Pregnant and lactating women and girls

Interventions addressing pregnant and lactating women and girls have been at the forefront of HIV prevention activities since 1998. This was when the short-course zidovudine and single-dose nevirapine clinical trials proved successful in offering a relatively simple, low-cost intervention that could substantially reduce the risk of HIV transmission from mother to baby.

Since then, prevention of mother to child transmission (PMTCT) interventions have evolved to focus not only on promoting neonatal, infant and child health, but also on ensuring the health of the women and girls, particularly while pregnant or breastfeeding. Newer and more effective ways to prevent paediatric infections – particularly in high-burden, low-resource settings – in addition to the global public health community’s commitment to support scale-up of effective PMTCT services, are now aimed towards virtually eliminating new paediatric infections.

Highly effective interventions for pregnant and lactating women and girls focus on:

• prevention of new HIV infections;
• prompt and effective lifelong HIV treatment for those living with HIV;
• effective management of HIV-exposed infants and children, including appropriate infant feeding practices, antiretroviral prophylaxis, and timely HIV infant testing; and
• contraception and other sexual reproductive health and rights services to prevent unintended pregnancies, prevent and treat sexually transmitted infections and provide other related reproductive health services post-delivery.

Preferably, women and girls living with HIV should be on treatment before conception to eliminate vertical transmission. However, a large proportion of women and girls are still are diagnosed during pregnancy, facilitated by provider-initiated HIV testing services, particularly in countries with higher HIV burden.

The WHO recommendations on antenatal care for a positive pregnancy experience include recommendations from the consolidated guidelines on HIV testing services for high-prevalence settings. These recommendations state that provider-initiated testing and counselling for HIV should be considered a routine component of the package of care for pregnant women in all antenatal care settings. In low-prevalence settings, provider-initiated testing and counselling can be considered for pregnant women in antenatal care settings to:

• contribute to elimination of mother-to-child transmission of HIV;
• integrate HIV testing with syphilis, viral hepatitis and other key tests, as relevant to the setting; and
• strengthen the underlying maternal and child health care systems.

The policy brief consolidated guidelines on HIV testing services for a changing epidemic also recommend the use of dual HIV/syphilis rapid diagnostic tests as the first test in antenatal care, and that all pregnant women should be tested for HIV, syphilis and hepatitis B surface antigen (HBsAg) at least once during pregnancy and as early as possible. This direction promotes integration and endorses the Triple Elimination Initiative, which facilitates country commitment to elimination of vertical transmission of all 3 conditions (HIV, syphilis and hepatitis B virus).

Identification of women and girls living with HIV by offering HIV testing during breastfeeding has become more important, as evidence has shown a high proportion of incident infections occur during the post-partum period.

A key principle of WHO guidelines has been to harmonize antiretroviral therapy regimens across all populations by promoting options that are suitable for children, adolescents, pregnant women, adults and people with coinfections, including tuberculosis. Guidance for HIV treatment and care for pregnant and lactating women and girls identified as living with HIV can be found in the consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection as well as the updated rec.

Recent experience with dolutegravir has highlighted the need for a woman-centred approach that consciously adopts the perspectives of women, their families and their communities, and the need to prescribe antiretroviral therapy with a human rights-based approach. This way the pregnant or breastfeeding woman receives comprehensive information and medical guidance appropriate to her situation, and is supported in making voluntary choices around medical therapy initiation, continuation and adherence/retention in care, as applicable.

The dolutegravir experience has also highlighted the need for a transformational shift in the way we conceptualize research of new antiretroviral drugs for HIV treatment and prevention.This call to action outlines how stakeholders involved in studying antiretroviral drugs should support greater inclusion of pregnant and breastfeeding women and contribute to a more equitable investigation of new HIV drugs.