Service Delivery

The comprehensive approach to service delivery for prevention of mother-to-child transmission (PMTCT) of HIV recommended by the World Health Organization (WHO) and UNAIDS has four components:
1) primary prevention of HIV among women of childbearing age
2) preventing unintended pregnancies among women living with HIV
3) preventing HIV transmission from a women living with HIV to her infant
4) providing appropriate treatment, care and support to women living with HIV and their children and their families.

Service delivery issues are different for each intervention, but an optimal evidence-based PMTCT "package" will reduce the overall risk of maternal to child transmission to less than 2%. These interventions include:
• optimal detection of HIV-infected pregnant women through effective HIV testing and counseling
• for HIV-positive pregnant women, assessment of their eligibility for lifelong anti-retroviral therapy (ART)
• provision of highly active ART (HAART) to those eligible for lifelong ART
• provision of the most highly feasible antiretroviral (ARV) prophylactic regimen
• safe obstetrical practices, including Cesarean-section when indicated and feasible
• safe infant feeding options, including complete avoidance of breastfeeding

The resources provided in this section of the PMTCT Toolkit will help providers offer quality services for the range of needs experienced by mothers, families and children infected with or at risk for HIV, including manuals to help with service provision and resources on counseling and testing, family centered care, antiretroviral treatment and prophylaxis for PMTCT, infant feeding in the context of HIV, and integrating delviery of services. Job aids and tools throughout this section of the toolkit are collated in the Job Aids and Tools section below.

Counseling and Testing in Programs to Prevent Mother-to-Child Transmission of HIV (6 resources)

The foundation of effective PMTCT programs is the identification of HIV-positive pregnant women and linking them and their babies with appropriate HIV-related treatment, care and support services. Provider initiated HIV counseling and testing (PICT), now generally considered a standard component of medical care, is a strategy used to maximize identification of women in need of PMTCT services.

    Family-Centered Treatment, Care, and Support (4 resources)

    Family-centered care offers HIV/AIDS prevention, testing, care, and treatment to the whole family at one location. Such an approach has been shown to increase the identification of HIV infection in women and children, and also increases the uptake of treatment services. Studies have shown that a bundled package of family-centered services decreases mother-to-child transmission (MTCT), reduces infant AIDS mortality, and decreases the incidence of malnutrition -- while increasing the uptake of testing and treatment for HIV-positive mothers. Studies have also shown that family-centered programs are able to locate infections at earlier disease stages and decrease AIDS-related deaths for all members of the family.

      Preventing Unintended Pregnancies Among HIV-Positive Women (10 resources)

      To help reduce the numbers of children infected with HIV, the World Health Organization (WHO) and the United Nations Joint Program on HIV/AIDS (UNAIDS) have outlined a four-element strategy to guide the prevention of mother-to-child transmission (PMTCT) of HIV, including the prevention of unintended pregnancies among HIV-infected women. This is an essential component of preventing babies from acquiring HIV from their infected mothers. If efforts are made to alleviate current unmet need for family planning, which is often high among HIV-infected women, programs and countries could substantially increase the number of HIV-positive births averted. Studies have shown that this strategy is at least equally as cost-effective, if not more cost-effective, than applying the traditional model of PMTCT services.

        Antiretroviral Therapy for Prevention of Mother-to-Child Transmission of HIV (4 resources)

        In 2010, new guidance from the World Health Organization (WHO) indicated that HIV-infected pregnant women in need of antiretroviral therapy (ART) for their own health--that is, women with a CD4 count ≤ 350 cells/mm3 or in WHO clinical stages 3 or 4--should receive lifelong ART. In addition, HIV-infected pregnant women not in need of treatment for their own health should receive antiretroviral (ARV) prophylaxis to prevent mother-to-child transmission (PMTCT) during pregnancy, delivery, and breastfeeding. The reality, however, is that very few women receive ART in the context of PMTCT services. In addition to challenges of determining ART eligibility for HIV-infected pregnant women, several health system and social factors contribute to low uptake of ART. PMTCT sites often do not have the capacity to initiate ART onsite. Instead, women are referred to another location, which may require another visit to the health care site. In resource-limited settings, where transportation to health care facilities can be quite difficult, women may be less likely to return for initiation of ART. Resources related to the provision and use of antiretrovirals in the context of PMTCT, including the current WHO guidelines for HIV-infected women who are pregnant, are included in this section of the toolkit.

          Infant Feeding Options and the Prevention of Mother-to-Child Transmission of HIV (8 resources)

          The optimal infant feeding decision for HIV-infected mothers living in resource-constrained settings remains a major challenge in preventing mother-to-child transmission of HIV. HIV-infected mothers who breastfeed their babies risk transmitting the virus to their babies through breastmilk. However, replacement feeding (with infant formula) often poses risks of illness and death from malnutrition, pneumonia, and diarrheal diseases due to contaminated water. The 2010 WHO guidelines emphasize that breastfeeding is a strategy for maximizing infant HIV-free survival and have revised the guidelines on infant feeding in the context of HIV accordingly. This section of the toolkit includes the full 2010 WHO guidelines on safe infant and young child feeding in the context of HIV and related resources. Additional resources included report on the context and challenges of infant feeding and PMTCT as well as tools for counseling clients on HIV, infant feeding and PMTCT.

            Integration of PMTCT with Other Health Services (6 resources)

            Prevention of mother-to-child transmission (PMTCT) services should be integrated into health services already being provided in the health system, including maternal and child health (MCH) services, sexually transmitted infection (STI) and HIV counseling and testing (HCT) services, and other sexual and reproductive health (SRH) services including family planning (FP). Integration of PMTCT with other health services capitalizes on the strengths and resources of both programs, improves access to the health care needs of women and children, and increases the overall public health impact of HIV programs. This section of the toolkit provides resources on integrating PMTCT services with child survival programs, HIV/AIDS and STI services, and family planning services.

              Job Aids and Tools (9 resources)

              This section of the toolkit includes a collection of all of the job aids and tools listed throughout the Service Delivery tab. These job aids and tools are intended to help PMTCT service delivery providers offer PMTCT clients quality counseling and care that reflects the most current knowledge and guidelines surrounding PMTCT.