The EMTCT Plus initiative aims to achieve and sustain the elimination of mother-to-child transmission (EMTCT) of HIV, syphilis, Chagas disease, and hepatitis B. In the Americas, Cuba in 2015, followed by Anguilla, Antigua and Barbuda, Bermuda, Cayman Islands, Montserrat, and St. Kitts and Nevis, in 2017 and Dominica in 2020, were validated by WHO for the dual elimination of MTCT of HIV and syphilis. Building on the experience and lessons learned from the first phase of the EMTCT of HIV and syphilis, countries are encouraged to incorporate the elimination of perinatal hepatitis B and congenital Chagas as an opportunity to advance elimination of communicable diseases and further strengthen the quality and coverage of maternal and child health services.
The coverage of HIV screening among pregnant women during antenatal care in Latin America and the Caribbean reached a historic high of 80% in 2019 reducing to 68% in 2021, possibly a result of the impact of the COVIC-19 pandemic on antenatal care services. Likewise, the access to antiretroviral therapy for pregnant women living with HIV has increased in Latin America and Caribbean between 2010 and 2019 reaching a coverage of 87% in Latin America and The Caribbean, the highest coverage in the past decade, followed by a sharp reduction in 2020 and 2021.
There were 30,071 cases of congenital syphilis reported by countries in the Americas in 2021, corresponding to an incidence rate of 2.1 per 1,000 live births. In Latin America syphilis screening coverage among pregnant women have been relatively stable at around 70% over the years but reducing to its lowest level in 2018 with a 57% screening coverage. The Caribbean maintained higher syphilis screening coverage, reaching 95% in 2020 and 2021. The reported coverage of appropriate syphilis treatment in the Latin America and the Caribbean showed an increase to 88% in 2019 and 2020. Additionally, an increase in the incidence of syphilis among different population groups, most concentrated in the young population of reproductive age, may contribute to increases in the number of cases of congenital syphilis. Countries must bolster their maternal and child health systems to revert the increasing incidence of congenital syphilis.
Regarding Hepatitis B, reductions in vaccination coverage have been observed before the COVID-19 emergence, but have been aggravated during the pandemic, more noticeable among Latin America countries. The vaccination is the foundation of the efforts to eliminate MTCT of hepatitis B, however, countries are encouraged to expand protective measures particularly among most vulnerable populations including HBsAg screening among pregnant women, access to treatment for eligible seropositive women, and the use of hepatitis B immunoglobulin to exposed children.
Even though the Chagas disease has several routes of transmission, mother to-child transmission has gained relevance while vector transmission is in a sharp decline. Countries are encouraged to seize the EMTCT Plus initiative as an opportunity to combine efforts and integrate services, leveraging on robust maternal and child health systems. Nonetheless, national responses to congenital Chaga still remains very verticalized and compartmentalized, and only a small number of countries are addressing the elimination of Congenital Chagas as part of an integrated approach.
The impact of COVID-19 is evident in the set of interventions linked to reproductive and maternal and child health, and countries will need extra effort to keep up with the goals of better care to pregnant women and babies free of preventable mother to child transmission diseases.
This report is a 10-year evaluation of the initiative for the Elimination of mother-to-child-transmission of HIV, syphilis, hepatitis B and Chagas Disease in the Region of the Americas, including some early indicative of the Covid-19 impact in the EMTCT in the Region.
PAHO gratefully acknowledges the financial support from Global Affairs Canada.
Excellent experiences and results of integrating HIV and syphilis in an initial phase, motivated the expansion of the EMTCT efforts to eliminate hepatitis B and congenital Chagas. The EMTCT Plus initiative promotes the synergies within health system, leveraging on existing programs to improve access to health services during the continuum of life course, focusing on pregnant women and their children, while targeting the most vulnerable among these group.
After years of continuous progress in the elimination of MTCT of HIV and syphilis, the data reported show a decelerating trend in recent years. Syphilis is on the rise throughout the Regions with many countries reporting outbreaks, disproportionally affecting key populations, but also resonating in the general population resulting in higher prevalence of syphilis among pregnant women and increasing incidence of congenital syphilis. The number of new HIV cases among children decreased during the past decade, evolving to a stabilized trend in recent years, most likely due to the inconsistent progress on the coverage of HIV testing and treatment services among pregnant women.
The Covid-19 pandemic disrupted immunization programs across the Region, with record declines in vaccination coverage. However, the reported data indicates a stalled progress and challenges to sustain vaccination coverages in the Region during the years preceding the pandemic, highlighting the need to address not only issues related to the apparent disruption, but also systemic challenges to ensure access to hepatitis B vaccines.
Congenital Chagas deserves attention due to its high prevalence among women of childbearing age and pregnant women in the Americas. Effective vector control and donor screening in transfusion centers have resulted in a significantly decreased rate of new infections in recent decades, making the MTCT the most important cause of new infections in many countries. Advocacy, political support, and programmatic efforts, including the design and update of information systems are needed to eliminate congenital Chagas.
Countries have been slow in adapting and revising their national systems to incorporate hepatitis B and Chagas disease key programmatic and impact indicators, limiting the monitoring of the EMTCT of these diseases. This issue can be added to other limitations of the EMTCT data in the Region, including underreporting of the number of perinatal HIV, congenital syphilis, and Chagas disease cases, under recording of seropositive pregnant women and subsequent treatment, the use of non standardized case definitions for congenital syphilis. Improving the information systems and the generation and analysis of disaggregated EMTCT Plus data in the Region, are crucial to understand gaps and to inform tailored national policies to ensure access to services by specific vulnerable and most affected populations.
This report highlights some worrisome trends, and although the progress of EMTCT has been affected by the COVID-19 pandemic, it is not yet possible to determine the extension of this impact. Its seems that the COVID-19 aggravated an ongoing situation, considering that countries have reported decreasing levels of activities related to prevention, testing, and treatment indicators in years prior to the pandemic. Some countries however, managed to sustain previous achievements, indicating a quicky recovery and encouraging results for the future.
Efforts to recovery from the pandemic, transforming resilient health systems, play a meaningful role to revert the situation. However, it is also critical to regain political commitment to the specific goals and objectives of the EMTCT Plus initiative, expressed by political will, strengthened public health capacity at the local levels, and community collaboration. PAHO/WHO, in collaboration with key partners such as UNICEF and UNAIDS, will provide technical cooperation to countries, particularly those with major gaps and programmatic challenges to strengthen their efforts toward triple (HIV, syphilis, and hepatitis B) and quadruple EMTCT of HIV, syphilis, Chagas disease, and hepatitis B.
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