© UNICEF South Africa/2013/Marinovich
TOWARDS AN AIDS-FREE GENERATION – Children and AIDS: Sixth Stocktaking Report, 2013
strongly support the integration of PMTCT and ART programmes by emphasizing that HIV outcomes in children are inextricably linked to the health of their mothers. Furthermore, increasing evidence of poorer health outcomes for infants born to mothers living with HIV, regardless of the HIV status of the infants, points to the importance of early treatment for women living with HIV to protect their own health and that of their babies. The provision of ARV prophylaxis only during pregnancy and breastfeeding for women living with HIV with higher CD4 counts (the approach previously known as Option A) is no longer recommended by WHO and should be phased out as soon as possible.
2. P revent mother-to-child transmission among women from key populations Outside sub-Saharan Africa, the majority of cases of mother-to-child transmission are occurring among key populations, including women who inject drugs and female partners of men who inject drugs, sex workers, female partners of men who also have sex with men, and other marginalized groups such as women in prisons. For example, in Ukraine, where the epidemic is driven by injecting drug use, a study in 2010 showed mother-to-child transmission rates of 11 per cent in women who injected drugs versus 6 per cent in women who did not.72 Scaling up harm reduction programmes and integration with sexual and reproductive health and maternal and child health services has led to substantial increases in coverage of HIV testing and ART for pregnant women injecting drugs. To achieve elimination of mother-to-child transmission in this population wherever they may live, further action is needed to ensure early access to services that can address both
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drug dependency and HIV-related issues, including provision of medication-assisted substitution treatment for women with opioid drug dependence.73 Women represent 5–10 per cent of the over 30 million people in prisons each year, but this proportion is increasing and women in prisons are at higher risk for HIV than their male counterparts.74 Women can be pregnant, give birth and breastfeed while in prison and other closed settings. The isolation of prison health services from general health services and the substandard conditions and services, including HIV and reproductive health services, means access to PMTCT can be limited. It should be a priority for countries to include populations in closed settings in their efforts to prevent transmission of HIV through comprehensive services equivalent to those in the community.
3. Integrate TB prevention, diagnosis and treatment as a core component of the PMTCT package of care in high TB prevalence settings Active tuberculosis (TB) has been diagnosed at rates up to 10 times higher in pregnant women living with HIV than in women without HIV infection.75 There is also increasing evidence to show that untreated TB in pregnant women living with HIV is associated with a higher risk of poor obstetric and perinatal outcomes, including the death of both the infant and mother. TB in pregnant women living with HIV is also associated with more than double the risk of transmission of HIV to the unborn child.76 It is therefore vital that collaborative TB/ HIV activities be incorporated as part of the package of care at all stages of pregnancy and neonatal, postpartum and post-natal care, particularly in high HIV and TB burden settings. The inclusion of regular TB symptom screening, as recommended by WHO, will help ensure early diagnosis and treatment of TB and also identify women who do not have active TB and are eligible for isoniazid preventive TB therapy. 77 Should full integration of TB diagnostic, prevention and treatment services in maternal, newborn and child health services not be possible, effective patient-centred referral mechanisms with TB services need to be established.