**MTCT STRATEGIC APPROACH**

**Strategic planning for MTCT activities**

**Low Prevalence Settings**

-   Promote HIV prevention in women of childbearing age through HIV
    prevention education and services in FP and ANC settings

-   Focus should be on integrating VCT, MCH and family planning (to
    address the first two prongs of the three prong strategy addressed
    below) into antenatal care settings

-   Ensure that VCT incorporates strong messages on the importance of
    maternal health and HIV prevention during pregnancy and
    breastfeeding (seroconversion during pregnancy or lactation poses
    the greatest risk for MTCT)

-   Encourage male involvement to address issues of maternal health, HIV
    prevention and monogamy

-   Encourage community-wide breastfeeding programs to focus on
    exclusive breastfeeding and breast health

**High Prevalence Settings**

-   Focus on increasing incorporating VCT into the antenatal setting and
    increasing VCT rates, strong counseling for HIV positive women

-   Incorporate family planning into VCT post-test counseling to include
    protection from infection during pregnancy (condom use by HIV
    negative pregnant women) and post-pregnancy use of contraceptive,
    including dual methods (for HIV positive women) and information
    about birth spacing.

-   Strengthen obstetric care for the availability, access and use of
    safe delivery practices

-   Train health care workers on appropriate antiretroviral prophylaxis
    regimen

-   Mobilize community around reducing the risks of HIV transmission
    during breastfeeding; discuss "informed choice" with HIV positive
    women

-   Conduct community outreach to encourage women to know their status
    by accessing MTCT services

-   Establish prevention programs aimed at adolescents/women of
    reproductive age

-   Implement or make linkages with care, treatment and support programs
    when possible (MTCT Plus)

**Technical Level -- for USAID missions**

-   Provide technical assistance to government to help establish,
    strengthen, or implement national guidelines on MTCT (including
    antiretroviral prophylaxis)

-   Participate on national MTCT task force

-   Communicate and coordinate activities of various partners (including
    UN agencies, donors, CDC, and implementing agencies)

-   Coordinate MTCT activities with activities being funded/proposed for
    the Global Fund money

Need to integrate health care activities and strengthen health care
systems. Examples include:

-   Integrate prevention/risk reduction strategies into ANC settings to
    keep HIV negative women negative

-   Integrate family planning into ANC/PNC to prevent unwanted
    pregnancies

-   Integrate MTCT services into MCH

-   Integrate MTCT activities into long-term care and support to keep
    the mother/infant/family healthy. Long-term support includes not
    only ARVs where indicated but treatment of opportunistic infections,
    nutrition, social and legal support

-   Involve community/males in MTCT/MCH activities

-   MTCT Plus (Care, treatment, and support)

**Implementation level**

-   Identify partners (existing and new)

-   Establish partnerships with PVOs and NGOs that have experience in
    MTCT activities, community mobilization, and maternal health/child
    survival

-   Do country assessment of current policies, activities (tool will
    soon be available)

-   Is country ready for scale-up of existing sites, or is there a need
    for more demonstration sites?

-   Are programs ready for expansion into MTCT Plus?

**CSH Definition of MTCT activities**: *Mother to Child Transmission of
HIV (MTCT):* Mother to child transmission of HIV can occur during
pregnancy, during labor and delivery, and after birth through
breastfeeding. The best way to avoid MTCT is to prevent women of
reproductive age from becoming HIV-infected. However, for the millions
of women who are already infected and for those who will become infected
in the future, services should be available to women to help protect
their infants from HIV infection. Successful programs to prevent MTCT
include the following components: voluntary and confidential counseling
and testing services for pregnant women; antiretroviral (ARV)
prophylaxis for HIV-infected pregnant women and newborns; and counseling
and support for safe infant feeding practices. In addition to these core
components, preventing primary HIV infection in pregnant and lactating
women and offering family planning services to HIV-infected women are
essential to prevent MTCT.

In settings where pregnant women receive antenatal care, HIV/AIDS
laboratory and testing facilities, health worker training and counseling
and support services may need to be strengthened in order to support the
addition of MTCT program elements (VCT, ARV prophylaxis, infant-feeding
counseling).

# 

# Background: Comprehensive Programming

USAID follows the World Health Organization's three prong strategic
approach to prevention of Mother to Child Transmission of HIV (MTCT):

1)  Prevention of HIV infection in young women

2)  Prevention of unwanted pregnancies in HIV positive women

3)  Provide ARV prophylaxis to all HIV positive pregnant women to reduce
    MTCT and reinforce with infant feeding counseling

In addition to these three strategies, a comprehensive MTCT program
should provide long term care and support to families, especially
mothers and young children.

A comprehensive approach to MTCT activities includes the following
components:

**Improvement of antenatal services.** Pregnant women must have access
to quality antenatal, delivery, and postpartum services in order to
benefit from interventions to prevent MTCT. Training should focus on
delivery of maternal health and antenatal services.

**Voluntary and confidential counseling and testing services.** VCT is
the entry point to MTCT services. Whenever possible, HIV testing should
be incorporated into the ANC setting. There are two approaches: the
"opt-in approach allows pregnant women to accept VCT whereas the
"opt-out approach" allows pregnant women to decline VCT, where testing
is routinely incorporated with testing for syphilis.

**Short-course antiretroviral prophylaxis for HIV-infected pregnant
women.** Recent studies have shown that short, affordable courses of
antiretroviral therapy for HIV-infected pregnant women can reduce HIV
transmission to newborn babies by 20 to 50 percent.

**Counseling and support for safe infant feeding practices.** Because
breastfeeding plays a critical role in protecting children\'s health,
safe infant feeding is one of the most complex aspects of MTCT
prevention. USAID supports the WHO policy, which states: "When
replacement feeding is acceptable, feasible, affordable, sustainable and
safe, avoidance of all breastfeeding by HIV-infected mothers is
recommended. Otherwise, exclusive breastfeeding is recommended during
the first months of life." Regardless of chosen infant feeding method,
counseling should provide links to basic child survival services such as
EPI, ORT, and ARI.

**Strengthened health, family planning, and safe motherhood programs.**
Avoiding unsafe obstetrical practices can reduce MTCT during delivery.
Health counseling and safe and effective contraception can help women
practice safer sex and prevent unintended pregnancies thus potentially
reducing the number of HIV-infected children. Family planning programs
should be developed and strengthened to train family planning providers,
traditional birth attendants, counselors, and other health care
providers to improve their ability to provide counseling on MTCT and
HIV, refer women for testing and services, and use safe delivery
practices while addressing client's unmet need for family planning and
increasing knowledge about the benefits of birth spacing. Community
mobilization efforts should be addressed through partnerships with PVOs
and NGOs.

# MTCT Plus

MTCT programs may provide good foundations for care and treatment
programs. These programs strive to keep the mother, infant, and family
healthy and maintain the family unit. Implementing care and treatment
programs in this environment is advantageous because the clients are
already identified and at least a minimal level of health care
infrastructure exists. Care and treatment programs can include
antiretroviral treatment for mothers and family members where clinically
indicated. They should also include nutritional, medical, and
psychosocial support.

# Monitoring and Evaluation

USAID's Expanded Response to HIV/AIDS provides both core and additional
indicators to monitor progress with MTCT activities. The core indicators
are:

-   Number of health facility sites providing the minimum package of
    PMTCT services in the past twelve months (minimum package: services
    must include VCT, ARV prophylaxis, and infant feeding counseling or
    as determined by national policy guidelines)

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-   Number and percent of women who attended PMTCT sites (as defined
    above) for a new pregnancy in the past 12 months

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-   Number and percent of women with known HIV infection among those
    seen at PMTCT sites within the past year.

-   Percentage of HIV-positive women attending antenatal clinics
    receiving a complete course of ARV therapy to prevent MTCT