|UNAIDS Technical Update Mother-to-Child Transmission of HIV - Update 1.2 (UNAIDS, 2001, 9 p.)|
|Issues for Policy decision options|
|Potential operational packages for countries of East Asia and Pacific|
|Conclusion: Crosscutting issues for scaling up|
1. There is now a large range (figure 11) of potential interventions, which are effective for PMTCT. In this menu of interventions each country is to choose the intervention most appropriate to its own epidemiological, economic, and health system situation.
2. Although the intervention regimens are still not fully defined, there is enough information about ARV and VCCT to move towards to scaling up. VCCT and ARV are cost-effective strategies that reduce MTCT regardless of the mode of infant feeding.
3. As illustrated in Phayao Province, Northern Thailand, 1998: 97% of pregnant women had ANC, 94% were tested for HIV, of which 4% tested positive; 95% of these returned for confirmation, 76% initiated ARV treatment and 71% finished the treatment. This implies that in large-scale PMCT programs, VCCT and ARV effectively covered 69% of the estimated total number of HIV+ mothers.
4. In contrast, current knowledge points to the dangers of going to scale with replacement feeding in contexts where women will have low education, low access to water, low economic means, and strong cultural pressures to breastfeed. Emphasising replacement feeding in those contexts may fuel the mixed feeding practice for mothers who will have no other choice than breastfeeding, yet will try to follow the recommendations to replacement feed.
5. Regimens combining ARV during delivery, exclusive breastfeeding with ARV prophylaxis in children followed by early cessation of breastfeeding are likely to prove very cost-effective in reducing MTCT on a population basis and may even prove more effective in improving child survival than replacement feeding plus ARV.
6. The approach to envisioning implementation is to be discussed: are women to be recipients or stakeholders? VCCT can be seen as an empowering long-term oriented strategy, whereas ARV is an outcome oriented emergency strategy. Should both progress at the same pace or should we phase the implementation of emergency measures and capacity building measures along different time and space schedules?
7. A core package (or several options of core packages to depend on the country context) to be offered to HIV+ pregnant women and their families is to reduce not only MTCT but also overall U5 mortality rate. What is the right balance for scaling up between ARV only and a full package (life skills, condoms, VCCT, ARV, replacement feeding) with support to HIV affected families including orphans?
8. There is a need to scale up in order to broaden health economic studies beyond the cost-effectiveness of alternative regimens to address MTCT in isolation (well established now and of little concern to countries) to analysis of cost-effectiveness in terms of child survival, allocative efficiency, and affordability. This includes:
· Analysis of the costs and benefits in terms of both child survival and decrease of the HIV epidemic from the full package of MCH services to be offered to HIV+ pregnant women
· Analysis of the opportunity costs of investing in this intervention as compared to investing in other activities to decrease child and maternal mortality as well as the spread of HIV
· The development of financing scenarios taking into account government, household (identifying the demand of women), and donor contributions