title: What will it take to eliminate pediatric HIV? Reaching WHO target rates of mother-to-child HIV transmission in Zimbabwe: a model-based analysis.
abstract: BACKGROUND
  The World Health Organization (WHO) has called for the "virtual elimination" of pediatric HIV: a mother-to-child HIV transmission (MTCT) risk of less than 5%. We investigated uptake of prevention of MTCT (PMTCT) services, infant feeding recommendations, and specific drug regimens necessary to achieve this goal in Zimbabwe.
  
  
  RESULTS
  We used a computer model to simulate a cohort of HIV-infected, pregnant/breastfeeding women (mean age, 24 y; mean CD4, 451/µl; breastfeeding duration, 12 mo). Three PMTCT regimens were evaluated: (1) single-dose nevirapine (sdNVP), (2) WHO 2010 guidelines' "Option A" (zidovudine in pregnancy, infant nevirapine throughout breastfeeding for women without advanced disease, lifelong combination antiretroviral therapy for women with advanced disease), and (3) WHO "Option B" (pregnancy/breastfeeding-limited combination antiretroviral drug regimens without advanced disease; lifelong antiretroviral therapy with advanced disease). We examined four levels of PMTCT uptake (proportion of pregnant women accessing and adhering to PMTCT services): reported rates in 2008 and 2009 (36% and 56%, respectively) and target goals in 2008 and 2009 (80% and 95%, respectively). The primary model outcome was MTCT risk at weaning. The 2008 sdNVP-based National PMTCT Program led to a projected 12-mo MTCT risk of 20.3%. Improved uptake in 2009 reduced projected risk to 18.0%. If sdNVP were replaced by more effective regimens, with 2009 (56%) uptake, estimated MTCT risk would be 14.4% (Option A) or 13.4% (Option B). Even with 95% uptake of Option A or B, projected transmission risks (6.1%-7.7%) would exceed the WHO goal of less than 5%. Only if the lowest published transmission risks were used for each drug regimen, or breastfeeding duration were shortened, would MTCT risks at 95% uptake fall below 5%.
  
  
  CONCLUSIONS
  Implementation of the WHO PMTCT guidelines must be accompanied by efforts to improve access to PMTCT services, retain women in care, and support medication adherence throughout pregnancy and breastfeeding, to approach the "virtual elimination" of pediatric HIV in Zimbabwe. Please see later in the article for the Editors' Summary.
authors.affiliation: Division of Infectious Disease, Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts, USA. aciaranello@partners.org
authors.forename: Andrea L
authors.initials: AL
authors.lastname: Ciaranello
authors.forename: Freddy
authors.initials: F
authors.lastname: Perez
authors.forename: Jo
authors.initials: J
authors.lastname: Keatinge
authors.forename: Ji-Eun
authors.initials: JE
authors.lastname: Park
authors.forename: Barbara
authors.initials: B
authors.lastname: Engelsmann
authors.forename: Matthews
authors.initials: M
authors.lastname: Maruva
authors.forename: Rochelle P
authors.initials: RP
authors.lastname: Walensky
authors.forename: Francois
authors.initials: F
authors.lastname: Dabis
authors.forename: Jennifer
authors.initials: J
authors.lastname: Chu
authors.forename: Asinath
authors.initials: A
authors.lastname: Rusibamayila
authors.forename: Angela
authors.initials: A
authors.lastname: Mushavi
authors.forename: Kenneth A
authors.initials: KA
authors.lastname: Freedberg
mesh_terms: D000293:Adolescent; D000328:Adult; D002648:Child; D002675:Child, Preschool; D003140:Communicable Disease Control / Q000331:legislation & jurisprudence / Q000706:statistics & numerical data*; D005260:Female; D015658:HIV Infections / Q000453:epidemiology / Q000635:transmission*; D015497:HIV-1 / Q000502:physiology; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D018445:Infectious Disease Transmission, Vertical / Q000517:prevention & control* / Q000706:statistics & numerical data; D008962:Models, Theoretical; D010372:Pediatrics / Q000379:methods; D011247:Pregnancy; D014944:World Health Organization; D055815:Young Adult; D015030:Zimbabwe / Q000453:epidemiology