HIV-positive mothers are likely to become infected. And half of all infants infected with HIV are likely to die before their second birthday if they do not receive treatment.

Reducing HIV transmission from mother to child requires a range of interventions, beginning with voluntary and confidential counselling and testing for the virus. This should be followed by lifelong antiretroviral treatment for pregnant women with HIV and the administration of antiretroviral drugs to their newborns as a preventive measure, as well as safe delivery practices, and retention of the mother and infant into long-term care and treatment including maintaining suppressed viral load levels.

About 2 in 3 pregnant women were already on antiretroviral treatment prior to their current pregnancy in 2021. Great gains have been made since 2010 to ensure that pregnant women are on lifetime antiretroviral medicines to prevent mother-to-child-transmission and for their own health; however, there are regional variations.

In West and Central Africa, Latin America and the Caribbean, East Asia and the Pacific and South Asia, nearly half of all pregnant women are newly initiating antiretroviral therapy during their current pregnancy. The Middle East and North Africa region shows a significant proportion (75 per cent) of women on lifelong antiretroviral treatment during their current pregnancy compared to Eastern and Southern Africa (72 per cent) and Eastern Europe and Central Asia (73 per cent), respectively.

Estimates from 2021 also show that about a quarter of all pregnant women or mothers needing ART are aged 15–24 years, with some regional variation. South Asia has the largest proportion of mothers needing ART aged 15–24 (30 per cent) compared to Middle East and North Africa, which has the smallest proportion (16 per cent).

The critical strategies through which elimination of new HIV infections among children and keeping mothers alive can be achieved include knowledge of HIV status, early initiation and retention on antiretroviral treatment, and attainment of viral suppression.

WHO guidelines recommend that all infants born to HIV-positive mothers should receive antiretroviral drugs preventively. Data show that the use of services related to the prevention of mother-to-child transmission of HIV is expanding. Poor service delivery in the post-partum period with significant low rates of maternal retention, populations living in hard-to-reach areas, aggravated by weak health systems, and the fear, stigma and denial that continue to discourage women from being tested for HIV are significant barriers to wider uptake of services. Almost 70 percent of new HIV infections among children in 2021 were due to the mother not receiving ART or dropping off from ART during either pregnancy or breastfeeding. This notion is highlighted by the fact that despite PMTCT coverage increasing from 2010 to 2021 by nearly 35 percentage points, the mother-to-child-transmission (MTCT) rate globally dropped by half during the same period from 24 per cent in 2010 to 12 per cent in 2021. This is still far from the 5 per cent path-to-elimination threshold for breastfeeding countries and 2 per cent for non-breastfeeding countries.

For information on UNICEF’s programme and policy work on HIV and AIDS, visit the Children & AIDS community of practice.

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