Integrated prevention of mother-to-child transmission for human immunodeficiency virus, syphilis and hepatitis B virus in China

Bull World Health Organ 2015;93:52–56 | doi: http://dx.doi.org/10.2471/BLT.14.139626 Lessons from the field 52 Integrated prevention of mother-to-child transmission for human immunodeficiency virus, syphilis and hepatitis B virus in China Ai-Ling Wang,a Ya-Ping Qiao,a Lin-Hong Wang,b Li-Wen Fang,b Fang Wang,a Xi Jin,a Jie Qiu,c Xiao-Yan Wang,a Qian Wang,a Jiu-Ling Wu,a Sten H Vermundd & Li Songc Introduction The World Health Organization (WHO) has called for inte- grated action to eliminate new paediatric human immuno- deficiency virus (HIV) infection and congenital syphilis by 2015.1,2 However, in 2009, mother-to-child transmission of these diseases was still high in China. At the end of 2009, the HIV prevalence in China was 0.057% (range: 0.042–0.071), with an estimated 740 000 people (range: 560 000–920 000) living with HIV.3 Before the antiretroviral therapy era, the mother-to-child transmission rate was estimated to be 34.8%.4 In 2009, this rate fell to 8.1% after widespread HIV screening of pregnant women, and HIV infected mothers were offered free antiretroviral prophylaxis for HIV and replacement feeding to avoid breast feeding their children. Syphilis, caused by a spirochete bacterium, was seldom reported in the Chinese population two decades ago, however the incidence has increased to 24.7 cases per 100 000 people in 2009.5 Reported congenital syphilis has increased from 25.5 per 100 000 live births in 2005 to 60.8 per 100 000 live births in 2009.5 In addition, hepatitis B virus (HBV) is a public health problem. In 2006, 7.2% of the Chinese population aged 1–59 years were hepatitis B surface antigen positive.6 In 2010, China’s Ministry of Health began to integrate and standardize prevention of mother-to-child transmission (PMTCT) efforts for HIV, syphilis and HBV. Subsequently, the ministry initiated comprehensive services nationwide. In this report, we describe China’s implementation of these integrated PMTCT services. Local setting Supported by the Government of China, the national PMTCT programme for HIV was initiated in 2003 and covered 453 counties, cities and districts by 2009. At the participating ante- natal care clinics, free HIV screening was offered for pregnant women. The interventions for HIV-infected mothers included HIV-tailored midwifery services, free antiretroviral therapy or prophylaxis and practical guidance on infant feeding. Exposed infants received free antiretroviral medicines, HIV antibody testing at 12 and 18 months of age and developmental monitor- ing. In 2003 there were no nationwide programmes designed to prevent maternal transmission of syphilis and HBV. Approach To meet the WHO goals for elimination of paediatric HIV infection and congenital syphilis by 2015, China faced many national challenges. In the second half of 2010, the Govern- ment of China incorporated a nationwide PMTCT programme for HIV, syphilis and HBV into the existing maternal and child health-care system. In February 2011, the Ministry of Health issued the Protocol for prevention of mother-to-child transmission of HIV, syphilis and hepatitis B, which contained the govern- Problem China continues to face challenges in eliminating mother-to-child transmission of human immunodeficiency virus (HIV), syphilis and hepatitis B virus (HBV). Approach In 2010, a programme that integrated and standardized prevention of mother-to-child transmission (PMTCT) efforts for HIV, syphilis and HBV was implemented in 1156 counties. At participating antenatal care clinics, pregnant women were offered all three tests concurrently and free of charge. Further interventions such as free treatment, prophylaxis and testing for mothers and their children were provided for HIV and syphilis. Local setting China’s national PMTCT HIV programme started in 2003, at which time there were no national programmes for perinatal syphilis and HBV. In 2009, the rate of maternal-to-child transmission of HIV was 8.1% (57/702). Reported congenital syphilis was 60.8 per 100 000 live births. HBV infection was 7.2% of the overall population infected. Relevant changes Between 2010 and 2013 the number of pregnant women attending antenatal care clinics with integrated PMTCT services increased from 5.5 million to 13.1 million. In 2013, 12.7 million pregnant women were tested for HIV, 12.6 million for syphilis and 12.7 million for HBV. Mother-to-child transmission of HIV fell to 6.7% in 2013. Data on syphilis transmission are not yet available. Lessons learnt Integrated PMTCT services proved to be feasible and effective, and they are now part of the routine maternal and child health services provided to infected women. The services are provided through a collaboration between maternal and child health clinics, the national and local Centers for Disease Control and Prevention, and general hospitals. a National Center for Women and Children’s Health, Chinese Center for Disease Control and Prevention, Beijing, China. b National Center for Chronic and Noncommunicable Disease Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China. c National Health and Family Planning Commission of the People’s Republic of China, No.1, Xizhimen South Road, Xicheng District, Beijing, China. d Vanderbilt Institute for Global Health and Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, United States of America. Correspondence to Li Song (email: songlimoh@126.com). (Submitted: 3 April 2014 – Revised version received: 10 October 2014 – Accepted: 13 October 2014 – Published online: 3 November 2014 ) Bull World Health Organ 2015;93:52–56| doi: http://dx.doi.org/10.2471/BLT.14.139626 53 Lessons from the field Prevention of mother-to-child transmission in ChinaAi-Ling Wang et al. ment’s response strategy, intervention measures, and requirements regard- ing organization and management.7 The protocol provided guidance to all regions for implementation of integrated PMTCT efforts for HIV, syphilis and hepatitis B. It also reiter- ated the official policy of strengthening government leadership, ensuring that all departments fulfil their respective responsibilities, promoting full social mobilization and broad participation, integrating service resources, improv- ing intervention quality, expanding coverage and promoting standardiza- tion.7 From 2010 to 2013, the central government allocated over 3.4 billion Yuan (573 million United States dol- lars), to implement these services. For PMTCT, testing and counsel- ling are the first intervention steps within the antenatal care environment. In 2010, health-care facilities providing midwifery and antenatal care services that participated in the programme at provincial, prefecture, county and township levels started to offer free HIV, syphilis and hepatitis B counselling and testing for pregnant women. Free PMTCT interventions were provided to all infected mothers and their children throughout the nation. The interventions for HIV were identical to interventions in the original national PMTCT programme for HIV, except that the current programme of- fered early HIV diagnosis for exposed infants at 6–8 weeks of age. Mothers infected with syphilis were provided free treatment with 2.5 mil- lion units of intramuscular benzathine penicillin once a week for three weeks and appropriate midwifery services to prevent transmission during labour. Exposed infants were provided with free prophylaxis with benzathine penicillin and offered testing for syphilis every three months up to 18 months of age. For infected infants, free treatment was offered. Children born to women testing positive for hepatitis B surface antigen were provided with free hepatitis B im- munoglobulin (100 IU) within 24 hours after birth and three hepatitis B vac- cinations within 24 hours of birth, at 1 month and 6 months of age, in accordance with national guidelines.8 Testing and treatment of children were not covered by the programme. The programme supported training of health-care providers. Between 2010 and 2012 training-of-trainers was pro- vided yearly at national and provincial level on the elements of the PMTCT care cascade. The training lasted for ap- proximately three days. Subsequently, at provincial and prefectural level, the instructors held yearly training sessions, that normally lasted for 1–3 days, for local health-care providers to improve programme capacity. Health-care pro- viders were trained on implementation of integrated PMTCT interventions and management of infected pregnant women and their children. They were also trained in data collection. Staff were trained in data management and analy- sis. The National Center for Women and Children’s Health incorporated all PMTCT data on HIV, syphilis and HBV into the pre-existing management infor- mation system of the national PMTCT programme. Relevant changes By 2013 the programme covered 41% (1156/2853) of counties, cities and dis- tricts within 31 provinces, autonomous regions and municipalities in China. In six provinces, autonomous regions and municipalities with the most serious epidemics, all counties were covered. The PMTCT programme reached 13.1 million pregnant women in 2013, 8.7 million more than in 2009. Of these, 12.7 million were tested for HIV anti- bodies, representing an increase in test- ing rates from 85.4% in 2009 to 97.3% in 2013. There was a 63.1% increase in pregnant women diagnosed with HIV, from 3662 cases in 2009 to 5973 cases in 2013. Mother-to-child transmission of HIV fell from 8.1% (57/702) in 2009 to 6.7% (145/2180) in 2013. In the same year, 12.6 million pregnant women in the programme were also tested for syphilis, covering 96.4% of women reached by the integrated programme. We commenced data collection on mother-to-child transmission of syphilis in the latter half of 2012. To be able to exclude transmission, syphilis-infected Table 1. The programme for integrated prevention of mother-to-child transmission of human immunodeficiency virus, syphilis and hepatitis B virus, China, 2009–2013 Characteristic Year 2009 2010 2011 2012 2013 No. of counties 453 1 156 1 156 1 156 1 156 Millions of pregnant women attending antenatal care 4.38 5.45 9.39 12.07 13.07 Millions of pregnant women tested for HIV (%) 3.74 (85.39) 4.84 (88.81) 8.73 (92.97) 11.64 (96.44) 12.72 (97.32) No. of pregnant women diagnosed with HIV (%) 3 662 (0.10) 4 146 (0.09) 5 313 (0.06) 5 779 (0.05) 5 973 (0.05) No. of children acquiring HIV through transmission from an HIV-infected mother (%)a 57 (8.12) 86 (7.90) 124 (7.41) 131 (7.05) 145 (6.65) Millions of pregnant women tested for syphilis (%) NA NA 7.30b,c (84.98) 11.48 (95.11) 12.60 (96.40) No. of pregnant women diagnosed with syphilis (%)b NA NA 14 822 (0.20) 24 307 (0.21) 30 520 (0.24) Millions of pregnant women tested for Hep B virus surface antigen (%) NA NA 7.67c (89.29) 11.72 (97.10) 12.73 (97.40) No. of Hep B virus exposed neonates that received Hep B immunoglobulin (%) NA NA 301 048 (86.21) 599 071 (94.42) 774 916 (97.74) Hep B: Hepatitis B; HIV: human immunodeficiency virus; NA: not available. a For 2009 n = 702; 2010 n = 1088; 2011 n = 1673; 2012 n = 1858; 2013 n = 2180. b Definition of syphilis seropositivity: both nontreponemal antigen serologic test and Treponema pallidum antigen serologic test are positive. c In 2011, in the first year of implementation, HIV, syphilis and HBV testing were not integrated in all programme sites, hence the coverage of screening for syphilis and HBV was less than that of HIV. The number of pregnant women covered by syphilis and HBV testing was 8.59 million. Bull World Health Organ 2015;93:52–56| doi: http://dx.doi.org/10.2471/BLT.14.13962654 Lessons from the field Prevention of mother-to-child transmission in China Ai-Ling Wang et al. mothers and their children are followed until the children are 18 months of age. Therefore, we do not yet have transmis- sion data for syphilis. Hepatitis B surface antigen testing was successfully done in 97.4% (12.7 million) pregnant women. Among neonates born to women testing positive for hepatitis B surface antigen, 97.7% received hepatitis B immuno- globulin (Table 1). Lessons learnt Integrated prevention of three vertically- transmitted diseases – HIV, syphilis and HBV – proved to be feasible and effective at a large scale in China. Pregnant women were offered all three tests concurrently, free of charge. The programme was fully nested within the existing maternal and child health-care system in China at county, township, and village levels. Pregnant women in- fected with HIV, syphilis or HBV were immediately enrolled for integrated PMTCT programme services as a part of their routine antenatal, postnatal, and children’s care. Maternal and child health clinics, the national and local Centers for Disease Control and Preven- tion, and general hospitals collaborated well, which led to a successful imple- mentation of the programme (Box 1). The integrated PMTCT programme has helped China meet the WHO goal. Implementing the integrated pro- gramme involved challenges including shortage of human resources, quality of services, and suboptimal availability of services in some areas. To address the concerns about availability, the Government of China has expanded the integrated PMTCT programme to 1638 counties in August 2014, using the same strategy that had been deployed in 2010. This expansion will allow more pregnant women to access free integrated PMTCT services. Improv- ing the capacity of health-care staff and quality-associated monitoring and evaluation through further training will be our future focus. In conclusion, the expansion of the integrated PMTCT programme both in content and coverage can significantly contribute towards achieving the dual goal of eliminating paediatric HIV in- fection and congenital syphilis, as well as addressing the ongoing burden of perinatal HBV transmission. Our expe- rience took place in a large population with high disease burdens. The Chinese model may be of interest to other nations that seek to better integrate HIV, syphilis and HBV services into the broader ma- ternal and child health context. ■ Funding: All funding was provided by the National Health and Family Planning Commission, China. Funding: SHV’s engagement was sup- ported by an NIH Fogarty training grant, D43 TW001035 and R01AI094562. Competing interests: None declared. صخلم في لفطلا لىإ ملأا نم ”ءاب“ دبكلا باهتلا سويرفو يرهزلاو يشربلا يعانلما زوعلا سويرف نايسر نم ةياقولا جاردإ ينصلا نايسر نم صلختلا في تايدتح هجاوت ينصلا لازت لا ةلكشلما باهتلا سويرفو يرهزلاو )HIV( يشربلا يعانلما زوعلا سويرف .لفطلا لىإ ملأا نم )HBV( ”ءاب“ دبكلا ديحوتو جاردلإ جمانرب ذيفنت مت ،2010 ماع في بولسلأا يرهزلاو يشربلا يعانلما زوعلا سويرف نايسر نم ةياقولا دوهج في )PMTCT( لفطلا لىإ ملأا نم ”ءاب“ دبكلا باهتلا سويرفو ةياعرلا تادايع في لماولحا ءاسنلا لىع ضرٌعو .ةعطاقم 1156 لكشب ةثلاثلا تارابتخلاا لك ءارجإ ،ةكراشلما ةدلاولل ةقباسلا نياجلما جلاعلا لثم ىرخأ تلاخدت جاردإ متو .ناجلمابو نمازتم .جمانبرلا في نلهافطأو تاهملأا صحفو ةيقوتلاو سويرف نايسر نم ةياقولل ينطولا جمانبرلا أدب ةيلحلما عقاولما ،2003 ماع ينصلا في لفطلا لىإ ملأا نم يشربلا يعانلما زوعلا دبكلا باهتلا سويرفو يرهزلل ةينطو جمارب اهنيح كانه نكي لمو لدعم ناك ،2009 ماع فيو .ةدلاولاب ةطيحلما ةترفلا في ”ءاب“ % 7.8 لفطلا لىإ ملأا نم يشربلا يعانلما زوعلا سويرف نايسر 60.8 هنع غلابلإا مت يذلا يقللخا يرهزلا ناكو .)ةقلطم دادعأ( دبكلا باهتلا سويرفب ىودعلا تناكو .يح ديلو فلأ 100 لكل .ماع لكشب ينباصلما ناكسلا نم % 7.2 ”ءاب“ ،2013 ماع لىإ 2010 ماع نم ةترفلا في ةلصلا تاذ تا ّريرغتلا ةياعرلا تادايع لىإ نضرح تيلالا لماولحا ءاسنلا ددع عفترا نم نايسرلا نم ةياقولا تامدخ تجردأ يتلا ةدلاولل ةقباسلا ماع فيو .ةأرما نويلم 13.07 لىإ نويلم 5.45 نم لفطلا لىإ ملأا سويرف نم ققحتلل لماح ةأرما نويلم 12.72 صحف مت ،2013 نم ققحتلل لماح ةأرما نويلم 12.60و يشربلا يعانلما زوعلا باهتلا سويرف نم ققحتلل لماح ةأرما نويلم 12.73و يرهزلا نم يشربلا يعانلما زوعلا سويرف نايسر ضفخناو .”ءاب“ دبكلا .2013 ماع في % 6.7 لىإ لفطلا لىإ ملأا لىإ ملأا نم نايسرلا نم ةياقولا جاردإ نأ تبث ةدافتسلما سوردلا ةحصل ةينيتورلا تامدلخا نم ءزج نلآا يه و ،لاعفو ٍدمج لفطلا ميدقت متيو .تاباصلما تاهملأل اهميدقت متيو ةلوفطلاو ةموملأا ةيلحلماو ةينطولا زكارلماو ةيحصلا تادايعلا عم نواعتلاب تامدلخا .ةماعلا تايفشتسلماو اهتحفاكمو ضارملأا نم ةياقولل Box 1. Summary of main lessons learnt • Integrated prevention of mother-to-child transmission proved to be feasible and effective for HIV, syphilis and hepatitis B virus in China. • This programme was implemented through the current maternal and child health-care system in China, improving its sustainability. • Collaboration between maternal and child health clinics/hospitals, the national and local Centers for Disease Control and Prevention, and general hospitals were crucial for the programme’s success. Bull World Health Organ 2015;93:52–56| doi: http://dx.doi.org/10.2471/BLT.14.139626 55 Lessons from the field Prevention of mother-to-child transmission in ChinaAi-Ling Wang et al. 摘要 中国综合预防艾滋病毒、梅毒和乙型肝炎病毒母婴传播 问题 中国继续面临消除艾滋病病毒（HIV）、梅毒和 乙型肝炎病毒（HBV）母婴传播的挑战。 方法 2010 年一项综合标准化 HIV、梅毒和 HBV 母婴 传播预防工作的工作在 1156 个县实施。在参与该工作 的产前保健诊所中，为孕妇同时免费提供所有三项检 测。工作包含进一步的干预措施，诸如母亲及其孩子 免费治疗、预防和检测。 当 地 状 况 中 国 全 国 预 防 艾 滋 病 毒 母 婴 传 播 工 作 （PMTCT HIV）始于 2003 年，当时还没有围产期梅毒 和乙型肝炎病毒的国家项目。2009 年，母婴 HIV 传播 的比例是 8.1% (57/702)。据报告，每 10 万例活产中先 天性梅毒有 60.8 例。HBV 感染占总人口 7.2%。 相关变化 在 2010 年和 2013 年间，在提供整合艾滋病 毒母婴传播预防服务的产前保健诊所获得保健服务的 孕妇从 5.5 万增加到 13.1 万人。在 2013 年，12.7 万名 孕妇接受了 HIV 检测，12.6 万名孕妇接受梅毒检测， 12.7 万名孕妇接受 HBV 检测。2013 年，HIV 母婴传播 降低至 6.7%。 经验教训 实践证明，整合预防艾滋病毒母婴传播可行 有效，目前是常规妇幼保健服务的组成部分。服务由 健康诊所、全国和地方疾病预防控制中心以及综合性 医院合作提供。 Résumé Prévention intégrée de la transmission mère-enfant pour le virus de l’immunodéficience humaine, la syphilis et le virus de l’hépatite B en Chine Problème La Chine est toujours confrontée à des difficultés dans l’élimination de la transmission mère-enfant du virus de l’immunodéficience humaine (VIH), de la syphilis et du virus de l’hépatite B (VHB). Approche En 2010, un programme qui intégrait et harmonisait les efforts de la prévention de la transmission mère-enfant (PTME) pour le VIH, la syphilis et le VHB, a été mis en œuvre dans 1156 pays. Au moment de bénéficier de soins prénatals, les femmes enceintes se sont vues proposer l’ensemble des trois tests en même temps et gratuitement. Des interventions supplémentaires telles que le traitement gratuit, la prophylaxie et le dépistage pour les mères et leurs enfants, ont été incluses dans le programme. Environnement local Le programme national chinois de PTME pour le VIH a débuté en 2003, au moment où il n’y avait encore aucun programme pour le dépistage périnatal de la syphilis et du VHB. En 2009, le taux de transmission mère-enfant pour le VIH était de 8,1% (57/702). Le nombre de cas de syphilis congénital signalés s’élevait à 60,8 pour 100 000 naissances vivantes. Le taux d’infection par le VHB était de 7,2% de l’ensemble de la population infectée. Changements significatifs Entre 2010 et 2013, le nombre de femmes enceintes bénéficiant de soins prénatals avec des services de PTME intégrés a augmenté de 5,5 millions à 13,1 millions. En 2013, 12,7 millions de femmes enceintes ont été testées pour le VIH, 12,6 millions pour la syphilis et 12,7 millions pour le VHB. La transmission mère-enfant pour le VIH a chuté à 6,7% en 2013. Leçons tirées Les services de PTME intégrée ont montré leur faisabilité et leur efficacité. Ils font maintenant partie des pratiques courantes des services de soins maternels et pédiatriques proposées aux femmes infectées. Ces services sont proposés en collaboration avec les cliniques de santé, les centres nationaux et locaux pour le contrôle et la prévention des maladies et les hôpitaux généraux. Резюме Комплексная профилактика передачи вируса иммунодефицита человека, сифилиса и вируса гепатита В от матери к ребенку в Китае Проблема Перед Китаем по-прежнему стоит проблема устранения передачи вируса иммунодефицита человека (ВИЧ), сифилиса и вируса гепатита В (ВГВ) от матери к ребенку. Подход В 2010 году в 1156 уездах страны была реализована программа, которая интегрировала и стандартизировала усилия по профилактике передачи от матери к ребенку (ППМР) таких заболеваний как ВИЧ, сифилис и ВГВ. В антенатальных клиниках, участвующих в программе, беременным женщинам одновременно и бесплатно предлагалось пройти все три теста. В эту программу также были включены дополнительные мероприятия, такие как бесплатное лечение, профилактика и тестирование матерей и их детей. Местные условия Национальная программа ППМР для ВИЧ- инфекции в Китае была запущена в 2003 году, когда еще не существовало национальных программ по профилактике перинатальной передачи сифилиса и ВГВ. В 2009 году уровень передачи ВИЧ от матери к ребенку составлял 8,1% (57/702). Врожденный сифилис был зарегистрирован у 60,8 из 100 000 живорожденных детей. Уровень ВГВ составлял 7,2% от общей численности инфицированного населения. Осуществленные перемены В период между 2010 и 2013 гг. число беременных женщин, посещавших антенатальные клиники, предлагающие комплексные услуги по ППМР, увеличилось с 5,5 млн. до 13,1 млн. В 2013 году 12,7 млн. беременных женщин прошли тестирование на ВИЧ, 12,6 млн. — на сифилис и 12,7 млн. — на ВГВ. В 2013 году уровень передачи ВИЧ-инфекции от матери ребенку снизился до 6,7%. Выводы Комплексные услуги по ППМР оказались реализуемыми и эффективными и в настоящее время входят в плановые услуги по обеспечению здоровья матери и ребенка, оказываемые инфицированным женщинам. Эти услуги предоставляются в сотрудничестве с поликлиниками, Центрами по контролю и профилактике заболеваний на местном и национальном уровнях и больницами общего профиля. Bull World Health Organ 2015;93:52–56| doi: http://dx.doi.org/10.2471/BLT.14.13962656 Lessons from the field Prevention of mother-to-child transmission in China Ai-Ling Wang et al. Resumen Prevención integrada de la transmisión maternoinfantil del virus de la inmunodeficiencia humana, la sífilis y el virus de la hepatitis B en China Situación China sigue haciendo frente a desafíos en la eliminación de la transmisión maternoinfantil del virus de la inmunodeficiencia humana (VIH), la sífilis y el virus de la hepatitis B (VHB). Enfoque En 2010 se puso en marcha en 1156 condados un programa que integraba y estandarizaba los esfuerzos de prevención de la transmisión maternoinfantil (PTMI) para el VIH, la sífilis y el VHB. En las clínicas de atención prenatal que participaron se ofrecieron a las mujeres embarazadas las tres pruebas al mismo tiempo y de forma gratuita. El programa incluyó otras intervenciones como el tratamiento gratuito, profilaxis y pruebas para las madres y sus hijos. Marco regional El programa nacional de PTMI del VIH en China comenzó en 2003, momento en el que no había ningún programa nacional para la sífilis y el VHB perinatales. En 2009, la tasa de transmisión maternoinfantil del VIH fue del 8,1 % (57/702). La sífilis congénita notificada fue de 60,8 por cada 100 000 nacidos vivos, y la infección por el VHB fue del 7,2 % de la población general infectada. Cambios importantes Entre 2010 y 2013, el número de mujeres embarazadas que asistieron a clínicas de atención prenatal con servicios integrados de PTMI aumentó de 5 450 000 a 13 070 000. En 2013, 12 720 000 mujeres embarazadas se sometieron a la prueba del VIH, 12 600 000 a la prueba de la sífilis y 12 730 000 a la del VHB. La transmisión maternoinfantil del VIH se redujo al 6,7 % en 2013. Lecciones aprendidas La PTMI integrada demostró ser factible y eficaz, y ha pasado a formar parte de los servicios rutinarios de salud maternoinfantil que se proporcionan a las mujeres infectadas. 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