A workshop on Prevention of HIV Mother-To-Child-Transmission organized by the DREAM program was held in Maputo from March 11thto the 15th, 2013. Attendees included medical doctors and medical practitioners, nurses, and public health expert representatives from a number of sub-Saharan African countries. The development of new international guidelines and a model of care based on the administration of Antiretroviral Triple Therapy to ALL HIV-positive pregnant women from early pregnancy until at least the weaning process, brings us closer to the goal of eliminating HIV vertical transmission. The results of our consensus workshop summary have been published.

1. In the last decade we have seen big developments in the field of Prevention of HIV Mother-To-Child Transmission. There is increasing awareness for the need of interventions that are broadly effective in preventing vertical transmission from pregnancy until the end of breastfeeding. The superiority of Combination Antiretroviral Therapy in lowering vertical transmission rates when compared to mono or dual therapy approaches has been clearly documented. The benefits of using Highly Active Antiretroviral Therapy (HAART) from pregnancy until the end of breastfeeding have   also been demonstrated in multiple studies. HAART is able to reduce vertical transmission to levels lower than 5% at 18-24 months of age, while also reducing Maternal Mortality and Infant Mortality Rates of HIV infected or exposed populations to levels seen in uninfected and unexposed individuals in Africa. The Options B/B+ are the most effective solutions for PMTCT in developing countries where cesarean section and formula feeding are not realistically feasible at the population level. Option B+ shows some advantages in terms of organization and protection of women’s health as well as reduction of HIV acquisition by uninfected partners as compared with Option B.
2. Critical to success of the Elimination of Mother-To-Child Transmission (EMTCT) programs in developing countries is the retention of patients in Care and their adherence to treatment protocols. On average no more than 50% of women in PMTCT programs complete the entire protocol. This is not only a matter of specific drug regimens or treatment protocols but mainly the model of care. In fact retention is primarily a matter of enhanced patient awareness regarding one’s own care and one’s realization of the significance of adherence in health maintenance.  
3. To increase retention and adherence, in the framework of the different country policies and health organizations as well as international guidelines, we must update the model of care through which we manage HIV and prevent Vertical transmission. Elements to be included in this model are :

1. Free Services: all services must be free-of-charge.
2. A secure supply chain for rapid test kits and ARV drugs must be in place.
3. The opt-out strategy for HIV counseling and testing must be in place in order to maximize the efficacy of the testing strategy
4. A comprehensive holistic family centred approach should drive the EMTCT service
5. Full integration of HIV EMTCT and ART care with ANC services in order to offer a full package of services according to international guidelines. This integration enables a safe birthing process and a healthy postpartum, with follow-up of women extended to the postpartum/ breastfeeding periods. 
6. Strategies which enable mothers to easily access EMTCT services (for example task shifting, mobile clinic) should be implemented.
7. Community support for continued adherence to EMTCT programs: it is crucial to help pregnant women to accept their HIV positivity and fully adhere to EMTCT protocols, supporting them from the time of diagnosis to the weaning of the infant and facilitating the partners’ involvement in care. Community Health Workers trained for this purpose are a powerful tool in increasing both retention and adherence rates.
8. EID is a pillar for support and encouragement of HIV+ mothers, providing the knowledge that their infant is negative, or otherwise ensuring early treatment to HIV infected babies. EID relying on Dried Blood Spot results must include timely turn-around times and reliability of results.
9. Nutritional assessment and assistance to mothers and infants is extremely important as proper nutrition remains one of the challenges in this setting.
10.  Supervision, monitoring and evaluation: timely supervision is crucial in order to assess impact and quality of programs. At the same time IT technology in order to support care and timely tracing of Loss-to-Follow up (if prior consent was obtained from patients), is a useful tool to enhance retention.

In conclusion we support the development of a comprehensive model to deliver EMTCT to urban, semirural and rural African sites in order to reach the aim of 0 new infections in our countries as soon as possible.

Signatories

Prof. Maria Cristina Marazzi

DREAM Program General Director

Esther Kuni Bonje MSc,

HIV Free NW, Project Manager Cameroon Baptist Convention Health Services – CAMEROON

Dr. Evelyne Ehua Amangoua,

Directrice de la Prévention du SIDA – Ministère de la Santé et de la lutte contre le SIDA – COTE D’IVOIRE

Prof Leonardo Palombi,

DREAM program Scientific Director,

Full Professor of Hygiene, Director of Biomedicine and Prevention Dept, University of Tor Vergata

ITALY

Dr Paola Germano,

DREAM Program General Coordinator

ITALY

Dr Gianni Guidotti

DREAM program General Secretary

ITALY

Prof Sandro Mancinelli

Associate Professor of Hygiene

Dept. of Biomedicine and Prevention, University of Tor Vergata, Rome

ITALY

Prof Pasquale Narciso

Infectious Disease Specialist

INMI Lazzaro Spallanzani, Rome

ITALY

Dr Andrea De Luca, MD,

Associate Professor of Infectious Diseases, Director, University Division of Infectious Diseases, Siena University Hospital, Siena

ITALY

Dr Giuseppe Liotta, MD, PhD

DREAM program Clinical Director,

Senior Researcher, Dept of Biomedicine and Prevention, University of Tor Vergata, Rome

ITALY

Mr Elard Alumando

DREAM program Country Director

MALAWI

Dr Ines Zimba

DREAM Country Director

MOZAMBIQUE

Dr Noorjeahn Abdul Magid

DREAM program Clinical Director

MOZAMBIQUE

Dr. Bernard Ngoy Belly Bossiky,

Secrétaire Exécutif National adjoint, Focal point ETME, Programme National Multisectoriel de Lutte contre le Sida

RDC

Mrs Precious Audia Robinson, Deputy Director:PMTCT National Dept. of Health

SOUTH AFRICA

Dr Eula Mothibi, Head: Health Services Cluster MBCHB; FCP (SA); Dip HIV Man – Khethimpilo

South Africa

Karin Nielsen, MD, MPH, Clinical Professor of Pediatrics, Director, Center for Brazilian Studies at UCLA Division of Infectious Diseases, David Geffen UCLA School of Medicine, Los Angeles

USA

Dr Kebby Musokotwane, Communicable Diseases Control Specialist, Provincial Medical Office,Livingstone

ZAMBIA