Perspective

Integrating HIV, hepatitis B and syphilis

screening and treatment through the
Maternal, Newborn and Child Health
platform to reach global elimination targets
Joseph Woodring,a Naoko Ishikawa,a Mari Nagai,b Maya Malarski,c Yoshihiro Takashima,a Howard Sobel,b and
Ying-Ru Loa
Correspondence to Joseph Woodring (email: [email protected])

Every year, an estimated 180 000 babies in the Western Pacific Region are infected by hepatitis B, 13 000 by syphilis and
1400 by HIV through mother-to-child transmission.1 These infections can be largely prevented by antenatal screening,
treatment and timely vaccination for newborns. Despite challenges in controlling each disease, major achievements
have been made. National immunization programmes have reduced the regional hepatitis B prevalence from over 8%
in 1990 to 0.93% among children born in 2012. In addition, HIV testing and treatment have helped keep the regional
prevalence of HIV infections at 0.1%. In contrast, the number of maternal syphilis cases is still high in the Western Pacific
Region, with an estimated 45 million cases in 2012. Elimination of mother-to-child transmission of these infections
cannot be achieved through vertically applied programming and require using and augmenting to the shared Maternal,
Newborn and Child Health platform to coordinate, integrate and enable cost efficiencies for these elimination efforts.
The Regional Framework for Triple Elimination of Mother-to-Child Transmission of HIV, Hepatitis B and Syphilis in
Asia and the Pacific 2018–2030 offers such a coordinated approach towards achieving the triple elimination of mother-
to-child transmission of HIV, hepatitis B and syphilis and provides guidance for decision-makers, managers and health
professionals working in programmes addressing maternal, newborn and child health, HIV, hepatitis, sexually transmitted
infections and immunization.

T
he Regional Framework for Triple Elimination of Endorsed by the World Health Assembly in 2016,
Mother-to-Child Transmission of HIV, Hepatitis the 2030 elimination targets for the Global Health
B and Syphilis in Asia and the Pacific 2018– Sector Strategy on HIV 2016–2021, the Global Health
2
2030 (Triple Elimination Framework) was endorsed Sector Strategy on Viral Hepatitis 2016–2021 and the
by all Member States at the sixty-eighth session of the Global Health Sector Strategy on Sexually Transmitted
Regional Committee for the Western Pacific. It was Infections 2016–2021 include: 0.1% or lower hepatitis B
developed to provide a coordinated approach to achieve surface antigen (HBsAg) prevalence among children and
and sustain elimination of these largely preventable 50 or fewer cases per 100 000 live births for paediatric
infections using the shared Maternal, Newborn and HIV infections and congenital syphilis.3–5
Child Health (MNCH) platform for planning, service
delivery, monitoring and evaluation. With nearly nine These three diseases have a significant burden in
out of 10 mothers and children in this Region already the Western Pacific Region: the Region alone accounts
receiving antenatal, perinatal, postnatal and well-baby for 45% of all global hepatitis B infections;2 an increasing
care services, it is more efficient to build additional trend of syphilis infections is observed among key popula-
prevention services upon the shared platform than tions including women of reproductive age;6 and while
delivering them as single uncoordinated interventions HIV prevalence is low throughout the Region at 0.1%,
solely through traditional, vertical, disease-specific the HIV mother-to-child transmission (MTCT) rate is high
control and surveillance programmes. at 12%.7

a
Division of Communicable Disease, World Health Organization Regional Office for the Western Pacific, Manila, Philippines.
b
Division of Building Healthy Communities and Populations, World Health Organization Regional Office for the Western Pacific, Manila, Philippines.
c
Imperial College London, London, England.
Submitted: 25 September 2017; Published: 31 December 2017
doi: 10.5365/wpsar.2017.8.3.005

www.wpro.who.int/wpsar WPSAR Vol 8, No 4, 2017 | doi: 10.5365/wpsar.2017.8.3.005 1

Triple elimination of mother-to-child transmission of HIV, hepatitis B and syphilis Woodring et al Woodring et al Triple elimination of mother-to-child transmission of HIV, hepatitis B and syphilis

MNCH care has made significant progress in the dated in 2017.14 Several countries were already validated Fig. 1. Antenatal HIV and syphilis screening coverage and hepatitis B birth-dose coverage in eight countries in
Region. From 1990 through 2015, the maternal mortality as having achieved elimination. In this Region, EMTCT the Western Pacific Region
ratio decreased by 64% from 114 to 41 maternal deaths of HIV and syphilis has seen limited progress to date.
per 100 000 live births,8 in part due to the increases in With the target of a 90% reduction in new HIV infections
antenatal care coverage and births attended by skilled among infants by 2015, actual reductions have only been Syphilis screening coverage HIV screening coverage Hepatitis B birth dose coverage
birth attendants. Nearly nine in 10 pregnant women in the 27%.2 Maternal and congenital infections decreased
Region have attended at least one antenatal care visit and by one-third from 2008 to 2012; however, coverage of
have delivered in a health facility, while provision of quality 100
antenatal syphilis screening and treatment remains low in
services and access to at least four antenatal visits still several countries in the Region.15

Antenatal HIV, hepatitis B and

syphilis screening coverage
remain as challenges.9 DTP3 vaccine coverage for children 80
has remained over 95% since 2009 with 97.3% coverage Antenatal HIV and syphilis screening coverage and
in 2016.10 These multiple entry points in receiving peripar- hepatitis B birth-dose coverage were assessed between 60
tum services provide a unique opportunity for coordination October 2016 and June 2017 in 161 randomly selected
and integration of HIV, hepatitis B and syphilis interven- health facilities that had introduced Early Essential New-
40
tions to move towards elimination of mother-to-child born Care (EENC) in Cambodia, China, the Lao People’s
transmission (EMTCT) of these infections. Democratic Republic, Mongolia, Papua New Guinea, the
Philippines, Solomon Islands and Viet Nam. Account- 20
The Region has shown remarkable progress with ing for 97% of all neonatal deaths in the Region, these
national immunization programmes, reducing the regional eight countries have been selected as priority countries 0
HBsAg prevalence to less than 1% among children born since 2014 under the Action Plan for Healthy Newborn

Cambodia

China

Lao People’s
Democratic Republic

Mongolia

Papua New Guinea

Philippines

Solomon Islands

Viet Nam

Overall
in 2012. Not all countries met the 2012 or 2017 regional Infants in the Western Pacific Region (2014–2020).16
prevalence targets among 5-year-olds (less than 2% and Hepatitis B birth-dose vaccination has been promoted
less than 1%, respectively) or the regional 2017 mile- through EENC coaching to health workers dealing with
stones of 95% or higher hepatitis B birth dose and 95% intrapartum and postnatal care.17 Fig. 1 shows that
or higher hepatitis B third-dose vaccine coverage.11,12 hepatitis B birth-dose coverage was higher than syphilis
Thirty countries had evidence of meeting the 2012 goal and HIV antenatal screening coverage in seven of eight Country surveyed
of less than 2%; as of November 2017, 18 countries have countries, with China having 100% coverage for all
been verified as meeting the 2017 goal of less than 1%, three. This shows that coordination among the different
with five additional countries having evidence of meeting programmes can improve access to essential services for
this same goal. Introduction of additional interventions both women and their babies, while lack of collaboration programmes for better health outcomes for mother and The Triple Elimination Framework suggests a set
are likely to be required to reach the 0.1% HBsAg could result in limited access and inefficiencies. child.1 of key indicators under the headings of policy, impact
prevalence elimination target by 2030, including ante- and programme for monitoring and evaluating EMTCT.
natal HBsAg screening, antiviral treatment of pregnant Some countries in the Region have already begun Current interventions must be scaled up substantially, This includes eventually developing global guidance that
women with high viral loads and the use of hepatitis B pioneering a coordinated approach to triple elimination. other interventions introduced and coordination among incorporates hepatitis B into WHO established criteria for
immunoglobulin among infants born to HBsAg-positive For example, China has an EMTCT strategy that inte- programmes improved to achieve the global EMTCT tar- EMTCT of HIV and syphilis. The Triple Elimination Frame-
mothers.4 Modelling has shown that global elimination grates provision of the essential package of services for gets.1,13 In response, the Triple Elimination Framework pro- work will also need to be supplemented by an economic
of hepatitis B as a major public health threat can only universal HIV, hepatitis B and syphilis screening where poses a vision to provide every child the greatest chance to analysis of the introduction of additional interventions for
be achieved by scaling up hepatitis B vaccine third-dose all three tests are offered concurrently and free of charge. start a healthy life free of three preventable communicable EMTCT of hepatitis B. This is particularly pertinent for
coverage to 90% and birth-dose coverage to 80%, peri- Further interventions such as HIV and syphilis treatment, diseases. By better coordinating service delivery among countries with high hepatitis B vaccine birth-dose and
partum antivirals to 80% of hepatitis B e-antigen-positive including hepatitis B prophylaxis and follow-up testing and programmes and including the incorporation of hepatitis third-dose coverage rates that are looking to expand their
mothers and increasing testing and treatment to 80% care for mothers and their children are provided for free. B screening into existing HIV and syphilis screening at perinatal programmes.
of those eligible.13 To meet these suggested screening As a result, MTCT of HIV decreased to 6.7% in 2013, antenatal clinic, the Triple Elimination Framework looks to
and treatment targets, immunizations programmes must and over 1200 paediatric HIV infections were averted in integrate these programmes to enable pregnant women Moving towards triple elimination should result in
work with MNCH and sexually transmitted infection pro- 2014.18 Mongolia has developed national guidelines for to know their own and their partners’ infection status. It greater collaboration between programmes and thus
grammes through an integrated effort to reach hepatitis HIV, syphilis and hepatitis B and C antenatal screening, also allows pregnant mothers to understand and receive improve accessibility, effectiveness, efficiency and sus-
B EMTCT. recommending antiviral treatment of women with high the necessary interventions for themselves and their baby tainability of MNCH services for every woman, child and
viral loads and hepatitis B immunoglobulin to infants during pregnancy, delivery and postnatally and to ensure their family.
In 2014, WHO established the global criteria for born to these mothers. These underpin the importance that their babies receive these necessary interventions to
dual EMTCT of HIV and syphilis that were further up- of coordination and collaboration among concerned prevent transmission of these infections (Fig. 2).

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Pending WHO recommendations

Ethics statement Acknowledgements

The findings and conclusions in this report are those of The authors would like to acknowledge the multiple
the authors and do not necessarily represent the views Member States and experts who have critically reviewed
of the World Health Organization (WHO) or the WHO the Triple Elimination Framework.
regional offices.
References
Conflict of interest 1. Provisional agenda item 12. Triple elimination of mother-to-child
transmission of HIV, hepatitis B and syphilis. In: Sixty-eighth ses-
sion of the WHO Regional Committee for the Western Pacific, Bris-
None.
bane, Australia 9–13 October 2017. Manila: WHO Regional Office
for the Western Pacific; 2017 (http://www.wpro.who.int/about/re-
Funding gional_committee/68/documents/wpr_rc68_7_hiv_hepa_syphilis.
pdf, accessed 20 December 2017).
2. Regional framework for the triple elimination of mother-to-child
All authors are employees of the WHO and have not transmission of HIV, hepatitis B and syphilis in Asia and the Pa-
received outside funds to conduct this work. cific 2018–2030 [DRAFT]. Manila: WHO Regional Office for the

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