June 2015

In Cuba, less than 2% of children whose mothers have HIV are born with the virus, the lowest rate possible with prevention methods available today. As a result, Cuba recently received formal validation from PAHO/WHO that it has eliminated mother-to-child transmission of HIV.

Yunaisy found out she was HIV-positive before her third pregnancy, during a routine check-up at the Bernardo Posse health center in the San Miguel del Padrón district of Havana, Cuba. Knowing that she was living with HIV did not stop her from wanting to have another baby. "All I wanted was for my baby to be born healthy," she says. And he was.

Mother and baby girl
A mother and her baby during a routine medical visit, in Havana, Cuba.

The doctors and nurses who attended her followed a series of steps to prevent transmission of the HIV virus to her baby during pregnancy, childbirth, and lactation. After testing for and confirming the virus, they prescribed antiretroviral therapy and, with her consent, scheduled a caesarean section for her 38th week of pregnancy. After delivery, they gave her newborn baby, Raúl Antonio, medication as well and then followed him up with periodic check-ups until he was 18 months old. His mother followed the doctor's recommendation not to breastfeed him when she learned that breast milk could transmit HIV to her baby. Instead, she used a milk formula.

Yunaisy is one of more than 2600 Cuban women aged 15-49 living with HIV who can now bring a child into the world without the virus. Since 2012, Cuba has registered 1-2 cases of pediatric HIV per year, a figure so low that transmission is considered to have been eliminated (because fewer than 2% of babies born to HIV-positive mothers are infected - the lowest rate possible with current prevention means). This achievement earned Cuba recognition from WHO as the first country in the world to eliminate mother-to-child transmission of HIV and congenital syphilis.

María Isela Lantero, head of Cuba's national STI/HIV/AIDS program, attributes the achievement to the country's elimination strategy and an "accessible, free, universal health system that enables us to reach everyone and ensure that they receive services to prevent these diseases."

According to Lantero, all pregnant women on the island normally have at least 10 prenatal check-ups. They are offered HIV and syphilis testing in the 3 trimesters of their pregnancy and given information on prevention of sexually transmitted diseases along with family planning counseling and access to condoms.

In Cuba, 98.6% of HIV-positive pregnant women and 100% of exposed babies had received treatment in 2013, according to the latest available official data for that year. "Drugs are provided free of charge in the pharmacy," said Dr. Raisa Montero López, who sees Yunaisy at the Bernardo Posse polyclinic. "Every month, she or a family member comes for the drugs with a card that doesn't bear the patient's name, to keep the diagnosis confidential. The card is also a way to monitor compliance with treatment."

A historic achievement

It was in late June 2015 that Cuba became the first country in the world to receive WHO validation of the elimination of mother-to-child (vertical) transmission of HIV and congenital syphilis. The validation process was extensive and included the preparation of a country report on the status of both diseases, a mission to Cuba by a regional committee of independent experts convened by the Pan American Health Organization (PAHO), and a review by a global validation committee, which recommended that WHO Director-General Margaret Chan confirm elimination.

The process also led to validation of Cuba's elimination of vertical transmission of syphilis. Syphilis is an old disease, but one easily eliminated with proper treatment. Cuba's achievement consists of registering fewer than 0.5 syphilis cases per 1000 live births per year. Between 2012 and 2013, the country reported 3 cases of congenital syphilis (zero in 2012 and 3 in 2013, for infection rates of zero and 0.02, respectively).

Eva Correa, a dermatologist at the Bernardo Posse polyclinic, sees pregnant women who test positive for syphilis and are referred to her by physicians and by nurses specialized in HIV and STIs known in Cuba as "survey nurses" (enfermeras encuestadoras).

"Here we see the patient, interview her, conduct a physical examination, start her on treatment, and explain that all this is done so that her child is not born with congenital syphilis," Correa said. Congenital syphilis, transmitted to newborns by their mothers, can cause severe health problems in children.

Correa explained that after a woman with syphilis gives birth, she is monitored for 2 years. Testing determines the status of the baby, who may be started on a 10-day treatment. "At this polyclinic we have not had a single baby born in this situation," she said.

Cuba's strategy for achieving elimination consisted of offering pregnant women syphilis tests in the 3 trimesters of pregnancy, treating positive cases, and also testing and treating their partners and newborns. Women are examined when they are admitted for delivery. According to official data for 2013, 99.3% of pregnant women were tested to determine their status, and over 97.8% of positive cases were treated.

"By eliminating the transmission of these diseases, Cuba is showing the world that the health of mothers and newborns is a priority and that it is possible to stop the transmission of the HIV epidemic to new generations," said Marcos Espinal, director of PAHO/WHO's Department of Communicable Diseases and Health Analysis. Other critical factors, he said, are the "strong integration" of Cuba's health system and "the synergy between the Ministry of Public Health's HIV program and its maternal and child health program, which has been key to achieving elimination."

In addition to Cuba, other countries that may also have successfully eliminated these diseases and that may be in a position to request WHO validation include Anguilla, Barbados, Canada, Montserrat, Moldova, Puerto Rico, Thailand, and the United States of America.

Since 2010, PAHO/WHO has collaborated with the countries of the Americas to implement a regional initiative for the elimination of mother-to-child transmission of HIV/AIDS and congenital syphilis. In 2013, 2324 children were born with HIV in Latin America and the Caribbean, 45% less than in 2010. "We need to make even greater efforts so that no child in our region is born with HIV or syphilis," Espinal said.

Meanwhile, little Raúl Antonio remains healthy, showing that the goal of having boys and girls throughout the Americas born free of HIV and syphilis is an achievable goal.