Progress of mother-to-child transmission of HIV programs in China: successes, challenges and way forward

HIV still remains a global public health problem despite decades of interventions to eliminate the virus. In 2010, there were 390 000 children globally, under 15 years old, newly infected with HIV, mainly through mother-to-child transmission.1 China had 780 000 HIV infected people at the end of 2011, of these, 28.6% were women and 1.1% were children infected through mother-to-child transmission.2 The first case of mother-to-child transmission (MTCT) of HIV in China was reported in 1995.3 Few years later, the proportion of MTCT in China increased from 0.1% in 1997 to 0.4% in 2002.4 The Ministry of Health in China in conjunction with the Central for Maternal and Child Healthcare and the Chinese Centre for Disease Control launched prevention of mother-child transmission of HIV (PMTCT) programs in China in 2003. The programs were launched in five provinces with high prevalence of HIV namely, Henan, Guangdong, Yunnan, Guangxi and Xinjiang.5 MTCT is the commonest route of HIV infection for HIV positive children under five years and in the absence of any interventions, transmission rates range from 15%-45%. The rates can be reduced to levels below 5% with effective interventions.6 PMTCT programs consist of a range of interventions, including improved antenatal services, HIV counseling and testing for pregnant women, antiretroviral drug prophylaxis for HIV positive pregnant women and newborns, referral to support groups, and counseling on options for safer infant feeding practices. Comprehensive PMTCT programs also include continued follow-up and treatment for HIV positive mothers and their children, especially for the first 18 months of the child's life. Women and their families in China are also given the choice of either terminating the pregnancy or receiving clinical interventions to reduce the risk of transmitting the virus to the infant.7 Strategic direction number six of World Health Organization (WHO) PMTCT strategic vision 2010-2015, emphasizes on tracking program performance and impact on MTCT rates and on maternal and child health outcomes.8 Since PMTCT was launched in China in 2003, studies that have been conducted to track the progress of the programs in China are scanty. It is against this background that this paper has been written. The paper aimed to analyze the progress of PMTCT programs in China. It addresses the following areas: (1) provision of PMTCT in China; (2) successes of PMTCT programs in China; (3) challenges of PMTCT programs in China and (4) way forward on the challenges faced in PMTCT programs. PROVISION OF PMTCT INTERVENTIONS IN CHINA PMTCT services in China are provided to pregnant women presenting for antenatal, labor, delivery and postnatal care in hospitals and clinics. Women are counseled for HIV testing, thereafter, HIV screening test is performed among women who provide consent, by using rapid HIV immunoassays such as Determine®HIV-1/2 test kit.9 Since 2011, the provision of PMTCT programs follows 2010 WHO recommendations. According to the WHO recommendations, antiretroviral drugs (ARV) prophylaxis is provided by following one of the two options as follows: For option A, the mother takes Zidovudine during the antenatal period, starting from as early as 14 weeks of pregnancy. A single dose of Nevirapine and Lamivudine is added during labor, and Zidovudine and Lamivudine are continued for seven days after delivery as a “tail” to decrease the risk of Nevirapine resistance. If the mother chooses to breastfeed, the infant receives Nevirapine syrup from birth until one week. If the mother gives the baby replacement feeding, the infant is given either Nevirapine or Zidovudine from birth to 4-6 weeks of age. For option B, the mother takes a prophylaxis regimen consisting of three antiretroviral drugs during pregnancy, labor and after delivery until one week. Infants born to mothers on option B receive either Nevirapine or Zidovudine from birth until 4-6 weeks of age, regardless of their feeding method. Follow-up services are provided to mothers at 1 and 4 weeks after birth which include a nutritional assessment of the infant.10 Most HIV-infected women in China are encouraged to avoid breastfeeding and exclusively formula feed their infants. Studies in Yunnan and Henan provinces have reported 96%-100% avoidance of breastfeeding among known HIV-infected mothers.11-13 Infants are diagnosed for HIV using antibody test after 18 months of age when maternal antibodies are no longer present in the child's blood.14 In February 2011, the Ministry of Health in China launched the comprehensive service models for prevention of mother-to-child transmission of HIV, syphilis and hepatitis B. The central government allocated a total of over 1.7 billion Yuan, to ensure the successful implementation of the model. After one year of implementation, the comprehensive service model has been expanded to cover 1156 counties (or districts) 347 prefectures within 31 provinces (or autonomous regions, municipalities) across China, providing PMTCT coverage to 39% of all counties (or districts) in the country. In 7 provinces with the most serious epidemics, including Henan, Guangdong, Guangxi, Yunnan, Sichuan, Guizhou and Xinjiang, full coverage has already been achieved. Approximately 44% of all pregnant women in China receive free HIV screening services.2 A summary of some studies conducted in China showed that MTCT prevalence rate ranged from 0% to 38.4%.15-21 The prevalence rate of women who chose to terminate their pregnancy to avoiding passing the virus to their infants ranged from 31.4% to 40.0%.21,22 SUCCESSES OF PMTCT PROGRAMS PMTCT programs have registered many successes since their introduction. In 2003, the government of China introduced a “Four Frees and One Care” policy. The policy advocated for the provision of free ARV drugs to HIV infected pregnant women to prevent MTCT, and HIV testing of newborns babies.23 The policy helped many poor pregnant women and their infants to access free PMTCT services. Within the same year, the government launched China Comprehensive AIDS Response Program (China CARES) in order to explore the most appropriate models of comprehensive HIV/AIDS response that would meet international standards. China CARES covered 83.3 million people in 127 program sites chosen from 28 provinces based on HIV prevalence. The program focused on rural, resource-poor and ethnic minority areas with relatively high HIV prevalence. The activities of China CARES included: strengthening HIV/AIDS surveillance, distributing comprehensive HIV prevention activities such as information, education and communication (IEC), free voluntary counseling and testing (VCT), promotion of condom use, diagnosis and treatment of sexually transmitted infections (STIs), needle exchange and methadone maintenance treatment (MMT), PMTCT, provision of free HIV care and treatment such as ARV treatment, care and support to people living with HIV/AIDS.24 Furthermore, in 2004 the ministry of health published guidelines on prevention of mother-to-child transmission of HIV, addressing issues of testing for HIV infection, provision of antiretroviral treatment, and infant feeding.25 In 2011, the government of China introduced comprehensive service model for prevention of HIV among children. Since 2001, the government of China has also increased funds for HIV/AIDS prevention, including PMTCT programs, from 15 million Yuan to a total of 1.7 billion Yuan in 2011.2,26 The commitment of the government in supporting PMTCT programs has helped in the reduction of the mother-to-child transmission of HIV rate from 33.3% in 2003 to 9.1% in 2008.2,18,27 By the end of 2008, 81.8% pregnant women in areas with high HIV prevalence rates received counseling services and 75.8% received HIV testing during antenatal care. In addition, 92.9% of HIV-infected pregnant women and 85.5% of their newborns received anti-retroviral prophylaxis.2,17 By the end of 2011, more than 8.4 million pregnant women nationwide received HIV counseling services and more than 3.8 million in 2010. Counseling rates increased from 85.2% in 2010 to 89.8% in 2011, more than 8.7 million received HIV antibody testing services, representing an increase in HIV testing rates from 88.7% in 2010 to 92.9% in 2011. A total of 5313 pregnant women were diagnosed with HIV, an increase of 1167 cases from the 4146 diagnosed in 2010. Among women diagnosed with HIV in 2011, 3407 HIV positive women gave birth. Of these, 74.1% received antiretroviral treatment, an increase from 73.8% observed in 2010. A total of 3380 live births were recorded, with pediatric antiretroviral medication used in 85.2% of the cases. The proportion of infants fed using infant formula increased from 95.3% in 2010 to 95.9% in 2011.2 CHALLENGES OF PMTCT PROGRAMS Despite registering successes, PMTCT programs in China are facing many challenges. These challenges include: stigma and discrimination, emergence of ARV drug resistance, low level of knowledge of PMTCT programs by pregnant women, low coverage of PMTCT programs, delayed infant HIV diagnosis and increase in risk behaviors among pregnant women and their partners. Stigma and discrimination Social stigma and discrimination are a significant barrier to HIV prevention in China.28 HIV/AIDS is associated with promiscuity, infidelity and prostitution; as such people with the virus are stigmatized and discriminated. In a study conducted among pregnant women and health professionals in Yunnan province, 23% of health professionals and 45% of pregnant women thought HIV was a disease of “low class and illegal", 48% of health professionals and 59% of pregnant women thought that HIV positive individuals should not be allowed to get married, and 30% of the health professionals were not willing to treat an HIV positive individual.29 Emergence of ARV drug resistance Emergence of ARV drug resistance is a problem faced by PMTCT programs in China.30 A study conducted in Henan, revealed primary drug resistance in 8.8% of pregnant women. Two women had mutations associated with nucleoside reverse transcriptase inhibitors (NRTI) while six women harbored mutations associated with non-nucleoside reverse transcriptase inhibitors (NNRTI). No protease inhibitor (PI) drug resistance was detected.31 Low level of knowledge of PMTCT programs among pregnant women Several studies have shown that pregnant women have a low level of knowledge of PMTCT programs in China.32 A study conducted in Hunan province found that only 64% had heard about mother-to-child transmission of HIV.33 One survey found that two out of five Chinese women and men, could not name a single way to protect them against HIV.34 A study conducted in Shenzhen city and rural Guangxi found that fewer women were aware of HIV transmission during pregnancy and breast-feeding or through unprotected sex, to make matters worse, only one-tenth of the women were aware of the availability of antiretroviral drugs.35 A study conducted in Anhui province found that 41% of the study participants knew that HIV could be vertically transmitted from parents to a child. Only 2 couples realized that ARV drugs were available to prevent vertical transmission.36 Low coverage of PMTCT programs By 2011, coverage of the standard and comprehensive PMTCT programs in China was less than 50%.2 Furthermore, among the people living with HIV/AIDS in China, fewer than 6% have actually been tested.37,38 This implies that untested HIV-infected individuals are the main reservoir of HIV transmission in pregnant women. Delayed infant HIV diagnosis Currently, confirmation of infant HIV diagnosis in China is done after a child is over 18 months of age using the free HIV antibody testing. It is likely that a significant proportion of children would have already died without receiving ARV drugs by that time. HIV DNA polymerase chain reaction (PCR) testing is available only as a research tool, and remains too expensive to be used routinely.28 Increased risk behaviors among pregnant women and their male partners A study conducted in rural China found that less than 50% of the couples agreed that they would use condoms consistently if one of them was HIV-positive.34 Furthermore, 80% of gay men in China are married, and less than 10% report regular condom use with their homosexual partners or spouses.39 In another study conducted in Aksu, less than half of the study participants said that they would disclose their HIV status to their husbands if found HIV positive.40 WAY FORWARD TO IMPROVE PMTCT PROGRAMS IN CHINA Stigma and discrimination in PMTCT programs implied that many women would refrain from HIV counseling and testing for fear of being stigmatized and discriminated. This can have a negative impact in the effectiveness of the programs. Government should come up with policies that will help to reduce stigma and discrimination. Health workers, community leaders and the general public should be educated on the dangers of stigma and discrimination. Studies, which are qualitative in nature, should be conducted to explore ways in which stigma and discrimination against people with HIV can be eradicated. Non-adherence to ART has been clearly implicated in the development of antiretroviral-resistant virus.41 It is therefore, beneficial for health workers to encourage pregnant women to adhere to ARV treatment to avoid drug resistance. Better adherence leads to better outcomes, but even suboptimal adherence can have a significant clinical benefit. Achieving 90% to 95% adherence significantly reduces the likelihood of virologic failure and drug resistance, which provides, by far, the best chance for long-term clinical success.42 In addition, studies that examine ARV drug resistance should be encouraged. Women on ARVs should be routinely tested for ARV drug resistance. Women should be equipped with knowledge of their HIV infection, availability of treatment and accurate information about the benefits and risks of interventions to minimize the chance of transmission of HIV to their infants. Healthcare workers should be trained to provide counseling to the women, to support them make sound decisions, and to facilitate communications with their spouses and family members. Furthermore, government, health workers and all stakeholders involved with planning and implementation of PMTCT programs should explore the use of mass media for health promotion. This was found to be effective and efficient in reaching large numbers of pregnant women in Aksu, north west China.40 Many families in China own television sets in their homes. Television health education programs aimed at imparting knowledge of prevention of mother-to-child transmission of HIV to the pregnant women and the general population can be very beneficial. Pregnant women and their partners should also be taught on behavioral interventions such as consistent use of condoms and disclosure of HIV infection to their spouses. Couple counseling and testing, as well as involvement of male partners in PMTCT programs in China should be promoted in all facilities offering PMTCT services, as this has shown to have a big impact in prevention of mother-to-child transmission of HIV in sub-Saharan Africa.43 Government should put in place mechanisms to scale-up PMTCT programs nationwide. For this to be possible government and all stakeholders involved in planning and implementation of PMTCT programs should mobilize resources both human and material to enable smooth scaling up of the services. Health workers should also be trained on how to provide PMTCT services. Government should come up with policies that will promote early infant diagnosis. Use of DNA PCR to diagnose HIV infection in infants should be implemented in all facilities. This will ensure early identification of HIV infection in children and timely implementation of appropriate interventions to minimize morbidity and mortality. CONCLUSION PMTCT programs in China have made a significant progress. MTCT rates in areas where HIV epidemic is prevalent have decreased. The government of China has also shown a great commitment by supporting the programs with good policies and financial support. Nevertheless PMTCT programs are facing many challenges such as stigma and discrimination, delayed infant HIV diagnosis, low coverage, emergence of ARV drug resistance and low level of knowledge of MTCT and its prevention among pregnant women. This paper highlights the need to scale up PMTCT services so that more women can access and utilize them. It is by scaling up PMTCT services that China can achieve the global plan set by the United Nations to eliminate new HIV infections among children by 2015.44 Pregnant women and their families should be equipped with knowledge on PMTCT programs through health education. Early infant diagnosis should be implemented and scaled up in all health facilities offering PMTCT programs in order to prevent untimely death of HIV infected children. More studies are needed on ARV drug resistance, ARV drug adherence and loss to follow-up among women and their children enrolled in PMTCT programs.