Prevention of Parent to Child Transmission of HIV

Mother to child transmission of HIV is the primary route of transmission for HIV among children. This transmission is known to occur during pregnancy, delivery and breast-feeding period with equal frequency. It is estimated that without any intervention the risk of transmission of HIV from infected mother to her child is between 20 to 45%. But with effective use of Anti-retroviral (ARV) drugs, this risk reduces significantly. Therefore to address burden of HIV among children, the National AIDS Control Programme (NACP) launched Prevention of Parent to Child (HIV) Transmission (PPTCT) of HIV services in the year 2002. This provided access to HIV testing services to all pregnant women enrolled into Ante Natal Care (ANC) along with provision of ARV prophylaxis with single dose of Nevirapine (SD-NVP) at the time of delivery to mother and baby.

These services were rapidly scaled-up across India during the NACP-III (2007-2012). Although implemented effectively in the high HIV prevalence states reach of PPTCT services to all pregnant women in the country remains limited. In line with WHO recommendation, India has successfully launched (September 2012) the more efficacious PPTCT Option B regimen in the three States of Andhra Pradesh, Karnataka initially and later in Tamilnadu.

Globally evidence suggest that although ARV prophylaxis using SD-NVP is highly effective in reducing risk of transmission from about 45% to less than 10%, the 10% uncovered risk is unacceptably high since paediatric HIV can be eliminated if currently available drugs are used effectively. The World Health Organization (WHO) therefore recommends use of more efficacious ARV regimens, using multiple drugs for PPTCT. These regimens can reduce transmission to less than 5% if started early in pregnancy and continued throughout period of delivery and breasts feeding.

WHO has moved away from the previous terms “Options A, B and B+”. Instead, the WHO new guidelines (June 2013) recommend two options:

  • Providing lifelong ART to all the pregnant and breastfeeding women living with HIV regardless of CD4 count or clinical stage OR
  • 2. Providing ART (ARV drugs) for pregnant and breastfeeding women with HIV during the mother to child transmission risk period and then continuing lifelong ART for those women eligible for treatment for their own health.
The Government of India in-turn has committed itself to work towards achieving the global target of elimination of new HIV infections among children by 2015. Department of AIDS Control (DAC) has decided to provide lifelong ART for all pregnant and breast feeding women living with HIV, in which all pregnant women living with HIV receive a triple-drug ART regimen (TDF+3TC+ EFV) regardless of CD4 count or clinical stage, both for their own health and to prevent vertical HIV transmission and for additional HIV prevention benefits. These PPTCT services are scaled-up rapidly across the country, in a phased manner to replace currently available SD-NVP prophylaxis.

According to WHO providing an optimized, fixed-dose combination first-line ART regimen of TDF + 3TC+ EFV to all pregnant and breastfeeding women with HIV provides important programmatic and clinical benefits, including the following.

  • Ease of implementation: The same simplified ART regimen is administered to all pregnant women (regardless of “eligibility” for treatment) and continued during pregnancy and labour and postpartum.
  • Harmonized regimens: The optimized first-line fixed-dose combination regimen can be harmonized with guidelines for ART in non-pregnant adults.
  • Increased coverage of ART: This ensures that immune-compromised women who do not have access to CD4 testing receive appropriate ART without delay.
  • Vertical transmission benefit. Provides coverage with ART to maximize the prevention of infant infections.
  • Maternal health benefit: Will delay disease progression over the course of treatment.
  • Acceptability: Reviews conducted for these guidelines generally indicated strong community preference and acceptability for this approach.
  • Sexual prevention benefit: ART will reduce sexual transmission of HIV to sexual partners

Karnataka Scenario:

Karnataka’s Annual Pregnancy estimation was 12.53 lakh for 2014-’15. Out of which 12.32 lakh ANCs have been counseled and tested from April 2014 - Mar 2015 thus achieving 98.4% testing of annual estimated pregnancies .

WHO new guidelines (Option B) on Prevention to Parent to Child transmission of HIV was implemented in Karnataka from September 2012, with a goal to reduce mother to child transmission to less than 5%. The state responded to the challenge of roll out of multi drug regimen from August to December 2012. A total of 3800 field workers were trained to augment successful implementation. Multiple levels of the capacity building was done. A resource pool at the district level was also created. Subsequently in December 2013 training of 1000 Government health functionaries & others were conducted which led to the promising result of achieving less than 5% HIV transmission from mother to child.

New Guidelines for Lifelong ART for all Pregnant Women Living with HIV for Prevention of Parent-to-Child Transmission (PPTCT) of HIV is implemented from January 2014 across the country.

Indicator 2008-09 2009-10 2010-11 2011-12 2012-13 2013-14 2014-15
Annual number of pregnancies in a year
(In Lakhs)
11.35 11.47 11.58 11.75 12.07 12.90 12.53
No. pregnant women counseled and tested 569474 796721 784794 1014012 759366 1136056 12.32
No. of pregnant women detected positive 3257 3544 2536 2333 1397 1446 1295
HIV Positive ANCs (%) 0.57 0.44 0.32 0.23 0.23 0.13 0.11
MB pairs coverage for NVP (%) 50 60 85 98 91 95 95

Institutional deliveries in Karnataka is approx. 95%. Out of which, 75% is in the public sector and 25% is in the private sector. Under the Karnataka Private Medical Establishment Act (KPME), 2007, the District Health & Family Welfare Officers issue licences to the private hospitals, clinics and laboratories which then gives them the authority to also seek information on the number of ANCs who have been counseled and tested for HIV in their institutions. DAPCU Officers have been collecting this information from the District Health & Family Welfare Officers which not only gives information on number of ANCs who have been counseled and tested for HIV in the private sector but also gives them an opportunity to forge partnership with the private sector for establishing ICTCs in them (PPP ICTCs).

HIV counseling and testing services in Karnataka has been brought almost to the door step of the ANCs through the variety of ICTC facilities they can choose to access viz., Stand-alone ICTCs (SA ICTCs); Facility Integrated ICTCs (F ICTCs); PPP ICTCs; Mobile ICTCs; Mobile Medical Units (MMUs – NRHM and Karnataka Health Systems Project) as well as Whole Blood Finger Prick Testing done for screening by ANMs in Bijapur, Belgaum and Bagalkot (3’B’ districts) where the HIV epidemic is at its peak.

CME on PPTCT & EID- Hassan

NACO & WHO team visit to Karnataka

HIV RCH Integration workshop- Raichur

Training of Trainers (TOT)