What will it take to achieve virtual elimination of mother-to-child transmission of HIV? An assessment of current progress and future needs.

BACKGROUND: The number of HIV-positive pregnant women receiving antiretroviral drugs (ARVs) to prevent mother-to-child transmission (MTCT) of HIV has increased rapidly. OBJECTIVE: To estimate the reduction in new child HIV infections resulting from prevention of MTCT (PMTCT) over the past decade. To project the potential impact of implementing the new WHO PMTCT guidelines between 2010 and 2015 and consider the efforts required to virtually eliminate MTCT, defined as <5% transmission of HIV from mother to child, or 90% reduction of infections among young children by 2015. METHODS: Data from 25 countries with the largest numbers of HIV-positive pregnant women were used to create five scenarios to evaluate different PMTCT interventions. A demographic model, Spectrum, was used to estimate new child HIV infections as a measure of the impact of interventions. RESULTS: Between 2000 and 2009 there was a 24% reduction in the estimated annual number of new child infections in the 25 countries, of which about one-third occurred in 2009 alone. If these countries implement the new WHO PMTCT recommendations between 2010 and 2015, and provide more effective ARV prophylaxis or treatment to 90% of HIV-positive pregnant women, 1 million new child infections could be averted by 2015. Reducing HIV incidence in reproductive age women, eliminating the current unmet need for family planning and limiting the duration of breastfeeding to 12 months (with ARV prophylaxis) could avert an additional 264 000 infections, resulting in a total reduction of 79% of annual new child infections between 2009 and 2015, approaching but still missing the goal of virtual elimination of MTCT. DISCUSSION: To achieve virtual elimination of new child infections PMTCT programmes must achieve high coverage of more effective ARV interventions and safer infant feeding practices. In addition, a comprehensive approach including meeting unmet family planning needs and reducing new HIV infections among reproductive age women will be required.

Under-5 mortality due to HIV: regional levels and 1990-2009 trends.

BACKGROUND: Since at least the late 1990s, HIV has been viewed as a major threat to efforts by countries to reduce under-5 mortality. Previous work has documented increased under-5 mortality due to HIV from 1990 to 1999 in Africa. The current analysis presents estimates and trends in under-5 mortality due to HIV in low- and middle-income countries by region up to 2009. METHODS: The analyses are based on the national models of HIV and AIDS produced by country teams in coordination with UNAIDS and its partners for the years 1990-2009. These models produce a time series of estimates of HIV-related mortality as well as overall mortality in children aged <5 years. RESULTS AND CONCLUSION: These analyses indicate that, in 2009, HIV accounted for roughly 2.1% (1.2-3.0%) of under-5 deaths in low- and middle-income countries and 3.6% (2.0-5.0%) in sub-Saharan Africa. The percentage of under-5 deaths due to HIV has been falling in the last decade--for example, from 2.6% (1.6-3.5%) in 2000 to 2.1% (1.2-3.0%) in 2009 in low- and middle-income countries and from 5.4% (3.3-7.3%) in 2000 to 3.6% (2.0-5.0%) in 2009 in sub-Saharan Africa. This fall in the percentage of under-5 deaths due to HIV has been driven by a combination of factors including scale-up of prevention of mother-to-child transmission programmes and treatment for pregnant women and children, as well as a decrease in the prevalence of HIV among pregnant women.

Who is the vulnerable child? Using survey data to identify children at risk in the era of HIV and AIDS.

Over the past decade, there has been increasing global attention to mitigating the impacts of the HIV/AIDS epidemic on children's lives. Within this context, developing and tracking global child vulnerability indicators in relation to HIV and AIDS has been critical in terms of assessing need and monitoring progress. Although orphanhood and adult household illness (co-residence with a chronically ill or HIV-positive adult) are frequently used as markers, or definitions, of vulnerability for children affected by HIV and AIDS, evidence supporting their effectiveness has been equivocal. Data from 60 nationally representative household surveys (36 countries) were analyzed using bivariate and multivariate methods to establish if these markers consistently identified children with worse outcomes and also to identify other factors associated with adverse outcomes for children. Outcome measures utilized were wasting among children aged 0-4 years, school attendance among children aged 10-14 years, and early sexual debut among adolescent boys and girls aged 15-17 years. Results indicate that orphanhood and co-residence with a chronically ill or HIV-positive adult are not universally robust measures of child vulnerability across national and epidemic contexts. For wasting, early sexual debut, and to a lesser extent, school attendance, in the majority of surveys analyzed, there were few significant differences between orphans and non-orphans or children living with chronically ill or HIV-positive adults and children not living with chronically ill or HIV-positive adults. Of other factors analyzed, children living in households where the household head or eldest female had a primary education or higher were significantly more likely to be attending school, better household health and sanitation was significantly associated with less wasting, and greater household wealth was significantly associated both with less wasting and better school attendance. Of all marker of child vulnerability analyzed, only household wealth consistently showed power to differentiate across age-disaggregated outcomes. Overall, the findings indicate the need for a multivalent approach to defining child vulnerability, one which incorporates household wealth as a key predictor of child vulnerability.

Estimation of antiretroviral therapy coverage: methodology and trends.

PURPOSE OF REVIEW: To present the methodology used to calculate coverage of antiretroviral therapy (ART) and review global and regional trends in ART coverage. RECENT FINDINGS: There has been a steady increase in ART coverage over the last decade with a more rapid increase in recent years. Current estimates of ART coverage are 43% for adults and 38% for children (ages 0-14 years). Methods for calculating coverage rely on good-quality patient monitoring systems in countries, and well informed models are needed to estimate the number of people in need of treatment. SUMMARY: The estimated coverage rates show that ART programs have improved over the past 8 years; however, approximately 58% (53-60%) of those people in need of ART are still not on treatment. High quality data are needed to accurately measure changes in ART coverage.

Fertility preferences and the need for contraception among women living with HIV: the basis for a joint action agenda.

OBJECTIVES: HIV-positive women have particular needs for contraception to avoid unwanted pregnancy, to protect their own health and to eliminate the risk of transmitting HIV to an infant. In 2004, the United Nations described a four-element strategy to preventing mother-to-child transmission of HIV; the second element is preventing unintended pregnancies among HIV-positive women. However, fertility preferences among HIV-positive women who know their status remain poorly understood. This study seeks to demonstrate the degree to which knowledge of one's own serostatus is associated with fertility preferences and contraceptive demand and use. METHODS: This study uses Demographic and Health Surveys data and bivariate and multivariate methods to assess the contribution of a proxy variable for knowledge of own HIV serostatus to women's fertility desires, demand for contraception and contraceptive method choice for Zambia, Swaziland, Zimbabwe and Lesotho. RESULTS: Knowledge of one's own HIV-positive serostatus is significantly associated with a desire to limit childbearing with contraceptive use, but not necessarily with unmet need for contraception. HIV-positive women who know their status are more likely than other women to use condoms. CONCLUSION: HIV-positive women who know their serostatus exhibit fertility desires and contraceptive behaviors that are different from those of other women. These findings support the argument that efforts to scale up the second element of the strategy to prevent mother-to-child transmission of HIV should be accelerated: it is a cost-effective, rights-based approach to preventing incidence of mother-to-child transmission of HIV. Scaling up requires full commitment by both reproductive health/family planning and HIV constituencies to concerted integration at all levels of program planning, coordination and implementation.

Global progress in PMTCT and paediatric HIV care and treatment in low- and middle-income countries in 2004-2005.

A growing number of countries are moving to scale up interventions for prevention of mother-to-child transmission (PMTCT) of HIV in maternal and child health services. Similarly, many are working to improve access to paediatric HIV treatment. This paper reviews national programme data for 2004-2005 from low- and middle-income countries to track progress in these programmes. The attainment of the UNGASS target of reducing HIV infections by 50% by 2010 necessitates that 80% of all pregnant women accessing antenatal care receive PMTCT services. In 2005, only seven of the 71 countries were on track to meet this target. However PMTCT coverage increased from 7% in 2004 (58 countries) to 11% in 2005 (71 countries). In 2005, 8% of all infants born to HIV positive mothers received antiretroviral prophylaxis for PMTCT, up from 5% in 2004, though only 4% received cotrimoxazole. 11% of HIV positive children in need received antiretroviral treatment in 2005. In 31 countries that had data, 28% of women who received an antiretroviral for PMTCT also reported receiving antiretroviral treatment for their own health. Achieving the UNGASS target is possible but will require substantial investments and commitment to strengthen maternal and child health services, the health workforce and health systems to move from pilot projects to a decentralised, integrated approach.

Perception of risk of HIV/AIDS and sexual behaviour in Kenya.

The association between perception of risk of HIV infection and sexual behaviour remains poorly understood, although perception of risk is considered to be the first stage towards behavioural change from risk-taking to safer behaviour. Using data from the 1998 Kenya Demographic and Health Survey, logistic regression models were fitted to examine the direction and the strength of the association between perceived risk of HIV/AIDS and risky sexual behaviour in the last 12 months before the survey. The findings indicate a strong positive association between perceived risk of HIV/AIDS and risky sexual behaviour for both women and men. Controlling for sociodemographic, sexual exposure and knowledge factors such as age, marital status, education, work status, residence, ethnicity, source of AIDS information, specific knowledge of AIDS, and condom use to avoid AIDS did not change the direction of the association, but altered its strength slightly. Young and unmarried women and men were more likely than older and married ones to report risky sexual behaviour. Ethnicity was significantly associated with risky sexual behaviour, suggesting a need to identify the contextual and social factors that influence behaviour among Kenyan people.