Eliminating mother-to-child transmission of HIV and syphilis: where does Sri Lanka stand?

By Dr. Dineshani Hettiarachchi Sirisena

The World Health Organisation (WHO) is currently evaluating Sri Lanka’s achievements in order to declare it a country that has successfully eliminated mother-to-child transmission of HIV. Mother-to-child transmission of HIV is the spread of the human immunodeficiency virus (HIV) from a woman living with HIV to her child during pregnancy, childbirth, or breastfeeding. Sri Lanka launched a national endeavour to eliminate this transmission in 2013 and over 95% of pregnant women have been tested for both HIV and syphilis by 2017. According to official statistics, Sri Lanka currently has around 3,500 HIV patients and less than 100 child HIV patients with the goal of ending AIDS by 2030. To gain more insight into the process and implementation of the national strategy, we spoke to Consultant Venereologist and National STD/AIDS Control Programme Coordinator – Strategic Information Dr. Ariyaratne Manathung.

The National STD/AIDS Control Programme (NSACP) of the Ministry of Health is the main government organisation which co-ordinates the national response to sexually transmitted infections including HIV/AIDS in Sri Lanka. It collaborates with many national and international organisations such as the Global Fund to Fight Against AIDS, Tuberculosis, and Malaria (GFATM) and UN organisations while providing leadership and technical support to 34 islandwide STD clinics and 23 ART (Antiretroviral Therapy) centres.

Mother-to-child transmission of HIV

Mother-to-child transmission (MTCT) is the main mode of HIV transmission in children under 15 years old. HIV can be transmitted from a HIV-positive mother to her child during pregnancy, labour, delivery, or breastfeeding. In the absence of any intervention, transmission rates range from 15% to 45%. This rate can be reduced to below 2% with effective interventions during the periods of pregnancy, labour, delivery, and breastfeeding. These interventions primarily involve antiretroviral treatment for the mother and a short course of antiretroviral drugs for the baby. They also include measures to prevent HIV acquisition in the pregnant woman and appropriate breastfeeding practices.

What does the term ‘elimination’ mean for EMTCT validation process?

Typically, when a disease or an infection incidence falls to zero within a geographical area, it is considered “eliminated”. However, currently, the minimum EMTCT impact targets as outlined by the WHO are:

  • Less than 50 new paediatric HIV infections per 100,000 live birth
  • HIV Transmission rate of less than 2%
  • Less than 50 cases of congenital syphilis per 100,000 live births

Additionally, to accomplish EMTCT of HIV and syphilis, there are five process targets that need to be met:

  • Antenatal care coverage (at least one visit) of more than or equal to 95%
  • Coverage of HIV testing of pregnant women of more than or equal to 95%
  • Treatment of HIV positive pregnant women of more than or equal to 95%
  • Coverage of syphilis testing of pregnant women of more than or equal to 95%
  • Treatment of syphilis-seropositive pregnant women of more than or equal to 95%

Achieving these targets

Dr. Ariyaratne stated that necessary targets have been achieved as given by WHO for the year 2017 and 2018. However, this must be validated by the WHO, and the certification as a country which has eliminated mother-to-child transmission of HIV and syphilis is only given if we succeed in this validation process.

Challenges faced

  • HIV and syphilis testing must be done at all antenatal clinics islandwide for every pregnant woman. This requires the involvement of many stakeholders including different levels of healthcare workers, pregnant women, and their families. We had to desensitise societies to reduce stigma associated with sexually transmitted infections
  • Many advocacy programmes had to be conducted to convince policymakers, programme managers, and service providers to initiate and continue activities related to EMTCT of HIV and syphilis
  • To succeed in the validation process, HIV and syphilis testing and treatment services had to be established even in the most remote and resource-constrained settings

Challenges to come

  • The validation process will be done again in another two years. We have to maintain the necessary service coverage throughout the country for years to come
  • We have to keep up with the momentum towards maintaining the required level of high coverage. This can be threatened due to the possible complacency due to low HIV and syphilis prevalence in the country
  • People living with HIV (PLHIV) including pregnant women need support and encouragement from their families and communities to seek care and treatment services. We must create awareness to enhance their positive attitude towards people living with HIV to achieve this

New treatment trends

  • Currently, ART is indicated for all the people living with HIV (PLHIV) as soon as they are diagnosed, irrespective of their pregnancy status. In Sri Lanka, all PLHIV are treated with ART free of charge from government health funds similar to any other infection
  • Current ART has to be given as a lifelong treatment without any interruptions to maintain a healthy and productive life. The life expectancy of a PLHIV who got infected with HIV as an adult is almost similar to that of an HIV-uninfected person
  • A combination of three drugs is given as ART. We have a fair number of different ART regimens to treat PLHIV depending on their status

What is the Government doing?

The main financial contributor to the National STD/AIDS Control Programme of the Ministry of Health is the Government. It spearheads the national response to HIV epidemics in Sri Lanka. Maternal and child health services are also provided mainly by the government health budget. According to the last Demographic and Health Survey (DHS), only around 5% of total deliveries take place in the private sector. Hence, the contribution by the government sector is paramount in achieving this milestone.

Transmission of HIV in Sri Lanka compared to the rest of the world

  • Sri Lanka continues to maintain a low HIV prevalence (0.1% in the general population). Total estimated number of PLHIV is around 3,500. These are relatively low numbers
  • Other countries which have obtained the certification of the elimination of mother-to-child transmission of HIV and syphilis status in the region are Thailand, Malaysia, and the Maldives

Dr. Ariyaratne said that the country has made good progress in eliminating mother-to-child transmission of HIV and he is certain that we will soon be declared a country which has eliminated mother-to-child transmission of HIV and syphilis. The use of ARV prophylaxis by the mother during pregnancy and the breastfeeding period, and use of infant ARV prophylaxis together with HIV testing and counselling programmes for women and their partner, enhanced at antenatal, labour, delivery, and postnatal settings have contributed to this magnanimous achievement.

About the writer

The writer, Dr. Dineshani Hettiarachchi Sirisena, is a family physician with a special interest in rare genetic diseases and regenerative medicine currently working as a lecturer at the Department of Anatomy, Faculty of Medicine, University of Colombo, Sri Lanka.