should breast feed and receive ARVs or avoid all breast feeding with the goal of achieving maximum HIV-free survival for the child. When breast feeding is the best option, it should be exclusive for the first 6 months and then continued with the introduction of appropriate complementary foods; breast feeding should continue until the infant is 12 months of age (WHO, 2010a). In 2012 WHO released a programmatic update to its 2010 guidelines, which included a new third option called Option B+. Option B+ includes the same recommendations for prophylaxis but suggests that ARV treatment for women be continued beyond pregnancy regardless of CD4 count (WHO, 2012a).
UNAIDS has set a goal of increasing coverage to 90 percent of HIV-positive women with WHO-recommended regimens with the target of decreasing the number of children infected annually to fewer than 43,000 (WHO, 2011). PMTCT programs have expanded over time and are present in most low- and middle-income countries. WHO estimated that only 10 percent of the world’s HIV-positive women had access to PMTCT services in 2004 (WHO, 2008a). The subsequent scale-up in global resources contributed to an increase in PMTCT coverage, and in 2010 an estimated 35 percent of pregnant women in low- and middle-income countries received HIV testing and counseling, with coverage of counseling and testing for pregnant women increasing from an estimated 35 percent to 42 percent between 2009 and 2010 in sub-Saharan Africa (WHO, 2011). In 2009 an estimated 53 percent of pregnant women living with HIV in low- and middle-income countries received antiretroviral medication to prevent MTCT of HIV, up from an estimated 45 percent in 2008 (WHO, 2010b).
There are few countries that provide access to services for at least 80 percent of pregnant women, the target given in the commitment document released following the 2001 UNGASS session (United Nations, 2001; WHO, 2011). Challenges to reaching this goal include establishing services in health systems that are not optimally staffed; ensuring a reliable supply chain for diagnostics and ARVs; and having the essential funds to support the necessary costs of implementation (UNAIDS, 2011). The knowledge of how to virtually eliminate pediatric HIV transmitted from mother-to-child currently exists; the greatest gap is in providing access to services. Figure 5-3 illustrates the cascade of services that, if available and accessible to pregnant women, can maximize children’s HIV-free survival and improve maternal health (Stringer et al., 2008).