Academic journal article Bulletin of the World Health Organization

Country Adaptation of the 2010 World Health Organization Recommendations for the Prevention of Mother-to-Child Transmission of HIV/Adaptation Nationale De la Version 2010 Des Recommandations De l'OMS Relatives a la Prevention De la Transmission De la Mere a L'enfant Du VIH/La Adaptacion a Cada Pais De Las Recomendaciones De la Organizacion Mundial De la Salud del Ano 2012 Para la Prevencion De la Transmision del VIH De Madres a Hijos

Academic journal article Bulletin of the World Health Organization

Country Adaptation of the 2010 World Health Organization Recommendations for the Prevention of Mother-to-Child Transmission of HIV/Adaptation Nationale De la Version 2010 Des Recommandations De l'OMS Relatives a la Prevention De la Transmission De la Mere a L'enfant Du VIH/La Adaptacion a Cada Pais De Las Recomendaciones De la Organizacion Mundial De la Salud del Ano 2012 Para la Prevencion De la Transmision del VIH De Madres a Hijos

Article excerpt

Introduction

Considerable progress has been made by programmes for the prevention of mother-to-child transmission (PMTCT) of the human immunodeficiency virus (HIV), as evidenced by the drop in the estimated annual number of children born to HIV-positive (HIV+) mothers from 570 000 in 2003 to 330 000 in 2011. (1) These gains are mostly attributed to increases in PMTCT service coverage. In low- and middle-income countries, the percentage of HIV+ pregnant women receiving antiretroviral therapy (ART) for PMTCT has increased from 15% in 2005 to 57% in 2011.1 The Joint United Nations Programme on HIV/AIDS has now called for the "elimination" of mother-to-child transmission of HIV by 2015. (2) Elimination necessitates lowering the risk of transmission of HIV from mother to child to less than 5% and reducing the infection rate among young children by at least 90%. (3) To attain these goals, an increase in PMTCT programme coverage and a scale-up in the use of the more efficacious ART regimens currently available are needed. (4)

The World Health Organization (WHO) revised its global guidance on the use of ART to treat HIV+ pregnant women and prevent HIV infection in infants (herein referred to as the 2010 PMTCT recommendations) with initial draft recommendations released in November 2009 (4) and final guidelines launched in July 2010.5 Key changes reflected in the 2010 PMTCT recommendations are summarized in Box 1. (5)

Implementation of the new guidelines in developing countries would allow PMTCT programmes to attain rates of mother-to-child HIV transmission comparable to those in developed countries. (6) Yet putting the new recommendations into operation, especially in resource-limited settings, is complex, costly and involves significant planning, human capacity and resources. In addition, the new guidelines call for longer patient follow-up than previous guidelines. Ministries of health (MOH) therefore faced a series of challenging decisions as they revised national guidelines to make them consistent with the 2010 PMTCT recommendations and at the same time appropriate for local contexts (herein referred to as the adaptation process).

The revision of international health guidelines is a dynamic process informed by emerging scientific evidence and practical programmatic experience. This article explores perspectives on the collective adaptation process, common issues, key themes and challenges and the decisions reached in relation to adaptation of the 2010 PMTCT recommendations in the 14 African countries where the Elizabeth Glaser Pediatric AIDS Foundation (EGPAF) works. This information is being provided to inform subsequent adaptation processes in response to future guideline revisions.

Since 2000, EGPAF has provided comprehensive technical support for the delivery of PMTCT and HIV care and treatment services to more than 13.6 million women in over 5900 health-care facilities in 16 countries, 14 in sub-Saharan Africa and 2 in Asia (data from EGPAF database, available from corresponding author). Of the 16 countries where EGPAF works, 15 are among the 22 countries with the highest estimated numbers of pregnant women living with HIV. This analysis focuses on experiences in 14 EGPAF-supported countries in sub-Saharan Africa (Table 1).

EGPAF staff work closely with ministries of health in supporting programme implementation, policy and advocacy, and research. Many of EGPAF's country-based technical staff actively participate in national PMTCT technical working groups, where they provide technical assistance on national policy related to PMTCT and HIV care and treatment. Thus, they have first-hand knowledge of country experiences in adapting the 2010 PMTCT recommendations.

Box 1. Summary of key changes in the 2010 PMTCT recommendations
issued by the World Health Organization

Expand access to CD4+ lymphocyte testing for all HIV+ pregnant
women.

Raise the recommended CD4+ lymphocyte threshold for eligibility for
treatment to < 350 cells/ [mm. … 
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