WHO’s path to elimination of mother-to-child transmission of HIV and syphilis

In their recent article in The BMJ (“Is elimination of vertical transmission of HIV in high prevalence settings achievable?”)¹ Goga and colleagues make several important points, including that more realistic targets are needed to maintain momentum to reduce vertical transmission of HIV in countries with high prevalence. They also make a constructive proposal to encourage countries to use “dashboards” to track key coverage and process indicators, particularly during the “pre-elimination period,” and to encourage continuous programme assessment and use of data for improvement.

We are concerned, however, that they misrepresent the World Health Organization (WHO) and global partners’ elimination of mother-to-child transmission of HIV and syphilis (EMTCT) initiative.² The authors include a box showing the criteria for elimination of vertical transmission of HIV from the WHO guidance, but they omit the section in the guidance that specifically refers to high burden countries and outlines several tiers of progress on a “path to elimination” (p 23).² Moreover, they omit the subject and criteria for eliminating mother-to-child transmission of syphilis, the second leading cause of stillbirth globally.

Several of the authors of The BMJ’s article participated directly in development of the original WHO EMTCT framework and the update that includes the path to elimination section. They are aware, therefore, that this section was added in 2017 to make it more relevant for high burden countries with strong programmes and demonstrable progress that are unable to achieve the stringent final case rate criterion for elimination because of high maternal HIV and syphilis seroprevalence.

The WHO EMTCT guidance outlines three tiers of progress towards EMTCT (bronze, silver, and gold). Each tier recognises progressive improvements in antenatal care coverage, HIV and syphilis testing, and treatment of pregnant women, as well as progressive declines in infant case rates. The validation framework, although initially conceived to recognise the final stage of eliminating vertical HIV and syphilis transmission as a public health problem, has evolved considerably to engage countries and keep the momentum going on the path to elimination. With the active support of UN partners, bilateral partners, and international non-governmental organisations we now have an active regional validation secretariat in sub-Saharan Africa, working directly to engage many high burden countries on the path to elimination of HIV and syphilis. The regional secretariat is also taking the lead in considering new revisions to the path to elimination guidance.

Apart from the required process and impact indicators, the current guidance already includes an extensive list of additional indicators that countries are encouraged to track and report (see Annex B).² This global guidance document is coming up for another review, which will be an opportune time to consider several of the indicators proposed by Goga and colleagues, as well as others proposed by countries in sub-Saharan Africa, and to consider best practice models for implementing country dashboards.

We agree that elimination of vertical transmission of HIV and syphilis can only be accomplished with a robust infrastructure of comprehensive sexual, reproductive, and maternal-child health services. Although not mentioned by Goga et al, this is one of the reasons why the programme was originally developed as a dual initiative to eliminate mother-to-child transmission of both HIV and syphilis. Discussions are under way to include hepatitis B and move to “triple elimination”. The elimination of mother-to-child transmission of HIV and syphilis initiative has been endorsed by all WHO regions. With addition of the path to elimination in 2017, high burden countries are now engaged. We look forward to the ongoing partnership with Unicef and many others in supporting countries to achieve these milestones. We welcome the advice and suggestions of other colleagues and stakeholders to keep the momentum going and to participate by helping countries in their efforts to achieve these lifesaving targets for HIV and syphilis.