Path to Elimination
Countries with elevated background prevalence of HIV, syphilis and hepatitis B virus (HBV) among pregnant women may find it difficult to achieve elimination of mother-to-child transmission (EMTCT) validation targets, even if they have made considerable efforts to reduce MTCT. Countries in these situations can be recognized for their impressive achievements as they progress along the Path to Elimination (PTE).WHO developed a set of defining criteria for PTE in collaboration with the African Regional Validation Secretariat and with input from the Global Validation Advisory Committee. PTE recognizes three tiers of progress towards elimination, each with its own set of process and impact targets. The approach was agreed on during a series of consultations with countries in the African Region in 2016 and early 2017, and is published by WHO in the Global guidance on criteria and processes for validation: elimination of mother-to-child transmission of HIV, syphilis and hepatitis B virus. Path to Elimination of MTCT of hepatitis B virus (HBV) was incorporated into the global guidance in 2021.
Countries are expected to advance from one tier to the next over time, bringing them closer to, and ultimately reaching, elimination. This requires progressively increasing levels of service coverage for pregnant women and progressively lower HIV and/or syphilis case rates of new infections in children. Notably, for certification in all tiers, interventions must have been implemented in a manner consistent with protecting human rights, ensuring gender equality and engaging civil society.
A country seeking certification for PTE will follow the same procedure and complete the same assessment tools as a country requesting validation for EMTCT of HIV, syphilis and HBV. In 2021, Botswana became the first country to apply for PTE and received recognition for achieving the silver tier on the Path to Elimination.
High-burden countries
Many high-burden countries have made substantial progress in preventing new infections of HIV, syphilis and HBV in children. In some countries, new cases of HIV in children have reduced by more than 80% over the past 5 years, and several high-burden countries have achieved MTCT HIV rates below 5%. Due to the successful scale-up of antiretroviral treatment for HIV-positive pregnant women – resulting in improved maternal health and fertility in women living with HIV – prevalence rates among women of childbearing age are likely to remain stable in the near term.
Countries with high background prevalence of HIV, syphilis and HBV infection, are eligible for PTE and defined as those with maternal HIV prevalence above 2%, syphilis prevalence in pregnant women above 1% and general population prevalence of HBV above 5% and/or HBsAg prevalence among 5-year-olds above 1%.
Path to Elimination of MTCT of hepatitis B virus
The same principles apply for PTE of HBV. While the indicators on the PTE for HIV and syphilis are quite similar, there is global heterogeneity in the epidemiology of HBV and the implementation and coverage of key interventions for prevention of MTCT, especially HBV vaccination interventions (the birth dose and infant vaccination).
Since the HBV vaccine first became available almost 30 years ago, uptake of birth dose and infant vaccination has varied due to resource constraints, lack of political will and/or community awareness. Vaccination is a strong tool for preventing MTCT of HBV, but it takes time for a country to see results despite substantial efforts toward EMTCT. In countries unable to meet the elimination target at ≤ 0.1% HBsAg prevalence in ≤5-year-olds, PTE is a way to recognize country progress in the scale-up of infant HBV vaccination, with or without birth dose vaccination, to prevent MTCT of HBV.