REGIONAL FRAMEWORK FOR The Triple Elimination of Mother-to-Child Transmission of HIV, Hepatitis B and Syphilis in Asia and the Pacific, 2018–2030
Regional Framework for the Triple Elimination of Mother-to-Child Transmission of HIV, Hepatitis B and Syphilis in Asia and the Pacific, 2018–2030 © World Health Organization 2018 ISBN 978 92 9061 855 3 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any specific organization, products or services. The use of the WHO logo is not permitted. If you adapt the work, then you must license your work under the same or equivalent Creative Commons licence. 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Shimizu CONTENTS Abbreviations............................................................................................................................................................................................................................................................iv Acknowledgements.........................................................................................................................................................................................................................................v Foreword...........................................................................................................................................................................................................................................................................vi Executive summary...................................................................................................................................................................................................................................viii 1. BACKGROUND.......................................................................................................................................................................................................................................1 1.1 Global goals for elimination of mother-to-child transmission of HIV, hepatitis B and syphilis...............................................................................................................................................................................................1 1.2 Regional progress in Asia and the Pacific..................................................................................................................................2 1.3 A new approach to EMTCT of hepatitis B....................................................................................................................................5 1.4 Rationale and scope of the Regional Framework........................................................................................................7 2. REGIONAL FRAMEWORK.........................................................................................................................................................................................10 2.1 Vision, goal and principles.................................................................................................................................................................................10 2.2 Pillars: priority actions to achieve triple elimination.......................................................................................11 . Pillar.1..Coordinated.national.policy.and.strategy.....................................................................................................12 . Pillar.2..Seamless.quality.care.for.women,.newborns,.children. . and.their.families.................................................................................................................................................................................................................14 . Pillar.3..Coordinated.monitoring.and.evaluation.of.elimination....................................................16 2.3 Targets and milestones..............................................................................................................................................................................................18 Coordination.targets.and.milestones.............................................................................................................................................18 Disease-specific.elimination.targets................................................................................................................................................19 3. PROCESS OF VALIDATION...................................................................................................................................................................................21 3.1 Policy indicator........................................................................................................................................................................................................................21 3.2 Impact indicators.................................................................................................................................................................................................................21 3.3 Programme (process) indicators..............................................................................................................................................................22 References.................................................................................................................................................................................................................................................................23 Annex..................................................................................................................................................................................................................................................................................25 REGIONAL FRAMEWORK FOR THE TRIPLE ELIMINATION OF MOTHER-TO-CHILD TRANSMISSION OF HIV, HEPATITIS B AND SYPHILIS IN ASIA AND THE PACIFIC, 2018–2030 iv ABBREVIATIONS ANC. . antenatal.care ART . . antiretroviral.therapy ARV. . antiretroviral.(drug) EMTCT. . elimination.of.mother-to-child.transmission HBIG. . hepatitis.B.immunoglobulin HBsAg. . hepatitis.B.surface.antigen HBV. . hepatitis.B.virus MDGs. . Millennium.Development.Goals RMNCH. . reproductive,.maternal,.newborn.and.child.health STI . . sexually.transmitted.infection SDGs. . Sustainable.Development.Goals UNICEF . . United.Nations.Children’s.Fund UNAIDS . . Joint.United.Nations.Programme.on.HIV/AIDS WHO. . World.Health.Organization vACKNOWLEDGEMENTS This.Regional.Framework.was.developed.through.contributions.from.and.in.collabora- tion.with.Member.States.in.Asia.and.the.Pacific,.civil.society.organizations,.partner. organizations.and.individuals,.including:.the.United.Nations.Children’s.Fund.(UNICEF),. the.Joint.United.Nations.Programme.on.HIV/AIDS.(UNAIDS),.experts.from.the.Chinese. Center.for.Disease.Control.and.Prevention,.the.Center.for.Disease.Analysis,.the.Peter. Doherty.Institute.for.Infection.and.Immunity,.the.Global.Validation.Advisory.Committee. for.Elimination.of.Mother-to-Child.Transmission.of.HIV.and.Syphilis,.the.Hepatitis.B. Immunization.Expert.Resource.Panel,.the.Independent.Review.Group.for.Early.Essential. Newborn.Care,.the.London.School.of.Hygiene.&.Tropical.Medicine,.the.National.Center. for.Global.Health.and.Medicine.Japan,.TREAT.Asia.(Therapeutics.Research,.Education,. and.AIDS.Training.in.Asia),.the.United.States.Centers.for.Disease.Control.and.Prevention,. and.ZeShan.Foundation.. REGIONAL FRAMEWORK FOR THE TRIPLE ELIMINATION OF MOTHER-TO-CHILD TRANSMISSION OF HIV, HEPATITIS B AND SYPHILIS IN ASIA AND THE PACIFIC, 2018–2030 vi FOREWORD Every.child.should.be.given.the.best.chance.to.start.a.healthy.life,.free.from.preventable. infections.. The.Global Strategy for Women’s, Children’s and Adolescents’ Health (2016–2030).aims.for. the.highest.attainable.standards.of.health.and.well-being.of.children..Similarly,.in.2016,. the.World.Health.Assembly.endorsed.three.interlinked.global.health.sector.strategies.on. HIV,.viral.hepatitis.and.sexually.transmitted.infections.for.the.2016–2021.period,.which. set.ambitious.targets.for.elimination.of.mother-to-child.transmission.(EMTCT).of.HIV,. hepatitis.B.and.syphilis. Mother-to-child.transmission.of.these.infections.can.be.effectively.prevented.by.simple. interventions.including.antenatal.screening.and.treatment.for.women.and.her.partners,. and.vaccination.for.infants.through.reproductive,.maternal,.newborn.and.child.health. (RMNCH).services.. However,.many.infants.continue.to.be.born.with.these.preventable.and.treatable.infec- tions.in.Asia.and.the.Pacific.due.to.limited.availability.and.access.to.these.essential. interventions.. EMTCT.of.each.infection.shares.similar.interventions.providing.an.opportunity.for.synergy. and.efficient.service.delivery.through.the.common.RMNCH.platform..Suboptimal.coor- dination.among.concerned.programmes.results.in.gaps.or.duplication.of.activities,. thus.making.these.services.less.accessible.for.women,.children.and.their.families,.and. thereby.decreasing.the.effectiveness.of.these.services..An.introduction.of.additional. interventions.may.be.required.to.prevent.perinatal.infection.among.infants.born.to. mothers.with.high.hepatitis.B.viral.load..However,.the.current.capacity.and.resources.of. RMNCH.programmes.–.and.more.broadly.of.health.systems.–.limit.the.availability.and. accessibility.of.these.services.. Substantial.scale-up.of.existing.interventions.and.proposed.interventions.require.invest- ments.in.RMNCH.services..Experiences.from.Member.States.suggest.that.strengthened. RMNCH.services.and.better.coordination.among.programmes.will.make.services.more. accessible.for.women,.children.and.their.families.and.will.result.in.better.outcomes,. more.efficient.use.of.resources.and.sustainable.mechanisms. The.Regional Framework for the Triple Elimination of Mother-to-Child Transmission of HIV, Hepatitis B and Syphilis in Asia and the Pacific 2018–2030.was.developed.from.2016. in.collaboration.with.the.WHO.Regional.Office.for.South-East.Asia,.and.through.consul- tation.with.Member.States,.civil.society,.as.well.as.regional.and.global.experts.from. partner.organizations.to.guide.a.path.towards.triple.elimination.in.Asia.and.the.Pacific.. vii Subsequently,.this.Framework.was.endorsed.by.all.Member.States.during.the.sixty-eighth. session.of.the.Regional.Committee.for.the.Western.Pacific.(WPR/RC68.R2).in.October.2017. This.framework.proposes.an.integrated.and.coordinated.approach.towards.the.goal. of.triple.elimination,.emphasizing.the.principle.of.mother-newborn-and-child-centred. care.and.universal.health.coverage..Through.implementation.of.this.framework,.we.will. demonstrate.the.significance.of.collaboration.among.programmes.and.joint.efforts. towards.the.common.goal.of.triple.elimination.. Shin.Young-soo,.MD,.Ph.D. Regional.Director REGIONAL FRAMEWORK FOR THE TRIPLE ELIMINATION OF MOTHER-TO-CHILD TRANSMISSION OF HIV, HEPATITIS B AND SYPHILIS IN ASIA AND THE PACIFIC, 2018–2030 viii EXECUTIVE SUMMARY Every child should be given the best chance to start a healthy life, free from preventable communicable diseases. However, a significant number of infants each year in Asia and the Pacific are born with or infected early in life with HIV, hepatitis B or syphilis. The.Regional Framework for the Triple Elimination of Mother-to-Child Transmission of HIV, Hepatitis B and Syphilis in Asia and the Pacific 2018–2030.offers.a.coordinated.approach. towards.achieving.the.elimination.of.mother-to-child.transmission.(EMTCT).of.HIV,. hepatitis.B.and.syphilis.and.provides.guidance.for.decision-makers,.managers.and.health. professionals.working.in.programmes.addressing.reproductive,.maternal,.newborn.and. child.health.(RMNCH),.HIV,.hepatitis,.sexually.transmitted.infections.and.immunization.. The.Global Strategy for Women’s, Children’s and Adolescents’ Health (2016–2030).aims. for.the.highest.attainable.standards.of.health.and.well-being..Similarly,.the.global. health.sector.strategies.on.HIV,.viral.hepatitis.and.sexually.transmitted.infections.for. 2016–2021.set.specific.goals.for.the.EMTCT.of.HIV.by.2020.and.the.EMTCT.of.hepatitis.B. and.syphilis.by.2030..These.goals.can.only.be.achieved.when.access.to.quality.RMNCH. services.is.ensured.for.all.women,.children.and.their.families.in.the.context.of.universal. health.coverage. Mother-to-child.transmission.of.HIV,.hepatitis.B.and.syphilis.can.be.effectively.prevented. and.eliminated.by.similar.interventions,.including.the.prevention.of.new.infections.among. people.of.reproductive.age,.prevention.of.unintended.pregnancies,.antenatal.screening,. treatment.and.vaccination.through.the.RMNCH.platform..The.similarity.of.interventions. also.provides.an.opportunity.for.efficient.service.delivery.and.better.outcomes.. However,.these.interventions.are.not.always.provided.as.standard.components.of.RMNCH. services..The.planning,.implementation,.reporting.and.monitoring.of.these.interventions. do.not.always.occur.in.coordination,.resulting.in.gaps.or.duplications.–.thus.making. services.less.accessible.to.women,.their.partners,.children.and.families..This.also.results. in.missed.opportunities.to.use.available.resources.efficiently.and.limits.the.impact.of. the.interventions.. This.Regional.Framework.proposes.an.integrated.and.coordinated.approach.towards.triple. elimination.–.emphasizing.the.principle.of.mother-newborn-and-child-centred.care.and. a.human-rights-based.approach.for.every.child,.mother,.her.partner.and.their.families.. It.also.presents.potential.new.interventions.for.EMTCT.of.hepatitis.B,.building.upon.the. successful.vaccination.programmes.to.achieve.≤.0.1%.hepatitis.B.surface.antigen.(HBsAg). prevalence.among.children.by.2030. 1GLOBAL GOALS FOR ELIMINATION OF MOTHER-TO-CHILD TR ANSMISSION OF HIV, HEPATITIS B AND SYPHILIS HIV,.hepatitis.B.and.syphilis.can.be.transmitted.from.infected.mothers.to.their.infants,. causing.significant.morbidity.and.mortality..However,.transmission.of.these.infections. can.be.prevented.by.simple.and.effective.interventions,.including.the.prevention.of.new. infections.among.people.of.reproductive.age,.prevention.of.unintended.pregnancies,. antenatal.screening,.treatment.and.vaccination.. Every.child.should.be.given.the.best.chance.to.start.a.healthy.life,.free.from.preventable. communicable.diseases..This.can.only.be.possible.when.access.to.quality.reproductive,. maternal,.newborn.and.child.health.(RMNCH).services.is.ensured.for.all.women,.children. and.their.families.in.the.context.of.universal.health.coverage..The.Sustainable.Develop- ment.Goals.(SDGs).strive.to.end.poverty.and.hunger.and.ensure.that.all.human.beings.can. fulfil.their.potential.in.dignity.and.equality.and.in.a.healthy.environment..SDG.3.strives. to.ensure.healthy.lives.and.promote.well-being.for.all.at.all.ages.by.addressing.health. priorities,.including.reproductive,.maternal.and.child.health.(RMNCH),.and.communicable. diseases (1)..Similarly,.the.Global Strategy for Women’s, Children’s and Adolescents’ Health (2016–2030) (2).aims.for.the.highest.attainable.standards.of.health.and.well-being,.and. its.implementation.is.supported.by.the.Every Woman Every Child movement (3). With.specific.targets.for.elimination.of.mother-to-child.transmission.(EMTCT).of.HIV,. hepatitis.B.and.syphilis,.the.Global Health Sector Strategy on HIV 2016–2021.(4),.the. Global Health Sector Strategy on Viral Hepatitis 2016–2021 (5).and.the.Global Health Sector Strategy on Sexually Transmitted Infections 2016–2021.(6).set.global.goals.to.end.the.AIDS. and.sexually.transmitted.infections.(STIs).epidemics.and.to.eliminate.viral.hepatitis.as.a. 1.1 BACKGROUND1. 2REGIONAL FRAMEWORK FOR THE TRIPLE ELIMINATION OF MOTHER-TO-CHILD TRANSMISSION OF HIV, HEPATITIS B AND SYPHILIS IN ASIA AND THE PACIFIC, 2018–2030 public.health.threat.by.2030..Supported.by.the.endorsement.by.Member.States.of.these. goals.and.targets.in.2016,.multiple.calls,.including.the.2016.Political Declaration on HIV and AIDS (7),.have.also.been.established.to.support.these.control.and.elimination.endeavours.. The.World.Health.Organization.(WHO).has.defined.EMTCT.of.HIV.and.syphilis.and.set. the.global.criteria.for.elimination.(8)..The.Global Health Sector Strategy on Viral Hepatitis 2016–2021.defines.EMTCT.of.hepatitis.B.as.achievement.of.a.90%.reduction.in.new.chronic. infections,.equivalent.to.0.1%.prevalence.of.hepatitis.B.surface.antigen.(HBsAg).among. children.(5)..These.elimination.criteria.and.disease-specific.targets.are.summarized.in. Table.1,.section.2.3..In.order.to.achieve.elimination,.the.following.must.be.achieved:.a. reduction.of.the.overall.prevalence.of.HIV,.hepatitis.B.and.syphilis;.prevention.of.unin- tended.pregnancies;.provision.of.EMTCT.interventions.during.the.antenatal,.delivery.and. postnatal.periods;.and.high.hepatitis.B.vaccination.coverage.. REGIONAL PROGRESS IN A SIA AND THE PACIFIC Reproductive, maternal, newborn and child health The.Asia.and.Pacific.region.has.seen.significant.progress.in.achieving.Goals.4.(reduce. child.mortality).and.5.(improve.maternal.health).of.the.Millennium.Development.Goals. (MDGs)..In.the.WHO.Western.Pacific.Region.and.the.South-East.Asia.Region,.the.maternal. mortality.ratios,.between.1990.and.2015,.have.decreased.by.64%.and.69%,.respectively. (9)..The.decline.is.greater.than.the.global.rate..The.dramatic.increases.in.antenatal. care.(ANC).coverage.(at.least.one.visit),.births.attended.by.skilled.birth.attendants.and. improved.quality.of.care.are.the.main.contributors.to.this.success.(9, 10).. Challenges.remain.in.addressing.both.inequities.in.access.to.health.services,.especially. for.vulnerable.populations,.and.the.persistence.of.inappropriate.practices.by.health-care. providers.that.contribute.to.poor.quality.of.care..To.address.these.concerns.through. the.provision.of.evidence-based.guidelines.and.interventions,.Member.States.in.the. Western.Pacific.Region.endorsed.the.Action Plan for Healthy Newborn Infants in the Western Pacific Region (2014–2020) (11)..The.South-East.Asia.Region.is.developing.both. the.Regional Framework for Reproductive, Maternal, Newborn, Child and Adolescent Health. and.Strategic Guidance on Adolescent Health for Countries in the South-East Asia Region 2017–2020.to.further.accelerate.RMNCH.services. 1.2 3Dual elimination of mother-to-child transmission of HIV and syphilis HIV.prevalence.in.Asia.and.the.Pacific.remains.low.at.0.2%,.with.5.1.million.people.esti- mated.to.have.been.living.with.HIV.in.2016.(12)..In.2016,.approximately.71 000.pregnant. women.were.living.with.HIV,.and.15 000.cases.of.new.paediatric.HIV.infections.(21%. mother-to-child.transmission.rate).were.estimated.to.have.occurred.in.the.region..Only. 46%.of.pregnant.women.living.with.HIV.received.antiretroviral.therapy.(ART).in.2016,. which.was.significantly.lower.than.the.global.ART.coverage.of.76% (13)..This.was.primarily. due.to.low.HIV.testing.coverage.during.ANC,.which.resulted.in.a.significant.gap.in.diag- nosing.pregnant.women.with.HIV.in.many.countries.(Fig..1).. The.incidence.of.STIs.is.higher.in.Asia.and.the.Pacific.as.compared.to.the.other.regions. (6, 14)..While.quality.data.are.rather.limited.for.STIs,.a.modelling.study.estimated.the. regional.prevalence.of.maternal.syphilis.as.0.24%.for.the.Western.Pacific.Region.and. 0.32%.for.the.South-East.Asia.Region.in.2012.(15),.with.a.reported.increasing.trend.of. syphilis.infections.among.key.populations.and.young.people.in.several.countries..The. same.study.also.indicated.that.167 000.cases.of.maternal.syphilis.have.occurred.in.Asia. and.the.Pacific,.resulting.in.65 800.adverse.outcomes.including.early.fetal.deaths..Yet,. coverage.of.syphilis.screening.during.ANC.and.treatment.remains.low.in.many.countries. The.Asia-Pacific.Prevention.of.Parent-to-Child.Transmission.Task.Force.has.been.providing. technical.support.on.dual.EMTCT.of.HIV.and.syphilis..Building.on.this.effort,.the.WHO. regional.offices.for.South-East.Asia.and.the.Western.Pacific.jointly.established.the. Figure 1. EMTCT cascade for HIV in Asia and the Pacific (2016) ARV = antiretroviral (drugs), PMTCT = prevention of mother-to-child transmission Source: HIV and AIDS Data Hub for Asia Pacific (www.aidsdatahub.org) based on Global AIDS Response Progress Reporting 2016. Estimated pregnant women living with HIV Diagnosed HIV-positive pregnant women HIV-positive pregnant women received ARVs for PMTCT Infants born to HIV-positive mother received ARV prophylaxis within first 6 weeks Infants born to HIV-positive mother received an HIV test within 2 months of birth 80 000 60 000 40 000 20 000 0 N um be r o f p re gn an t w om en li vi ng w ith H IV Mothers Infants 46% received ARVs 52% received early infant diagnosis 71 000 n/a 32 000 17 000n/a 4REGIONAL FRAMEWORK FOR THE TRIPLE ELIMINATION OF MOTHER-TO-CHILD TRANSMISSION OF HIV, HEPATITIS B AND SYPHILIS IN ASIA AND THE PACIFIC, 2018–2030 Regional.Validation.Secretariat.in.2015.to.support.countries.seeking.validation.of.EMTCT. of.HIV.and.syphilis.in.partnership.with.the.United.Nations.Children’s.Fund.(UNICEF).and. the.Joint.United.Nations.Programme.on.HIV/AIDS.(UNAIDS).(16)..The.Regional.Secre- tariat.works.closely.with.the.Global.Validation.Advisory.Committee,.which.declared.in. June.2016.that.Thailand.had.become.the.first.country.in.Asia.and.the.Pacific.to.achieve. the.EMTCT.of.HIV.and.syphilis. Hepatitis B control through vaccination Asia.and.the.Pacific.bear.a.significant.burden.of.hepatitis.B..In.the.Western.Pacific.Region,. 115.million.people.are.estimated.to.be.living.with.chronic.hepatitis.B,.which.accounts.for. 45%.of.infections.worldwide.(17, 18)..In.the.South-East.Asia.Region,.39.million.people,. representing.15%.of.global.infections,.are.estimated.to.have.chronic.hepatitis.B.infec- tion.(17, 19).. As.a.result.of.successful.hepatitis.B.vaccination.programmes.in.the.Western.Pacific. Region,.21.countries.and.areas.have.been.verified.as.meeting.the.2017.goal.of.reducing. prevalence.to.<.1%.among.5-year-old.children.as.of.May.2018,.with.an.estimated.regional. prevalence.of.0.93%.among.children.born.in.2012..As.a.result.of.hepatitis.B.vaccination. programmes,.more.than.37.million.cases.of.chronic.hepatitis.B.infection.and.7.million. deaths.have.been.averted.among.children.born.between.1999.and.2014.(20)..The.Regional Action Plan for Viral Hepatitis in the Western Pacific 2016–2020.(21) provides.a.system- atic.approach.for.reducing.the.impact.of.viral.hepatitis.aligned.with.the.global.goal.of. reducing.the.prevalence.of.HBsAg.to.equal.or.below.0.1%.by.2030..The.Western.Pacific. Region.achieved 84%.birth-dose.coverage.and.94%.third-dose.coverage.among.countries. reporting.on.the.2015.WHO/UNICEF.Joint.Reporting.Form.(Fig..2).. In.the.South-East.Asia.Region,.hepatitis.B.vaccine.third-dose.coverage.reached.87%.in. 2015..A.birth.dose.is.currently.provided.in.six.countries.and.in.one.region.of.Thailand;. however,.the.birth.dose.continues.to.be.a.challenge.in.countries.with.low.rates.of.facility. deliveries.or.births.attended.by.skilled.birth.attendants..The.WHO.Regional.Committee.for. South-East.Asia.in.2016.endorsed.the Regional Action Plan for Viral Hepatitis in South-East Asia: 2016–2021.(22),.followed.by.the.recommendation.from.the.Regional.Immunization. Technical.Advisory.Group.to.adopt.the.2020.global.target.of.HBsAg.prevalence.of.<.1%. among.children.under.5.years.of.age. Uncoordinated approach among programmes A.review.of.the.current.situation.in.Asia.and.the.Pacific.revealed.that.EMTCT.interventions. for.HIV,.hepatitis.B.and.syphilis.were.not.necessarily.provided.as.standard.components. of.RMNCH.services..While.they.share.a.common.RMNCH-care.platform,.the.planning,. implementation,.reporting.and.monitoring.of.these.discrete.but.related.interventions.do. 5not.always.occur.in.coordination.–.resulting.in.gaps.or.duplications.and.thereby.making. services.less.accessible.to.women,.their.partners,.children.and.families..This.also.results. in.missed.opportunities.to.use.available.resources.efficiently.and.prevents.achieving. maximum.impact..Better.collaboration.and.synergy.among.programmes.are.urgently. needed.to.improve.accessibility,.effectiveness.and.efficiency.of.EMTCT.interventions.. A NEW APPROACH TO EMTCT OF HEPATITIS B A.comprehensive.package.of.interventions.is.needed.to.achieve.the.global.goal.of.≤ 0.1%. HBsAg.prevalence.among.children.(5)..This.should.be.built.on.a.strong.hepatitis.B.vaccina- tion.programme.and.strengthened.RMNCH.services,.and.includes.prevention.of.infec- tion.in.young.women,.screening.and.care.of.pregnant.women.with.chronic.hepatitis.B. infection,.the.possible.use.of.antiviral.drugs.and.the.use.of.hepatitis.B.immunoglobulin. (HBIG).among.infants.born.to.HBsAg-positive.mothers.(5). 1.3 Figure 2. Impact of hepatitis B vaccination on disease burden Source: Child L, Roesel S, Tohme RA. Vaccine 2018; 36: 6-14. Source: Wiesen E, Diortista S, Li X. Vaccine 2016; 34:2855-2862 Chronic infectionsHepatitis B vaccine 3rd dose* Hepatitis B vaccine birth dose 199 2 199 2 199 0 200 4 200 4 199 4 199 4 200 6 200 6 199 6 199 6 200 8 200 8 199 8 199 8 201 0 201 0 200 0 200 0 201 2 201 2 200 2 200 2 201 4 201 4 100 90 80 70 60 50 40 30 20 10 0 2.5 2.0 1.5 1.0 0.5 0 5.0 4.5 4.0 3.5 3.0 2.5 2.0 1.5 1.0 0.5 0 Va cc in at io n co ve ra ge (i n % ) N um be r o f c hr on ic H BV in fe ct io ns (i n m ill io ns ) South-East Asia Region Western Pacific Region Year of birth Year of birth * Hepatitis B vaccine third dose refers to the three-dose series of hepatitis B vaccine. In addition to receiving the hepatitis B birth dose within 24 hours, at least two additional hepatitis B-containing vaccinations induce protective antibody concentra- tions in > 95% of healthy infants, children and young adults. 6REGIONAL FRAMEWORK FOR THE TRIPLE ELIMINATION OF MOTHER-TO-CHILD TRANSMISSION OF HIV, HEPATITIS B AND SYPHILIS IN ASIA AND THE PACIFIC, 2018–2030 WHO.recommends.that.HBsAg.testing.be.routinely.offered.to.all.pregnant.women.in. antenatal.clinics.with.linkages.to.prevention,.care.and.treatment.services.in.settings.with. a.≥.2%.(intermediate).or.≥.5%.(high).HBsAg.seroprevalence.in.the.general.population.(23).. With.an.estimated.prevalence.of.hepatitis.B.virus.(HBV).infection.of.6.2%.in.the.Western. Pacific.Region.and.2.0%.in.the.South-East.Asia.Region.(17),.antenatal.screening.plays.an. important.role..It.is.reported.that.more.than.14.countries.have.already.included.HBsAg. screening.in.ANC.packages.in.Asia.and.the.Pacific.(24)... Recently,.some.countries.have.included.hepatitis.B.in.their.EMTCT.plans,.by.integrating. HIV,.syphilis.and.hepatitis.B.antenatal.screening,.prevention.and.treatment.interven- tions.into.their.RMNCH.package.of.services..Some.countries.face.challenges.of.limited. capacity.and.resources.for.their.RMNCH.programmes.–.and.more.broadly.capacity.and. resource.constraints.on.their.entire.health.system.–.that.present.barriers.to.the.intro- duction.of.new.interventions..In.this.regard,.a.tiered.approach.(Fig..3).is.proposed.in. order.to.introduce.a.comprehensive.package.of.interventions.for.EMTCT.of.hepatitis.B,. considering.various.levels.of.health.system.capacities..As.of.June.2017,.WHO.guidance. on.the.use.of.antiviral.drugs.for.HBsAg-positive.pregnant.women.with.high.HBV.DNA. levels.or.hepatitis.B.e-antigen-positive.status.was.not.available. Figure 3. Tiered approach to introduction of additional interventions for EMTCT of hepatitis B Screening of pregnant women, linkages to care and follow-up of exposed infants Hepatitis B birth dose and follow-up doses Hepatitis B immunoglobulin for exposed infants Antiviral 7R ATIONALE AND SCOPE OF THE REGIONAL FR AMEWORK The.objective.of.this.Regional.Framework.is.to.suggest.a.coordinated.approach.towards. achieving.triple.elimination.and.provide.guidance.for.decision-makers,.managers.and. health.professionals.working.in.programmes.addressing.RMNCH,.HIV,.hepatitis,.STIs. and.immunization... EMTCT.interventions.for.HIV,.hepatitis.B.and.syphilis.are.essential.components.of.quality. RMNCH.care..The.similarity.of.these.interventions.to.prevent.mother-to-child.transmis- sion.of.these.three.infections.through.the.common.platform.of.reproductive,.antenatal,. childbirth,.postnatal.and.child.care.provides.a.unique.opportunity.for.coordination.and. integration.of.services.and.maximizes.their.accessibility,.effectiveness,.efficiency.and. sustainability.(Fig..4)..This.also.aligns.with.and.supports.an.effort.towards.achieving. the.SDGs.within.a.context.of.declining.external.funding.for.health.in.some.countries. in.the.region.. In.order.to.provide.every.child.the.best.chance.to.start.a.healthy.life.free.of.preventable. communicable.diseases.and.recognizing.the.scope.of.the.problem.across.Asia.and.the. Pacific,.the.WHO.Regional.Office.for.the.Western.Pacific,.the.WHO.Regional.Office.for. South-East.Asia.and.their.partners.jointly.developed.this.Regional Framework for the Triple Elimination of Mother-to-Child Transmission of HIV, Hepatitis B and Syphilis,.in.close. consultation.with.Member.States.and.experts..Member.States.have.provided.inputs.to. this.Framework.from.2016.to.2017,.and.a.consultation.on.the.Framework.brought.together. national,.regional.and.global.experts.in.Manila.in.February.2017.(25)... Aligning.with.the.existing.global.and.regional.strategies,.action.plans.and.goals.for. RMNCH.and.control.of.HIV,.hepatitis.and.STIs,.this.Regional.Framework.is.intended.to. propose.an.integrated.and.coordinated.approach.towards.triple.elimination,.emphasizing. the.principle.of.mother-newborn-and-child-centred.care.and.a.human-rights-based. approach.for.every.child,.mother,.her.partner.and.their.families..This.Framework.also. discusses.potential.new.interventions.for.EMTCT.of.hepatitis.B,.building.upon.successful. vaccination.programmes.to.achieve.≤.0.1%.HBsAg.prevalence.among.children.by.2030. 1.4 8REGIONAL FRAMEWORK FOR THE TRIPLE ELIMINATION OF MOTHER-TO-CHILD TRANSMISSION OF HIV, HEPATITIS B AND SYPHILIS IN ASIA AND THE PACIFIC, 2018–2030 ARV = antiretroviral (drug), HBeAg = hepatitis B e-antigen, HBIG = hepatitis B immunoglobulin, HBsAg = hepatitis B surface antigen, HBV = hepatitis B virus Note: Screening tests are recommended at the first antenatal care visit, ideally before 20 weeks gestation; for women presenting after 20 weeks, screening tests and treatment should be done as soon as possible. DELIVERY GESTATION in WEEKS ANTENATAL VISITS ANTENATAL CARE SY PH IL IS Treatment Syphilis test Syphilis test/ Treatment Syphilis retest for high-risk women if (+) 12 1st 2nd 3rd 4th 5th 6th 7th 8th 20 26 30 34 36 38 40 HIV confirmatory test (+) HIV test HIV retest for high-risk women if (+) 1st trimester 2nd trimester 3rd trimester ANTIRETROVIRAL THERAPY H EP AT IT IS B HBeAg and HBV DNA tests HBsAg test 3 3 In settings with a ≥ 2% or ≥ 5% HBsAg seroprevalence in the general population if (+) MONITORING AND TREATMENT Figure 4. EMTCT interventions for HIV, hepatitis B and syphilis H IV 9Source: WHO recommendations on antenatal care for a positive pregnancy experience (2016), Consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection: recommendations for a public health approach – 2nd ed. (2016), WHO guidelines for the treatment of Treponema pallidum (syphilis) (2016), WHO guidelines on hepatitis B and C testing (2017), Hepatitis B vaccines: WHO position paper (2017). AFTER BIRTH POSTNATAL VISITS POSTNATAL CARE WELL-CHILD VISIT Day 0–1 Day 3 Day 7–14 Week 6 Week 10 Week 14 Month 6 Month 9 1st 1st2nd 2nd3rd 3rd 4th 4th 5th HIV retest for high-risk women ARV prophylaxis for 6–12 weeks 1 Co-trimoxazole prophylaxis (from 4–6 weeks) 2 Early infant diagnosis at 4–6 weeks HIV tests at 9 and 18 months (SOME MAY BE ON TREATMENT BEFORE PREGNANCY) 1 12 weeks of prophylaxis for high-risk breastfed infants 2 Continued until final diagnosis after cessation of exposure Treatment 6 6 Given to infants born to mothers who were inadequately treated/not treated ≥ 4 weeks ≥ 4 weeks ≥ 4–8 weeks Vaccine birth dose within 24 h 2nd dose 3rd dose Post-vaccination serologic testing 4,5 HBIG5 (POTENTIAL USE OF ANTIVIRAL TREATMENT FOR WOMEN WITH HIGH VIRAL LOAD 4) 4 Pending WHO recommendations 5 For infants of HBsAg-positive mothers REGIONAL FRAMEWORK FOR THE TRIPLE ELIMINATION OF MOTHER-TO-CHILD TRANSMISSION OF HIV, HEPATITIS B AND SYPHILIS IN ASIA AND THE PACIFIC, 2018–2030 REGIONAL FRAMEWORK2. VISION, GOAL AND PRINCIPLES VISION: Every infant free of HIV, hepatitis B and syphilis GOAL: Achieve and sustain elimination of mother-to-child transmission (EMTCT) of HIV, hepatitis B and syphilis and achieve better health for women, children and their families through a coordinated approach and efforts by 2030 PRINCIPLES • Mother-newborn-and-child-centred care Reproductive, maternal, newborn and child health (RMNCH) services including essential EMTCT interventions should be provided in the best interests of women, their partners, children and their families, putting them at the centre of care. • Universal health coverage for quality and equitable care Quality RMNCH services including essential EMTCT interventions should be available, accessible and affordable without the risk of financial hardship to all women, their partners, children and their families. • Sustainable mechanisms Efforts for triple elimination should be built into existing health systems and further strengthen them to ensure sustainability. • Promotion of human rights, gender equity and equality The rights of women, their partners, children and their families should be respected, and gender equity and equality need to be ensured. • Multi-stakeholder involvement including individuals, families and communities All stakeholders should be involved in planning, implementation, and monitoring and evaluation of efforts towards triple elimination, in particular affected communities and vulnerable populations. 2.1 10 11 PILL ARS: PRIORIT Y ACTIONS TO ACHIEVE TRIPLE ELIMINATION This.section.proposes.priority.actions.for.a.coordinated.approach.to.triple.elimination,. supported.by.three.pillars:.1).policy,.2).service.delivery,.and.3).monitoring.and.evaluation. (Fig..5)..Targets.and.milestones.are.set.for.each.pillar.to.support.coordinated.approaches. (Fig..6)..Member.States.are.encouraged.to.consider.and.implement.suggested.actions. reflecting.country-specific.contexts.and.health.system.capacities... 2.2 Figure 5. Structure of the Regional Framework for triple elimination Figure 6. Targets and milestones of the Regional Framework for triple elimination VISION Every infant free of HIV, hepatitis B and syphilis GOAL Achieve and sustain EMTCT of HIV, hepatitis B and syphilis and achieve better health for women, children and their families through a coordinated approach and efforts by 2030 PILLAR 1: POLICY Coordinated national policy and strategy PILLAR 3: MONITORING AND EVALUATION Coordinated monitoring and evaluation of elimination PILLAR 2: SERVICE DELIVERY Seamless quality care for women, newborns, children and their families IMPACT TARGETS < 50 new paediatric HIV infection per 100 000 live births HIV MTCT rate < 5% or < 2% ≤ 0.1% prevalence of HBsAg among children ≤ 50 congenital syphilis cases per 100 000 live births 2020 MILESTONES 2030 TARGETS – Coordination mechanism for EMTCT established – Coordinated EMTCT plan developed – EMTCT indicators included in national health information system – National RMNCH policy includes EMTCT as standard component – Universal access to core EMTCT services – Coordinated monitoring through interlinked system PROGRAMME TARGETS (95+) – Antenatal care coverage ≥ 95% – Births attended by skilled health personnel ≥ 95% – Antenatal HIV, hepatitis B and syphilis screening ≥95% – Treatment coverage (HIV and syphilis) ≥ 95% – Hepatitis B vaccine birth-dose coverage ≥ 95% – Hepatitis B vaccine third-dose coverage ≥ 95% EMTCT= elimination of mother-to-child transmission, MTCT = mother-to-child transmission, RMNCH = reproductive, maternal, newborn and child health 12 REGIONAL FRAMEWORK FOR THE TRIPLE ELIMINATION OF MOTHER-TO-CHILD TRANSMISSION OF HIV, HEPATITIS B AND SYPHILIS IN ASIA AND THE PACIFIC, 2018–2030 PILL AR 1 COORDINATED NATIONAL POLICY AND STRATEGY Proposed priority actions for Member States 1. Advocate.high-level.political.commitment.for.the.achievement.of.EMTCT.of.HIV,. hepatitis.B.and.syphilis. 2. Develop.coordinated.policies.and.strategies.for.triple.elimination.that.are.built.into. national.and.subnational.RMNCH.policies,.strategies,.plans.and.guidelines,.aligning. with.related.programmes.with.defined.roles.and.responsibilities.of.each.programme. and.stakeholders. 3. Establish.a.mechanism.for.coordination,.implementation.and.monitoring,.building. on.existing.systems.and.stakeholders.including.affected.communities. 4. Strengthen.RMNCH.and.other.related.programmes.by.ensuring.adequate.and.sustain- able.financial.and.human.resources.and.by.developing.capacities.to.provide.quality. services.including.interventions.for.triple.elimination. 5. Ensure.that.interventions.for.triple.elimination.are.included.in.essential.health.services. packages.and.access.to.services.are.ensured.and.covered.by.public.funding. 6. Address.and.remove.social.and.financial.barriers.for.all.women,.children.and.their. families,.including.vulnerable.and.marginalized.populations,.to.access.services.for. triple.elimination.within.reproductive,.antenatal,.childbirth,.postnatal.and.child.care. 7. Respect.human.rights.of.all.women,.their.partners,.children.and.families;.ensure. protection.of.their.privacy.and.confidentiality;.and.address.stigma.and.discrimination. associated.with.implementation.of.interventions. 8. Consider.possibility.to.expand.the.synergies.within.the.RMNCH.platform.to.include. other.health.issues.as.appropriate.in.view.of.potential.benefits. 13 Proposed priority actions for WHO and partners 1. Support.Member.States.to.advocate.high-level.political.commitment.for.triple.elimi- nation,.including.development.of.communications.materials.and.tools. 2. Support.Member.States.to.develop.coordinated.policies.and.strategies.for.triple. elimination.within.reproductive,.antenatal,.childbirth,.postnatal.and.child.care. 3. Ensure.coordination.across.programmes.among.WHO.and.partners.to.provide.coor- dinated.support.to.Member.States. 4. Support.Member.States.to.estimate.and.allocate.adequate.resources.and.develop. capacities.of.the.RMNCH.and.other.related.programmes.to.provide.quality.RMNCH. services,.including.interventions.for.triple.elimination. 5. Support.Member.States.to.include.triple.elimination.interventions.in.essential.health. service.packages.covered.by.public.funding.and.to.ensure.the.access.to.services.by. addressing.and.removing.social.and.financial.barriers.. 6. Facilitate.intercountry.and.regional.partnerships,.sharing.of.best.practices.and.lessons. learnt,.and.mentoring.among.countries.and.regions. 7. Support.Member.States.to.ensure.a.human-rights-based.approach.and.to.address. ethical.aspects.related.to.implementation.of.interventions. 8. Support.Member.States.to.consider.inclusion.of.other.health.issues.in.the.RMNCH. platform. 14 REGIONAL FRAMEWORK FOR THE TRIPLE ELIMINATION OF MOTHER-TO-CHILD TRANSMISSION OF HIV, HEPATITIS B AND SYPHILIS IN ASIA AND THE PACIFIC, 2018–2030 PILLAR 2 SEAMLESS QUALITY CARE FOR WOMEN, NEWBORNS, CHILDREN AND THEIR FAMILIES Proposed priority actions for Member States 1. Assess.and.map.where.and.how.interventions.for.triple.elimination.are.currently.being. provided.within.reproductive,.antenatal,.childbirth,.postnatal.and.child.care.services,. and.identify.gaps.and.opportunities.for.coordination.and.integration. 2. Update,.refine.and.link.national.policies,.guidelines.and.training.on.reproductive,. antenatal,.childbirth,.postnatal.and.child.care.to.provide.the.latest.evidence-based. quality.of.care.for.all.pregnant.women,.newborns.and.children,.including.interven- tions.for.triple.elimination. 3. Develop.a.plan.for.strengthening.or.scaling.up.coordinated.interventions.for.EMTCT,. including.universal.screening.for.HIV,.syphilis.and,.as.appropriate,.hepatitis.B.surface. antigen.(HBsAg).for.women.and.their.partners,.linkages.to.appropriate.care.and.treat- ment,.timely.hepatitis.B.birth.dose.and.follow-up.vaccination. 4. Provide.guidance.and.tools.for.health.workers.and.those.to.be.involved.in.service. provision.related.to.EMTCT.within.RMNCH.care,.through.pre-service.education.and. on-the-job.training. 5. Engage.communities.and.related.sectors.and.provide.information.to.all.women,.their. partners.and.families.to.improve.awareness.and.demand.for.quality.RMNCH.care. including.triple.elimination,.remove.barriers.to.access.services,.and.increase.utilization. 6. Apply.a.tiered.approach.to.introduce.additional.interventions.for.EMTCT.of.hepatitis.B. including.antenatal.screening,.the.possible.use.of.antiviral.drugs.and.the.use.of.hepa- titis.B.immunoglobulin.(HBIG).among.infants.born.to.HBsAg-positive.mothers.based. on.evolving.evidence.and.recommendations. 7. Consider.application.of.new.interventions.and.technologies.that.support.the.achieve- ment.of.EMTCT.of.HIV,.hepatitis.B.and.syphilis.and.other.communicable.diseases,. including.the.use.of.new.diagnostic.assays.such.as.dual.HIV/syphilis.rapid.test.kits. 8. Ensure.the.quality.of.services.provided.for.triple.elimination,.including.laboratory. services.and.those.delivered.by.private.health.facilities,.by.building.upon.existing. quality.assurance.mechanisms.and.approaches. 15 Proposed priority actions for WHO and partners 1. Support.Member.States.to.map.and.identify.gaps.and.opportunities.for.coordination. and.integration.for.EMTCT.interventions. 2. Support.Member.States.to.update.national.policies,.guidelines.and.training.on.repro- ductive,.antenatal,.childbirth,.postnatal.and.child.care.to.reflect.the.latest.evidence- based.WHO.recommendations.through.coordinated.approaches.across.programmes. and.expertise. 3. Support.Member.States.to.review.progress.on.EMTCT.of.HIV,.hepatitis.B.and.syphilis,. determine.additional.steps.and.develop.a.plan.for.strengthening.or.scaling.up.coor- dinated.interventions.to.achieve.elimination. 4. Develop.guidance.and.tools.for.health.workers.and.those.involved.in.service.provi- sion.on.interventions.related.to.EMTCT.including.screening,.referral,.treatment.and. follow-up.within.reproductive,.antenatal,.childbirth,.postnatal.and.child.care. 5. Support.Member.States.to.develop.communications.materials.and.tools.to.provide. information.to.women.and.their.partners. 6. Develop.guidance.on.a.tiered.approach.for.additional.interventions.for.EMTCT.of. hepatitis.B.and.provide.support.to.Member.States.for.its.implementation. 7. Support.Member.States.for.the.introduction.of.new.interventions.and.technologies. related.to.EMTCT.through.necessary.analysis.and.the.use.of.new.diagnostic.assays.. 8. Support.Member.States.to.improve.and.ensure.the.quality.of.interventions,.including. laboratory.services.for.triple.elimination. 16 REGIONAL FRAMEWORK FOR THE TRIPLE ELIMINATION OF MOTHER-TO-CHILD TRANSMISSION OF HIV, HEPATITIS B AND SYPHILIS IN ASIA AND THE PACIFIC, 2018–2030 PILLAR 3 COORDINATED MONITORING AND EVALUATION OF ELIMINATION Proposed priority actions for Member States 1. Standardize.key.indicators.to.be.monitored.based.on.global.and.regional.recommen- dations.and.set.national.and.subnational.milestones.and.targets.for.EMTCT. 2. Review.and.map.key.indicators.and.determine.how.these.key.indicators.are.collected,. analysed.and.used.by.national.programmes.and.stakeholders.to.identify.any.duplica- tions.or.gaps.and.develop.a.plan.to.improve.data.quality. 3. Refine.and. link.existing.data.collection.systems,. including.those. in.the.private. sector,.to.support.better.linkages.and.the.monitoring.of.EMTCT.progress.by.national. programmes.and.stakeholders. 4. Monitor.EMTCT.indicators.and.report.progress.regularly.through.a.coordinating. mechanism.to.prepare.for.validation.of.elimination.and.the.maintenance.of.elimina- tion.status.after.validation. 5. Conduct.research.to.inform.and.adjust.policy.and.improve.implementation.of.EMTCT. interventions.. 6. Share.experiences.of.implementation.and.lessons.learnt.with.stakeholders.within. and.outside.of.country. 17 Proposed priority actions for WHO and partners 1. Obtain.consensus.on.key.indicators.building.into.existing.global,.regional.and.national. reporting.mechanisms.and.contribute.to.global.discussions.on.setting.interlinked.elimi- nation.criteria.for.EMTCT.of.hepatitis.B.and.updating.the.HIV.and.syphilis.component. 2. Provide.clear.guidance.for.Member.States.on.the.validation.process.and.data.require- ments,.and.provide.support.to.standardize.indicators,.link.existing.data.collection. systems,.improve.data.quality.and.assess.EMTCT.progress.. 3. Identify.potential.areas.for.coordination.and.integration.of.regional.mechanisms. for.validation.of.EMTCT.and.support.Member.States.for.validation.through.existing. mechanisms,.including.the.network.created.by.the.Asia-Pacific.Prevention.of.Parent- to-Child.Transmission.Task.Force.for.HIV.and.syphilis,.the.Hepatitis.B.Immunization. Expert.Resource.Panel,.the.Regional.Immunization.Technical.Advisory.Group.and.the. biennial.meeting.on.accelerating.progress.in.Early.Essential.Newborn.Care. 4. Monitor.EMTCT.progress.in.Asia.and.the.Pacific,.and.summarize.and.publish.a.regional. report.regularly. 5. Support.Member.States.to.conduct.research.to.inform.and.adjust.policy.and.improve. implementation.of.EMTCT.interventions.. 6. Facilitate.dissemination.of.best.practices.and.experiences.of.countries.for.EMTCT. 18 REGIONAL FRAMEWORK FOR THE TRIPLE ELIMINATION OF MOTHER-TO-CHILD TRANSMISSION OF HIV, HEPATITIS B AND SYPHILIS IN ASIA AND THE PACIFIC, 2018–2030 TARGETS AND MILESTONES Coordination targets and milestones This.Framework.proposes.triple.elimination.coordination.targets.and.milestones.under. each.pillar.to.encourage.coordination.and.collaboration.among.programmes.and.stake- holders.to.maximize.impact.. PILLAR 1 POLICY — 2020 milestone A.coordination.mechanism.is.established.to.plan,.implement.and.monitor.EMTCT. of.HIV,.hepatitis.B.and.syphilis. — 2030 target The.national.policies.and.strategies.for.RMNCH.include.plans.and.interventions. for.EMTCT.of.HIV,.hepatitis.B.and.syphilis.as.standard,.integrated.components.of. quality.care.for.RMNCH. PILLAR 2 SERVICE DELIVERY — 2020 milestone A.plan.to.provide.quality.and.seamless.services.for.every.woman,.newborn,.child. and.their.families.to.achieve.triple.elimination.is.developed.through.coordination. and.collaboration.across.concerned.national.programmes.and.stakeholders. — 2030 target Core.services.for.EMTCT.of.HIV,.hepatitis.B.and.syphilis.are.available.through. accessible,.affordable.and.quality.reproductive,.antenatal,.childbirth,.postnatal. and.child.care.to.every.woman,.newborn,.child.and.their.families. PILLAR 3 MONITORING AND EVALUATION — 2020 milestone National.health.information.includes.key.indicators.for.EMTCT.of.HIV,.hepatitis.B. and.syphilis. — 2030 target Key.indicators.are.collected,.analysed.and.used.with.effective.communications. among.national.programmes.and.stakeholders.working.in.RMNCH,.immunization,. and.the.control.of.HIV,.STIs.and.hepatitis.through.interlinked.health.information. systems.to.monitor.progress.and.guide.actions.towards.triple.elimination. 2.3 19 Disease-specific elimination targets This.Regional Framework for the Triple Elimination of Mother-to-Child Transmission of HIV, Hepatitis B and Syphilis in Asia and the Pacific 2018–2030 aligns.its.targets.with.the.existing. global.and.regional.targets.suggested.by.the.global.health.sector.strategies.on.HIV,.Viral. Hepatitis.and.STI.2016–2021 (4, 5, 6).and.the.Regional Action Plan for Viral Hepatitis in the Western Pacific 2016–2020.(21),.which.have.been.endorsed.by.Member.States..It.also.aligns. with.the Global Guidance on Criteria and Processes for Validation: Elimination of Mother- to-Child Transmission of HIV and Syphilis.(8).. Table.1.presents.disease-specific.elimination.impact.and.process.targets. Table 1. Disease-specific elimination: impact and process targets IMPACT TARGET PROCESS TARGET Reproductive, maternal, newborn and child health (RMNCH) ANC coverage (at least one visit) ≥ 95% a Proportion of births attended by skilled health personnel ≥ 95% HIV a ≤ 50 new paediatric infections per 100 000 live births HIV testing coverage of pregnant women (pregnant women with known HIV status) ≥ 95% Mother-to-child transmission rate of < 5% (breastfeeding populations) or < 2% (non-breastfeeding populations) Antiretroviral therapy (ART) coverage of HIV-positive pregnant women ≥ 95% Hepatitis B * ≤ 0.1 % prevalence of the hepatitis B surface antigen (HBsAg) among children b (≤ 100 cases/100 000 live births) Hepatitis B birth-dose vaccine coverage ≥ 95% **, c Hepatitis B third-dose vaccine coverage ≥ 95% **, c HBsAg testing coverage of pregnant women ≥ 95% ***, d Syphilis a ≤ 50 congenital syphilis cases per 100 000 live births **** Syphilis testing coverage of pregnant women ≥ 95% Treatment of syphilis-seropositive pregnant women ≥ 95% * Targets may be added in due course based on evolving WHO guidance and recommendations on additional interventions required to eliminate mother-to-child transmission of hepatitis B. ** The Global Health Sector Strategy on Viral Hepatitis 2016–2021 sets the target of 90% vaccination coverage for hepatitis B vaccine birth dose and three-dose. The Regional Action Plan for Viral Hepatitis in the Western Pacific 2016–2020 sets regional 2017 milestones of ≥ 95% hepatitis B birth-dose and ≥ 95% hepatitis B third- dose coverage. *** In the 2017 Guidelines on Hepatitis B and C Testing, WHO recommends that HBsAg testing be routinely offered to all pregnant women in antenatal clinics with linkages to prevention, care and treatment services in settings with ≥ 2% or ≥ 5% HBsAg seroprevalence in the general population. A threshold of ≥ 2% or ≥ 5% seroprevalence was based on several published thresholds of intermediate or high seroprevalence. The threshold used will depend on other country considerations and epidemiological context. As the Regional Framework calls for coordinated screening for HIV, hepatitis B and syphilis, the proposed process target of HBsAg testing coverage of pregnant women ≥ 95% aligns with globally established process targets of ≥ 95% for HIV and syphilis screening. Hepatitis B looks to be incorporated into the global guidance for validating 20 REGIONAL FRAMEWORK FOR THE TRIPLE ELIMINATION OF MOTHER-TO-CHILD TRANSMISSION OF HIV, HEPATITIS B AND SYPHILIS IN ASIA AND THE PACIFIC, 2018–2030 elimination of mother-to-child transmission (EMTCT) of HIV and syphilis. **** The global surveillance case definition for congenital syphilis: 1) a live birth or fetal death at > 20 weeks of gestation or > 500 grams (including stillbirth) born to a woman with positive syphilis serology and without adequate syphilis treatment; or 2) a live birth, stillbirth or child aged < 2 years born to a woman with positive syphilis serology or with unknown serostatus and with laboratory, and/or radiographic and/or clinical evidence of syphilis infection (regardless of timing or adequacy of maternal treatment). Sources: a. Global guidance on criteria and processes for validation: elimination of mother-to-child transmission (EMTCT) of HIV and syphilis. Geneva: World Health Organization; 2017 (http://www.who.int/reproductive health/publications/emtct-hiv-syphilis/en). b. Global health sector strategy on viral hepatitis 2016–2021. Geneva: World Health Organization; 2016 (http://www.who.int/hepatitis/strategy2016-2021/ghss-hep/en). c. Regional action plan for viral hepatitis in the Western Pacific 2016–2020. Manila: World Health Organization Regional Office for the Western Pacific; 2016 (http://iris.wpro.who.int/handle/10665.1/13141). d. Guidelines on hepatitis B and C testing – policy brief. Geneva: World Health Organization; 2016 (http:// apps.who.int/iris/handle/10665/251330). 21 WHO will establish a coordinated process and mechanisms for validation of elimina- tion of mother-to-child transmission (EMTCT) of HIV, hepatitis B and syphilis. It is anticipated that for a country to seek validation of EMTCT of HIV, hepatitis B and/or syphilis, the country will be required to report focusing on a range of impact and programme indicators. An indicative list, most of which are already being collected by countries, is provided below for planning purposes. These key indicators may be revised and/or added as new evidence and recommendations become available. POLICY INDIC ATOR 1. National.policy.and.plan.for.elimination.and.validation.of.mother-to-child.transmis- sion.of.HIV,.hepatitis.B.and.syphilis.are.in.place IMPACT INDIC ATORS 1. Case.rate.of.new.paediatric.HIV.infections.per.100 000.live.births 2. Mother-to-child.transmission.rate.of.HIV 3. Hepatitis.B.surface.antigen.(HBsAg).prevalence.among.children 4. Case.rate.of.congenital.syphilis.per.100 000.live.births 3.1 3.2 PROCESS OF VALIDATION3. 22 REGIONAL FRAMEWORK FOR THE TRIPLE ELIMINATION OF MOTHER-TO-CHILD TRANSMISSION OF HIV, HEPATITIS B AND SYPHILIS IN ASIA AND THE PACIFIC, 2018–2030 PROGR AMME (PROCESS) INDIC ATORS 1. Percentage.of.pregnant.women.visiting.ANC.at.least.once. 2. Percentage.of.pregnant.women.visiting.ANC.at.least.four.times 3. Percentage.of.pregnant.women.with.known.HIV.status.(include.both.newly.tested. and.those.with.known.status). 4. Percentage.of.ANC.attendees.tested.for.HBsAg* 5. Percentage.of.women.accessing.ANC.who.were.tested.for.syphilis 6. Percentage.of.pregnant.women.living.with.HIV.who.received.antiretroviral.therapy. (ART). 7. Percentage.of.pregnant.women.with.a.positive.syphilis.serology.who.were.treated. adequately** 8. Proportion.of.births.attended.by.skilled.health.personnel. 9. Stillbirth.rate.(per.1000.total.births) 10. Percentage.of.infants.receiving.a.birth.dose.(disaggregate.for.timely.birth.dose.within. 24.hours.of.birth.and.outside.of.24.hours). 11. Coverage.of.the.third.dose.hepatitis.B.vaccine.among.infants * WHO recommends that HBsAg testing be routinely offered to all pregnant women in antenatal clinics with linkages to prevention, care and treatment services in settings with ≥ 2% or ≥ 5% HBsAg seroprevalence in the general population. ** At least one injection of 2.4 million units of intramuscular benzathine penicillin at least 30 days prior to delivery (26). 3.3 23 References 1. Sustainable.Development.Goal.3.[webpage]..New.York,.NY:.United.Nations;.2017.(https:// sustainabledevelopment.un.org/sdg3).. 2. Global.strategy.for.women’s,.children’s.and.adolescents’.health.(2016–2030)..Every.Woman. Every.Child;.2015..(http://who.int/life-course/partners/global-strategy/globalstrategyre- port2016-2030-lowres.pdf). 3. Every.Woman.Every.Child..http://www.everywomaneverychild.org. 4. Global.health.sector.strategy.on.HIV.2016–2021..Geneva:.World.Health.Organization;.2016. (http://www.who.int/hiv/strategy2016-2021/ghss-hiv/en).. 5. 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Organization;.2016.(http://apps.who.int/iris/handle/10665/249572).. 25 ANNEX Regional Framework for the Triple Elimination of Mother-to-Child Transmission of HIV, Hepatitis B and Syphilis in Asia and the Pacific 2018–2030 VISION: Every infant free of HIV, hepatitis B and syphilis GOAL: Achieve and sustain elimination of mother-to-child transmission (EMTCT) of HIV, hepatitis B and syphilis and achieve better health for women, children and their families through a coordinated approach and efforts by 2030 in Asia and the Pacific POLICY AND IMPACT TARGETS POLICY: National policy and plan for elimination and validation of mother-to-child transmission of HIV, hepatitis B and syphilis are in place HIV: ≤ 50 new paediatric infections per 100 000 live births Mother-to-child transmission rate of < 5% (breastfeeding populations) or < 2% (non-breastfeeding populations) HEPATITIS B: ≤ 0.1 % prevalence of the hepatitis B surface antigen (HBsAg) among children (≤ 100 cases per 100 000 live births) SYPHILIS: ≤ 50 congenital syphilis cases per 100 000 live births PROGRAMME TARGETS ANC coverage (at least one visit) ≥ 95% Proportion of births attended by skilled health personnel ≥ 95% HIV testing coverage of pregnant women (pregnant women with known HIV status) ≥ 95% Antiretroviral therapy (ART) coverage of HIV-positive pregnant women ≥ 95% Hepatitis B birth-dose vaccine coverage ≥ 95% Hepatitis B third-dose vaccine coverage ≥ 95% HBsAg testing coverage of pregnant women ≥ 95% Syphilis testing coverage of pregnant women ≥ 95% Treatment of syphilis-seropositive pregnant women ≥ 95% Additional programme indicators ANC coverage at least four times throughout pregnancy Stillbirth rate (per 1000 total births) 26 REGIONAL FRAMEWORK FOR THE TRIPLE ELIMINATION OF MOTHER-TO-CHILD TRANSMISSION OF HIV, HEPATITIS B AND SYPHILIS IN ASIA AND THE PACIFIC, 2018–2030 PILLAR 1. COORDINATED NATIONAL POLICY AND STRATEGY 2030 target The national policies and strategies for RMNCH include plans and interventions for EMTCT of HIV, hepatitis B and syphilis as standard, integrated components of quality care for RMNCH 2020 milestone A coordination mechanism is established to plan, implement and monitor EMTCT of HIV, hepatitis B and syphilis Proposed priority actions for countries 1. Advocate high-level political commitment for the achievement of EMTCT of HIV, hepatitis B and syphilis (triple elimination). 2. Develop coordinated policies and strategies for triple elimination that are built into national and subnational RMNCH policies, strategies, plans and guidelines, aligning with related programmes with defined roles and responsibilities of each programme and stakeholders. 3. Establish a mechanism for coordination, implementation and monitoring, building on existing systems and stakeholders including affected communities. 4. Strengthen RMNCH and other related programmes by ensuring adequate and sustainable financial and human resources and by developing capacities to provide quality services including interventions for triple elimination. 5. Ensure that interventions for triple elimination are included in essential health service pack- ages and access to services are ensured and covered by public funding. 6. Address and remove social and financial barriers for all women, children and their families, including vulnerable and marginalized populations, to access services for triple elimination within reproductive, antenatal, childbirth, postnatal and child care. 7. Respect human rights of all women, their partners, children and families; ensure protection of their privacy and confidentiality; and address stigma and discrimination associated with implementation of interventions. 8. Consider possibility to expand the synergies within the RMNCH platform to include other health issues as appropriate in view of potential benefits. Proposed priority actions for WHO and partners 1. Support Member States to advocate high-level political commitment for triple elimination, including development of communications materials and tools. 2. Support Member States to develop coordinated policies and strategies for triple elimination within reproductive, antenatal, childbirth, postnatal and child care. 3. Ensure coordination across programmes among WHO and partners to provide coordinated support to Member States. 4. Support Member States to estimate and allocate adequate resources and develop capacities of the RMNCH and other related programmes to provide quality RMNCH services, including interventions for triple elimination. 5. Support Member States to include triple elimination interventions in essential health services packages covered by public funding and to ensure the access to services by addressing and removing social and financial barriers. 6. Facilitate intercountry and regional partnerships, sharing of best practices and lessons learnt, and mentoring among countries and regions. 7. Support Member States to ensure a human-rights-based approach and to address ethical aspects related to implementation of interventions. 8. Support Member States to consider inclusion of other health issues in the RMNCH platform. 27 PILLAR 2. SEAMLESS QUALITY CARE FOR WOMEN, NEWBORNS, CHILDREN AND THEIR FAMILIES 2030 target Core services for EMTCT of HIV, hepatitis B and syphilis are available through accessible, affordable and quality reproductive, antenatal, childbirth, postnatal and child care to every woman, newborn, child and their families 2020 milestone A plan to provide quality and seamless services for every woman, newborn, child and their families to achieve triple elimination is developed through coordination and collaboration across concerned national programmes and stakeholders Proposed priority actions for countries 1. Assess and map where and how interventions for triple elimination are currently being provided within reproductive, antenatal, childbirth, postnatal and child care services, and identify gaps and opportunities for coordination and integration. 2. Update, refine and link national policies, guidelines and training on reproductive, antenatal, childbirth, postnatal and child care to provide the latest evidence-based quality of care for all pregnant women, newborns and children, including EMTCT interventions. 3. Develop a plan for strengthening or scaling up of coordinated interventions for EMTCT, including universal screening for HIV, syphilis and, as appropriate, hepatitis B surface antigen (HBsAg) for women and their partners, linkages to appropriate care and treatment, timely hepatitis B birth dose and follow-up vaccination. 4. Provide guidance and tools for health workers and those to be involved in service provision related to EMTCT within RMNCH care, through pre-service education and on-the-job training. 5. Engage communities and related sectors and provide information to all women, their partners and families to improve awareness and demand for quality RMNCH care including triple elimination remove barriers to access services and increase utilization. 6. Apply a tiered approach to introduce additional interventions for EMTCT of hepatitis B including antenatal screening, the possible use of antiviral drugs and the use of hepatitis B immunoglobulin (HBIG) among infants born to HBsAg-positive mothers based on evolving evidence and recommendations. 7. Consider application of new interventions and technologies that support the achievement of EMTCT of HIV, hepatitis B and syphilis and other communicable diseases, including the use of new diagnostic assays such as dual HIV/syphilis rapid test kits. 8. Ensure the quality of services provided for triple elimination, including laboratory services and those delivered by private health facilities, by building upon existing quality assurance mechanisms and approaches. Proposed priority actions for WHO and partners 1. Support Member States to map and identify gaps and opportunities for coordination and integration of interventions for triple elimination. 2. Support Member States to update national policies, guidelines and training on reproductive, antenatal, childbirth, postnatal and child care to reflect the latest evidence-based WHO recommendations through coordinated approaches across programmes and expertise. 3. Support Member States to review progress on EMTCT of HIV, hepatitis B and syphilis, deter- mine additional steps and develop a plan for strengthening or scaling up of coordinated interventions to achieve elimination. 28 REGIONAL FRAMEWORK FOR THE TRIPLE ELIMINATION OF MOTHER-TO-CHILD TRANSMISSION OF HIV, HEPATITIS B AND SYPHILIS IN ASIA AND THE PACIFIC, 2018–2030 PILLAR 2. SEAMLESS QUALITY CARE FOR WOMEN, NEWBORNS, CHILDREN AND THEIR FAMILIES (continued) Proposed priority actions for WHO and partners (continued) 4. Develop guidance and tools for health workers and those involved in service provision on interventions related to EMTCT including screening, referral, treatment and follow-up within reproductive, antenatal, childbirth, postnatal and child care. 5. Support Member States to develop communications materials and tools to provide informa- tion to women and their partners. 6. Develop guidance on a tiered approach for additional interventions for EMTCT of hepatitis B and provide support to Member States for its implementation. 7. Support Member States for the introduction of new interventions and technologies related to EMTCT through necessary analysis and the use of new diagnostic assays. 8. Support Member States to improve and ensure the quality of interventions, including labora- tory services for triple elimination. 29 PILLAR 3. COORDINATED MONITORING AND EVALUATION OF ELIMINATION 2030 target Key indicators are collected, analysed and used with effective communications among national programmes and stakeholders working in RMNCH, immunization, and the control of HIV, sexually transmitted infections (STIs) and hepatitis through interlinked health information systems to monitor progress and guide actions towards triple elimination 2020 milestone National health information includes key indicators for EMTCT of HIV, hepatitis B and syphilis Proposed priority actions for countries 1. Standardize key indicators to be monitored based on global and regional recommendations and set national and subnational milestones and targets for EMTCT. 2. Review and map key indicators and determine how these key indicators are collected, analysed and used by national programmes and stakeholders to identify any duplications or gaps and develop a plan to improve data quality. 3. Refine and link existing data collection systems, including those in the private sector, to support better linkages and the monitoring of EMTCT progress by national programmes and stakeholders. 4. Monitor EMTCT indicators and report progress regularly through a coordinating mechanism to prepare for validation of elimination and the maintenance of elimination status after validation. 5. Conduct research to inform and adjust policy and improve implementation of EMTCT inter- ventions. 6. Share experiences of implementation and lessons learnt with stakeholders within and outside of country. Proposed priority actions for WHO and partners 1. Obtain consensus on key indicators building into existing global, regional and national reporting mechanisms and contribute to global discussions on setting interlinked elimination criteria for EMTCT of hepatitis B and updating the HIV and syphilis component. 2. Provide clear guidance for Member States on the validation process and data requirements, and provide support to standardize indicators, link existing data collection systems, improve data quality and assess EMTCT progress. 3. Identify potential areas for coordination and integration of regional mechanisms for validation of EMTCT and support Member States for validation through existing mechanisms, including the network created by the Asia-Pacific Prevention of Parent-to-Child Transmission Task Force for HIV and syphilis, the Hepatitis B Immunization Expert Resource Panel, the Regional Immunization Technical Advisory Group and the biennial meeting on accelerating progress in Early Essential Newborn Care. 4. Monitor EMTCT progress in Asia and the Pacific, and summarize and publish a regional report regularly. 5. Support Member States to conduct research to inform and adjust policy and improve imple- mentation of EMTCT interventions. 6. Facilitate dissemination of best practices and experiences of countries for EMTCT.