Prevention of Mother-to-Child Transmission of HIV and Paediatric HIV Care and Treatment Monitoring: From Measuring Process to Impact and Elimination of Mother-to-Child Transmission of HIV
- 1.5k Downloads
Progress towards achievement of global targets for the prevention of mother-to-child transmission of HIV (PMTCT) and paediatric HIV care and treatment is an integral part of global and national HIV and AIDS responses. This paper documents the development of the global and national monitoring and reporting systems for PMTCT and paediatric HIV care and treatment programmes, achievements and remaining challenges. A review of the development of the monitoring and reporting process since 2002–2016 was conducted using existing published literature and taking into account changes in WHO HIV treatment guidelines, global HIV goals and targets, programmatic and methodological developments, and increased need for interagency partnerships, coordination and harmonization of global monitoring and reporting mechanisms. The number and type of indicators reported increased and evolved from monitoring of existence of national policies and guidelines, service delivery sites and trained health workers and coverage of PMTCT and paediatric HIV interventions to measuring outcomes and impact in reducing new HIV infections and AIDS related deaths, including efforts to validate elimination of mother-to-child transmission of HIV. These changes were required to mirror changes in WHO and national PMTCT and HIV treatment guidelines. The number of countries reporting PMTCT coverage increased from 53 in 2003 to over 130 in 2015. National monitoring processes have also expanded in scope and the capacity to report on disaggregated data by type of ARV regimen and for paediatric HIV care and treatment has increased. Monitoring of PMTCT and paediatric HIV programmes has contributed a rich body of evidence that helped monitor how quickly countries were adopting and implementing the latest WHO HIV treatment guidelines for pregnant and breastfeeding women and children. The reported data and experiences were instrumental in shaping global policies, national programmes, and investment choices.
KeywordsHIV AIDS PMTCT monitoring Paediatric HIV care and treatment Global and national monitoring
Background and Objectives
In 2000, member states committed to Millennium Development Goals (MDG) 4, 5, and 6 on health for women and children: reduce child mortality, improve maternal health and halt and begin to reverse the spread of HIV and AIDS by 2015 . At the United Nations General Assembly Special Session on HIV and AIDS (UNGASS) in 2001, member states further committed to reducing the proportion of infants infected by HIV by 20% by 2005 and 50% by 2010, and ensuring 80% of pregnant women accessing antenatal care should receive information, preventive services and treatment to reduce mother-to-child transmission of HIV, voluntary and confidential counselling and testing, access to treatment, especially antiretroviral therapy, and where appropriate, breastmilk substitutes and continuum of care . The High Level Global Partners Forum in Abuja, Nigeria in 2005 convened by the Inter-Agency Task Team on Preventing HIV Infection in Women, Mothers, and their Children (IATT), together with governments, donors and implementing partners resulted in a Call to Action for the Elimination of HIV Infection in Infants and Children . In the same year, the United Nations International Children’s Fund (UNICEF) and the Joint United Nations Programme on HIV/AIDS (UNAIDS) launched the global Unite for Children Unite against AIDS campaign to support universal access to treatment and address the impact of HIV and AIDS on children .
Since 2001, the HIV/AIDS monitoring and evaluation reference group (MERG), that brings together UN agencies, donors, implementing partners, government and civil society, played a critical role as a coordinating body for all HIV monitoring and a common and harmonized M&E framework for global and national reporting and monitoring of progress. More recently, the global community committed to the goal of eliminating paediatric HIV infections by 2015 . The Global Plan Towards the Elimination of New HIV Infections Among Children by 2015 and Keeping Their Mothers Alive adopted in 2011 (The Global Plan) includes a monitoring and evaluation (M&E) framework with specific targets, indicators and baselines against which progress is assessed . At the same time, the 2011 Political Declaration on HIV and AIDS: Intensifying Our Efforts to Eliminate HIV and AIDS included a target of elimination of mother to child transmission of HIV .
Since 2002, there has been unprecedented investment and efforts in developing harmonized global and national monitoring systems, reporting processes, and coordination mechanisms among UN organizations and key partners. The goal of this investment was to create data to inform policy, programming, track progress and ensure accountability of country results. This paper documents the development of monitoring and reporting systems for PMTCT and paediatric HIV care and treatment programmes. The paper also highlights some of the key achievements towards the global targets, outlines the challenges in data availability and quality, and proposes some areas for further strengthening and development in the monitoring of the HIV response in PMTCT and paediatric HIV care and treatment.
A document review of the MDGs, the UNGASS Declaration of Commitment, The Global Plan, the 2011 Political Declaration on HIV/AIDS, as well as, reports of high level meetings and IATT consultations was conducted to contextualize the basis and process of the establishment of the PMTCT and paediatric HIV care and treatment monitoring systems. Published M&E guidance on PMTCT and paediatric HIV care and treatment was reviewed to assess the evolving nature of the monitoring and evaluation system since 2002–2016, with specific emphasis on types of indicators and coordination mechanisms. Annual reports of comparable data on a set of core indicators by countries to UNAIDS, UNICEF and the World Health Organization (WHO), were also reviewed to assess progress towards achieving global and national goals and targets, as well as, data availability and quality. A review of published guidelines and reports on methodological and programmatic developments was done to assess advances in measuring PMTCT and paediatric HIV care and treatment programme outcomes and impact.
Global Coordination of PMTCT and Paediatric HIV Monitoring
Under the leadership of WHO and UNICEF, the IATT on PMTCT M&E formed in 2005 has played a major role in reviewing methodologies and technical issues and providing guidelines related to monitoring of PMTCT and paediatric HIV care and treatment . National and international experts and leading academic scholars have been involved in developing the internationally agreed definitions, classification, standards and recommendations for PMTCT and paediatric indicators. This work is undertaken through thematic sub-groups established within the IATT mechanism that brings together more than 30 specialized organizations and numerous experts.
WHO, UNICEF and UNAIDS ensure the coherence among existing global initiatives in the collection and compilation of HIV and AIDS data, including for PMTCT and paediatric HIV, ensure the harmonization of the M&E standards and methods for indicators and data collection, and the coordination of capacity building and technical assistance activities in countries for the production of high quality data and use at both global and country levels. The three United Nations (UN) organizations collaborate very closely with other key partners including the President’s Emergency Plan for AIDS Relief (PEPFAR) and the Global Fund for TB and Malaria (GFATM) and ensure harmonization of indicators, data, and processes.
Development of the process of monitoring PMTCT and paediatric HIV care and treatment programmes
2000 UNAIDS M&E guide for national programmes
2005-2008 UNICEF & WHO jointly facilitate country reporting and publications on behalf of the IATT
WHO, UNICEF, & UNAIDS joint reporting and publications under the universal access goals and on behalf of IATT
2011-2012 WHO, UNICEF & UNAIDS transition to a joint reporting and merged with UNGASS using an online excel-based reporting tool
2014 UNAIDS, WHO and UNICEF transition to the Global AIDS Response Progress Reporting (GARPR) online tool and publish the Global Plan progress report
2002 UNICEF initiates monitoring and reporting for PMTCT pilot countries
2006 WHO HIV treatment guidelines
2009 UNAIDS Monitoring the Declaration of Commitment on HIV/AIDS: Guidelines on construction of core indicators
2011 UNAIDS Global Plan M&E Framework;
2014 Option B + M&E Framework
2003 WHO PMTCT M&E guide
2007 UNAIDS Monitoring the Declaration of Commitment on HIV/AIDS: Guidelines on construction of core indicators
2010 WHO HIV treatment guidelines
2012 & 2013 UNAIDS Global Plan Progress reports
2015 WHO Consolidated Strategic Information Guidelines
2003, 2005 UNAIDS Monitoring the Declaration of Commitment on HIV/AIDS: Guidelines on construction of core indicators
2010 WHO PMTCT and paediatric HIV M&E guide for national programmes
2013 WHO HIV treatment guidelines
2014, 2015 & 2016 Global Plan progress reports
2011 WHO/UNICEF/UNAIDS Universal Access report
United Nations organizations also collaborate on reviewing, validating and analyzing country reported data with other key partners, mainly PEPFAR and the GFATM. The data are reviewed for consistency, gaps and any unusual spikes or drops in coverage levels for key indicators. In addition the data are triangulated with data submitted by countries on national HIV estimates files which require data on the number of pregnant women receiving antiretroviral medicine to prevent MTCT and children receiving antiretroviral therapy . The HIV estimates are generated annually by country teams and include estimates of the numbers of adults and children living with HIV, new HIV infections, AIDS-related deaths, as well as, mother-to-child transmission (MTCT) rates and the need for PMTCT. These estimates are currently used in the calculation of 8 of the 10 Global Plan indicators. These data are summarized and published in global reports by UN organizations .
Evolution of PMTCT and Paediatric HIV Monitoring and Evaluation Recommendations
Evolution of key PMTCT and paediatric HIV care and treatment indicators for monitoring and evaluation of the global and national responses
Phase 1: 2000–2005
Focus on process monitoring
Existence of guidelines on PMTCT; availability of trained health workers; number of health facilities providing PMTCT services; number of pregnant women tested for HIV and receiving their results; and number of HIV positive pregnant women receiving antiretroviral prophylaxis (ARVs) for PMTCT
Phase 2: 2006–2010
Emphasis on follow up and care of HIV positive pregnant women and postpartum mothers and their children
For mothers—use of more efficacious prophylactic regimens, assessment for ART eligibility; ART of eligible HIV-infected pregnant and breastfeeding women; family planning; disaggregation of ARVs for PMTCT by type of regimen
For children: cotrimoxazole prophylaxis, early diagnosis for HIV, ART for eligible; and exclusive breastfeeding
Phase 3: 2011–2013
Monitoring of lifelong ART to all HIV positive pregnant and breastfeeding women
Addition of new paediatric HIV infections; MTCT rate; AIDS-related maternal and child mortality; disaggregation by pregnancy status, and by timing of initiation of ARVs
Phase 4: 2014–2015
Monitoring of HIV cascade, including impact and EMTCT targets
Many countries were able to report PMTCT data by sub-national areas and on a 6-monthly basis. For ART a number of countries were able to report by more specific age groups
Additon of routine reporting of PMTCT outcomes, retention on ART, viral suppression for those on treatment; 50 or fewer new paediatric HIV infections per 100,000 live births and a transmission rate of either 5% or less in breastfeeding populations or 2% or less in non-breastfeeding populations
In the early 2000s (first phase) when PMTCT programmes were just starting in many countries, global PMTCT indicators focused on monitoring inputs, such as the existence of guidelines on PMTCT, the number of trained health workers, the number of health facilities providing services, the number of pregnant women tested for HIV and receiving their results, and the number receiving ARV prophylaxis. The indicators are summarized in the 2004 guidelines for monitoring and evaluation of PMTCT programmes developed by WHO and partners . The collection and reporting on these indicators was also included in the UNAIDS guidelines on Monitoring the Declaration of Commitment on HIV/AIDS of 2003 and 2005, which helped promote their use at country level [14, 15].
In the mid-2000s (second phase), as PMTCT interventions were scaling up, revised WHO guidelines in 2006 and 2010 called for an update of existing indicators, disaggregation, and development of new indicators. The focus shifted to monitoring follow-up and care of HIV positive pregnant and breastfeeding women, the use of more efficacious prophylactic regimens, HIV treatment of eligible HIV-infected pregnant and breastfeeding women, and unmet need for family planning among women living with HIV. Similarly, indicators for follow up and care of infants born to HIV positive mothers—cotrimoxazole prophylaxis, early diagnosis for HIV, access to paediatric ART and care, and exclusive breastfeeding—were also developed. In addition, the issue of potential double-counting was raised and explicitly addressed for the first time, calling for countries to review and develop mechanisms to minimize double counting and ensure reliable and consistent national data on multiple interventions across various service delivery platforms. Similarly, the UNAIDS guidelines on Monitoring the Declaration of Commitment on HIV/AIDS of 2007 and 2009 were updated to include the revised indicators [16, 17].
Aggregation of monthly or quarterly cross-sectional data often results in double-counting of women who access services in multiple facilities or multiple times at the same facility which could inflate national statistics. Retrospective cohort-based reporting was suggested as an alternative to aggregation of purely cross-sectional data. An important milestone during this phase was the recognition of the need to establish systems that can monitor linkages across service delivery clinics and sites. The interlinked patient monitoring tools for HIV care and ART, which outline a minimum data set and accompanying generic tools for data collection and reporting, were developed for country adaptation . The patient monitoring tools aimed to integrate PMTCT and paediatric HIV interventions within maternal and child health (MCH) service provision, and support and monitor the provision of tuberculosis (TB) prophylaxis and screening and TB-ART co-treatment within HIV services.
The third phase (2011–2013) commenced with the launch of the Global Plan which set the ambitious goal of eliminating mother-to-child transmission by 2015. Recognizing the importance of assessing the impact of PMTCT programmes, the Global Plan M&E Framework included four impact indicators—HIV incidence among children aged 0–14 years, mother-to-child transmission rate, AIDS-related maternal deaths and child deaths for children under five. The revised 2013 WHO Consolidated Guidelines on the Use of Antiretroviral Drugs for Treating and Preventing HIV Infection recommended the initiation of antiretroviral therapy (ART) for all pregnant and breastfeeding women with HIV and, in many settings, continuation on ART for life (known as Option B+). This called for further refinement of indicators to align with the new recommendations, particularly retention of HIV positive mothers and HIV-exposed and infected children in ART care and treatment to monitor quality of care and the impact of ART on MTCT. The guidelines also re-emphasized the need to disaggregate coverage of ARVs for PMTCT by type of regimen but also to monitor ART retention by pregnancy status to better assess quality of care, country progress in adoption of more efficacious regimens, and the impact on MTCT rates. Consequently, it became inevitable to ensure PMTCT monitoring is aligned with ART monitoring, and with maternal, new born and child health services.
In the fourth phase (2014–2015), countries started to move toward measuring the Global Plan goal of eliminating new paediatric HIV infections by 2015. It became imperative to revise or develop indicators and guidelines for monitoring retention, assessing impact, but also validating country progress. In 2014, the IATT PMTCT M&E working group developed guidance for operationalizing M&E for lifelong ART for pregnant and breastfeeding women and their infants and aligned with the 2013 WHO HIV treatment guidelines . The IATT PMTCT M&E guidelines recommend indicators for routine and enhanced monitoring and also for evaluating PMTCT programmes particularly in the early stages of rolling out lifelong ART for all pregnant and breastfeeding women, which is also aligned with the WHO 2015 consolidated strategic information (SI) guidelines for HIV in the health sector . The WHO 2015 SI guide brought together all of the separate health related HIV M&E guidelines into one, with emphasis on the HIV cascade and linkages across multiple services (prevention, diagnosis, care, treatment, quality and impact) for all population groups, including for pregnant women, children and adolescents. WHO, in collaboration with UNICEF, UNAIDS, United Nations Population Fund (UNFPA) and other partners developed guidance on criteria and process for validating EMTCT and syphilis . The guidance recommends two impact indicators for validating elimination of mother-to-child transmission (EMTCT) of HIV—50 or fewer new paediatric HIV infections per 100,000 live births and a final transmission rate of either 5% or less in breastfeeding populations or 2% or less in non-breastfeeding populations.
Compiling Data and Reporting on the Progress Achieved Towards the PMTCT and Paediatric HIV Care and Treatment Targets
At the UN General Assembly Special Session on HIV countries committed to report on their progress toward reversing and halting the HIV epidemic. UNAIDS and co-sponsors were given the mandate to support countries to report on progress toward the UNGASS targets. The UNGASS declaration included targets to reduce transmission of HIV to children by 20% in 2005, and by 50% in 2010. The UNGASS monitoring framework identified the indicators used to measure the UNGASS targets and included two indicators related to PMTCT—the proportion of women living with HIV receiving antiretroviral medicines to prevent transmission of HIV to their children and the proportion of children born to women living with HIV infected with HIV (modelled). Paediatric ART access was captured by disaggregating the HIV treatment coverage indicator by adults and children (under 15 years and over 15 years).
The remaining challenge is in ensuring availability of quality and complete data on all key interventions and outcomes. Few countries are able to systematically collect and report on complete reliable information on early infant diagnosis and more granular age disaggregated ART data for children. Most national monitoring systems have not been designed to report such data to the central level, even though these data may be available at the health facility level. Estimates for paediatric ART coverage were not published by UNAIDS in the early reports because of the challenges in estimating the number of children in need of ART. In 2010 the data were limited to countries with generalized epidemics with fewer estimation challenges. In 2015, estimating the number of children living with HIV and needing ART remains challenging especially in low level epidemics. A total of 54 countries were able to report on paediatric ART coverage, while 129 countries were able to report on the number of children receiving ART.
Since 2011 Progress Reports have been published to track progress toward the Global Plan. The impact indicators selected for monitoring the Global Plan—new HIV infections among children 0–14 years and MTCT rate—were highly reliant on models with little emphasis on developing routine monitoring systems to directly measure the impact of PMTCT programmes. Availability of programme coverage data to inform the modelled estimates, and in some countries sub-national estimates, provides insight on where the greatest gap is and which interventions are still lagging behind.
Discussion and Conclusions
The PMTCT and paediatric monitoring framework has strengthened information systems and fostered the use of data to improve programmes and ensure accountability by national governments and international organizations. Starting with fragmented global monitoring systems in the early 2000s, UNAIDS, WHO and UNICEF led the process of creating a coordinated and harmonized effort for HIV monitoring and reporting, including for PMTCT and paediatric HIV care and treatment. This resulted in reduced reporting burden on countries, created country ownership and accountability, and strengthened partnerships at both global and national levels, and brought coherence and harmonization in indicator definitions, guidelines, capacity building and technical support for M&E. The GFATM and PEPFAR key global and national monitoring indicators are now also harmonized with those of the UN organizations. While global monitoring and reporting among UN agencies has been harmonized, parallel reporting mechanisms and different timelines exist for PEPFAR and the GFATM.
The process of developing PMTCT and paediatric HIV care and treatment indicators and guidance has been inclusive and involved various organizations—UN organizations, multilaterals and bilaterals such as GFATM, United States Agency for International Development (USAID), Centers for Disease Control (CDC) and PEPFAR, international non-governmental organizations (NGOs), government representatives, civil society organizations (CSOs), people living with HIV and academia. The data collected jointly by UNAIDS, WHO and UNICEF are publicly available online on www.aidsinfo.unaids.org and also published in key reports, thus encouraging transparency and accountability. Many countries do not allow public access to their data, thus limiting analysis and use. Open and easily accessible data should be promoted to ensure government transparency and accountability and use of data for decision-making by government, citizens and other partners.
Monitoring of PMTCT and paediatric HIV programmes has also contributed to a rich body of evidence that has informed methodological and modelling processes. They have helped track the uptake of HIV treatment guidelines for pregnant and breastfeeding women, such as from less efficacious antiretrovirals (ARVs)—single dose nevirapine—to more efficacious simple to use lifelong combination ART of one pill a day, and HIV treatment for all children less than 5 years.
While availability of data on key indicators has dramatically increased, data quality for some of the indicators remains weak in a number of countries. Data incompleteness and inconsistencies in the values reported across indicators and time points are common. It is also difficult for countries to keep pace with frequent changes in WHO HIV treatment guidelines which may require revision of national monitoring systems and indicators every few years. The increased call for disaggregated and sub-national data is also making it difficult for countries to report data in the format that is required. In many countries ART data are only available in two broad age groups—under 15 years and over 15 years—making it difficult to assess progress in younger children and among adolescents. Reporting on ARVs for PMTCT regimens remains challenging since different regimens might be available in the same country, while patient registers do not allow for new regimen disaggregations. Similarly, the indicator on early infant diagnosis is often not reported accurately as the majority of children are tested beyond two months of birth, and even when the tests are conducted within two months, the average turnaround time for returning HIV test results is long and delays timely initiation of ART for those that need it. Countries will need support to strengthen the generation of relevant disaggregated data that can meaningfully inform targeting of limited resources to where there are most needed.
Currently, systems to monitor coverage indicators are well developed. However, few countries have established routine programme systems for monitoring the impact of PMTCT and paediatric HIV care and treatment programmes. Going forward, resources need to be mobilized and focused on developing robust routine monitoring systems to monitor new HIV infections and MTCT rates to the end of the breastfeeding period, including with maternal and child survival outcomes. Monitoring ART retention and postpartum follow up care for both HIV infected mothers and their infants remains critical to minimize new HIV paediatric infections occurring in the postnatal period.
Overall, the data reported and experiences have been instrumental in shaping global policies, programmatic shifts, investment choices, and to some extent, partnerships. However, additional investments are needed to develop robust routine national monitoring systems that address inequities and disparities and monitor progress towards the Sustainable Development Goals and the target of ending AIDS by 2030.
We wish to acknowledge all countries that submitted data to UNAIDS, WHO and UNICEF between 2000–2014 and that made the writing of this paper possible. We also thank members of the UNAIDS Indicator Working Group comprising many organisations from the UN, international agencies, governments, civil society, and government.
Compliance with Ethical Standards
Conflict of interest
All authors declare that they have no conflict of interest.
This article does not contain any studies with human participants or animals performed by any of the authors.
- 1.United Nations, Millenium Declaration, 6–8 Sept 2000. New York; 2000.Google Scholar
- 2.United Nations. Declaration of Commitment on HIV/AIDS, United Nations General Assembly Special Session on HIV/AIDS, 25–27 June 2001. New York; 2001.Google Scholar
- 3.Inter-Agency Task Team on Preventing HIV Infection in Women, Mothers, and their Children (IATT). Call to action for the elimination of HIV infection in infants and children, 1–3 Dec 2005. Abuja; 2005.Google Scholar
- 4.United Nations Children’s Fund. A call to action: children, the missing face of AIDS. New York: UNICEF; 2005.Google Scholar
- 5.UNAIDS. Countdown to zero. Global plan towards the elimination of new HIV infections among children by 2015 and keeping their mothers alive. Geneva, Joint United Nations Programme on HIV/AIDS, 2011. http://www.unaids.org/en/media/unaids/contentassets/documents/unaidspublication/2011/20110609_JC2137_Global-Plan-Elimination-HIV-Children_en.pdf. Accessed 29 Sept 2015.
- 6.WHO. Global monitoring framework and strategy for the Global Plan towards the elimination of new HIV infections among children by 2013 and keeping their mothers alive. World Health Organization, Geneva, 2012. http://www.who.int/hiv/pub/me/monitoring_framework/en/index.html. Accessed 29 Sept 2015.
- 7.United Nations. Political Declaration on HIV and AIDS: Intensifying Our Efforts to Eliminate HIV and AIDS, New York, 8 July 2011. http://www.unaids.org/sites/default/files/sub_landing/files/20110610_UN_A-RES-65-277_en.pdf. Accessed 29 Sept 2015.
- 8.The IATT is a consortium of over 30 organizations committed to give technical support to countries to achieve the goals of the Global Plan for EMTCT. The IATT, co-chaired by UNICEF and WHO, was established in 1998 and was reconfigured in 2010 to better support the Global Plan, with new sub-working groups and accountability mechanisms led by UNAIDS and PEPFAR.Google Scholar
- 9.Progress Report on the Global Response to the HIV/AIDS Epidemic, 2003. Joint United Nations Programme on HIV/AIDS, 2003. http://data.unaids.org/topics/ungass2003/ungass_report_2003_en.pdf. Accessed 3 Jan 2017.
- 10.Joint United Nations Programme on HIV/AIDS, 2015. http://www.unaids.org/en/dataanalysis/datatools/spectrumepp. Accessed 3 Jan 2017.
- 11.See Various Reports in UNICEF: www.childrenandaids.org, https://data.unicef.org/topic/hivaids/global-regional-trends/; WHO: http://www.who.int/hiv/pub/en/; UNAIDS: http://www.unaids.org/en/resources/documents/; and UN: http://www.un.org/millenniumgoals/reports.shtml. Accessed 3 Jan 2017.
- 12.WHO. Global Guidance on Criteria and Processes for Validation: Elimination of Mother-to-Child Transmission of HIV and Syphilis. Geneva, Switzerland; 2014.Google Scholar
- 13.WHO. National Guide to Monitoring and Evaluating Programmes for the Prevention of HIV in Infants and Young Children, 2004. http://www.who.int/hiv/pub/me/youngchildren/en/. Accessed 3 Jan 2017.
- 14.UNAIDS. Monitoring the Declaration of Commitment on HIV/AIDS: Guidelines on Construction of Core Indicators. Geneva, Switzerland; 2003.Google Scholar
- 15.UNAIDS. Monitoring the Declaration of Commitment on HIV/AIDS: Guidelines on Construction of Core Indicators. Geneva, Switzerland; 2005.Google Scholar
- 16.UNAIDS. Monitoring the Declaration of Commitment on HIV/AIDS: Guidelines on Construction of Core Indicators. Geneva, Switzerland; 2007.Google Scholar
- 17.UNAIDS. Monitoring the Declaration of Commitment on HIV/AIDS: Guidelines on Construction of Core Indicators. Geneva, Switzerland; 2009.Google Scholar
- 18.WHO. Three interlinked patient monitoring systems for HIV and TB/HIV: Standardized minimum data set and illustrative tools. Geneva, Switzerland; 2013.Google Scholar
- 19.Inter-agency Task Team on the Prevention and Treatment of HIV Infection in Pregnant Women, Mothers and Children. Monitoring & Evaluation Framework for Antiretroviral Treatment for Pregnant and Breastfeeding Women Living with HIV and Their Infants. CDC, WHO and UNICEF. New York; March, 2015.Google Scholar
- 20.WHO. Consolidated Strategic Information Guidelines for HIV in the Health Sector. Geneva, Switzerland; 2015.Google Scholar
- 21.WHO. Global guidance on criteria and processes for validation: elimination of mother-to-child transmission (EMTCT) of HIV and syphilis. Geneva, Switzerland; 2014.Google Scholar
- 22.The 21 sub-Saharan Africa Global Plan countries are Angola, Botswana, Burundi, Cameroon, Chad, Côte d’Ivoire, Democratic Republic of the Congo, Ethiopia, Ghana, Kenya, Lesotho, Malawi, Mozambique, Namibia, Nigeria, South Africa, Swaziland, Uganda, United Republic of Tanzania, Zambia and Zimbabwe.Google Scholar
- 23.Joint United Nations Programme on HIV/AIDS. http://aidsinfo.unaids.org/. Accessed 29 Sept 2015.
- 24.UNICEF. Re-analysis of UNAIDS 2016 HIV and AIDS Estimates, July 2016.Google Scholar
- 25.UNICEF. Re-analysis of UNAIDS 2016 HIV and AIDS Estimates, July 2016.Google Scholar
- 26.UNAIDS. Methods for Deriving UNAIDS Estimates. Geneva; 2016. http://www.unaids.org/sites/default/files/media_asset/2016_methods-for-deriving-UNAIDS-estimates_en.pdf. Accessed 29 Sept 2016.
- 27.Reporting on postnatal ARVs for PMTCT remains problematic due to weak national monitoring systems. Even though postnatal ARVs is happening less, there is also the problem that it is just not being reported, and that shows up as very low or 0 in the modelled estimates. Hence higher postnatal HIV transmission rates could be partially an artifact of lack of data availability. Also the data reflect provision and not adherence, so while women receive ARVs, some of them actually may not be adhering as reflected in low retention rates.Google Scholar
- 28.UNAIDS, UNICEF and WHO. Global AIDS Response Progress Reporting Databases, 2015.Google Scholar
Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.