Despite safe, effective and affordable interventions, opportunities are still being missed
Globally, more than 1.5 million infants are infected with human immunodeficiency virus (HIV), syphilis, and hepatitis B virus (HBV) every year. Approximately 80% of infections occur in low- and middle-income countries (LMIC). Pregnant women infected with HIV, syphilis, or hepatitis B virus can pass these infections to their babies during pregnancy, delivery, or postpartum. This is called vertical transfer. Without preventive measures, infants at risk for these infections may develop chronic disease and die prematurely.
Safe, effective, and affordable tools exist to prevent the spread of these deadly infections from mother to baby. Expanding access to preventive measures, including stopping new infections in people of childbearing age, timely screening, treatment and hepatitis B vaccination, all delivered through a common Reproductive, Maternal and Child Health (RMCH) platform, can significantly improve Infant survival rate. However, implementation of these measures varies widely across low- and middle-income countries across the three diseases, reflecting uneven investment levels and political will.
Unified planning and service delivery for three infections could save more lives
Shared touch points between pregnant women and newborns within the health system, as well as common transmission routes for HIV, syphilis, and hepatitis B viruses, provide opportunities to bundle life-saving interventions to achieve more person-centered care. This approach is called “triple elimination.” Many governments are developing triple elimination strategies; however, domestic resource constraints and limited international catalytic support hinder implementation and scale-up. In countries that have initiated triple elimination plans, coordination across multiple sectors to ensure timely and appropriate interventions has proven challenging, resulting in low coverage and poor access.
India and Uganda demonstrate triple elimination of HIV, syphilis and hepatitis B is within reach
Countries like India and Uganda are proving that with visionary approaches, solutions, optimal resource utilization and careful planning, these challenges are not insurmountable.
India It has strong reproductive, maternal, newborn, child health and adolescent health programs, as well as established disease-specific programs such as the National AIDS Control Program (NACP) and the National Viral Hepatitis Control Program (NVHCP). Although India has nearly 25 million births each year, coverage of antenatal services exceeds 95%, demonstrating the country’s commitment to improving quality maternal and child health services. In April 2022, India launched a guidance note on “Eliminating Vertical Transmission of HIV and Syphilis” to promote the integration of elimination efforts for both diseases. Despite high antenatal care coverage, gaps in screening, testing and treatment of pregnant women remain, highlighting the need for greater coordination across programmes.
India is beginning to address these gaps by promoting intersectoral coordination and convergent service delivery approaches that provide pathways for effective integration and improved outcomes of vertical elimination efforts. To achieve triple elimination, several priorities have been identified. These include revising hepatitis B prevention guidelines, integrating hepatitis B into HIV and syphilis guidance notes, and promoting integrated service delivery.
Additionally, CHAI is conducting service gap assessments in states with high disease burden and launching demonstration pilots in West Bengal to integrate and enhance service delivery, with the aim of leveraging lessons learned for rapid replication across the country.
“Eliminating vertical transmission of HIV, syphilis and hepatitis B is a unique opportunity that needs to be harnessed to ensure that our next generation of young people are protected from these three infections by 2030 – India has leveraged its existing infrastructure and investments have met this challenge to achieve these elimination goals.”
Dr. Po-Lin Chan, Head of the Infectious Diseases Team, World Health Organization India Country Office
Uganda Significant progress has been made by expanding testing and treatment for HIV, syphilis and hepatitis B, leveraging its HIV programmatic achievements and advancing comprehensive maternal and newborn health services. These services include combined HIV and syphilis screening using dual kits that detect both infections, as well as the upcoming expansion of hepatitis B screening for all pregnant women during prenatal care, linking eligible pregnant women to treatment, and Give babies (including newborns) the hepatitis B vaccine.
Currently, 95% of pregnant women are tested for HIV at least once, and 86% of pregnant women are tested for syphilis during prenatal care. Additionally, 94% and 82% of people who tested positive for HIV and syphilis respectively received timely treatment. Despite this progress, women and children still lack access to care. In 2022, at least 5,000 newborns tested positive for HIV, and many more stillbirths (defined as miscarriages after 28 weeks of pregnancy) were caused by syphilis infection. There are also significant gaps in service delivery for HBV, with only a small proportion of pregnant women receiving screening during antenatal care, even fewer associated with confirmatory testing, and less than two per cent eligible for treatment.
Uganda is working to close these gaps by increasing hepatitis B screening of pregnant women, ensuring they have rapid access to care, and rolling out the hepatitis B birth-dose vaccine in a timely manner for newborns. Uganda is also strengthening HIV treatment counseling and follow-up for pregnant women and increasing retesting during pregnancy and breastfeeding.
To scale up these efforts in Uganda, CHAI is supporting the government to close the resource gap in delivering triple ablation services. As part of Uganda’s 2023 grant application to the Global Fund for AIDS, Tuberculosis and Malaria (GFATM), CHAI advocates for and supports the inclusion of these life-changing interventions in funding proposals. In addition to funding advocacy, CHAI is working with the Ugandan Ministry of Health to strengthen initiatives to prevent vertical transmission of HIV, syphilis and hepatitis B viruses.
“A future where all children are born free of hepatitis B, syphilis and HIV is something we can achieve, it just requires us all coming together, working together and investing, and working with and in our communities”.
Dr. Linda Kisaakye, Head of Prevention of Mother-to-Child Transmission (PMTCT), Ministry of Health, Uganda
Product acquisition and innovation are enabling integrated patient-centered care
Technological advances and improved market access for drugs and diagnostics provide countries with the opportunity to rapidly expand and integrate best-in-class products and services to achieve triple elimination.
By partnering with MedAccess and WHO prequalified providers, CHAI facilitates entry of low- and middle-income countries into the competitive HIV/syphilis dual rapid diagnostic test (RDT) and HIV self-testing markets. CHAI is supporting countries to introduce and scale up dual RDT and working to address implementation barriers that hinder the testing and treatment of syphilis in pregnant women.
CHAI is paving the way for comprehensive screening approaches for HIV, syphilis and HBV, including demonstration models in Nigeria, Rwanda and Ethiopia, and advocating for the development of triple combination RDTs to streamline service delivery, save testing costs and time, and streamline processes. Supply chain barriers. Leveraging the experience of introducing dual RDTs, collaborative efforts among key stakeholders can create an enabling environment for the introduction of new products with triple RDTs. This includes ensuring that policymakers and governments align triple elimination policies, suppliers develop quality-assured and affordable products, governments and donors provide financial commitments to strategic plans, and health plans develop roadmaps for sustainable implementation.
CHAI also increases access to treatment for syphilis and hepatitis B. Earlier this year, an agreement was reached with providers that the maximum price for hepatitis B treatment would be $2.40, in line with HIV program pricing. As countries increase efforts to eliminate congenital syphilis, reliable supply of affordable, quality-assured long-acting injectable antibiotic benzathine penicillin G (BPG) is critical. CHAI, in collaboration with BMGF, WHO and other partners, continues to support activities to mitigate the risk of shortages, such as improving surveillance and information sharing, and deploying resources to support activities that drive adoption of quality-assured products. These opportunities, coupled with increasing catalytic funding and political will, demonstrate that triple elimination of HIV, syphilis, and hepatitis B is achievable.
Through increased strategic investments and an “all in” push globally and within countries, we can ensure that no child is born with HIV, syphilis or hepatitis B.
Contributing author:
Umesh Chawla, Critical and Priority Population Lead, Viral Hepatitis Team; Stephanie Dowling, Associate Director, Pediatric HIV, Global HIV Access Team; Obiageli Alintan, Senior Associate, Global MNH, SRMNCH; Robia Islam, Global Laboratory Services, Hepatitis, Global Diagnostics Team Assistant