title: Prenatal Transmission of Syphilis and Human Immunodeficiency Virus in Brazil: Achieving Regional Targets for Elimination.
abstract: Background.  The Pan-American Health Organization has called for reducing (1) human immunodeficiency virus (HIV) mother-to-child transmission (MTCT) to ≤0.30 infections/1000 live births (LB), (2) HIV MTCT risk to ≤2.0%, and (3) congenital syphilis (CS) incidence to ≤0.50/1000 LB in the Americas by 2015. Methods.  Using published Brazilian data in a mathematical model, we simulated a cohort of pregnant women from antenatal care (ANC) through birth. We investigated 2 scenarios: "current access" (89.1% receive one ANC syphilis test and 41.1% receive 2; 81.7% receive one ANC HIV test and 18.9% receive birth testing; if diagnosed, 81.0% are treated for syphilis and 87.5% are treated for HIV) and "ideal access" (95% of women undergo 2 HIV and syphilis screenings; 95% receive appropriate treatment). We conducted univariate and multivariate sensitivity analyses on key inputs. Results.  With current access, we projected 2.95 CS cases/1000 LB, 0.29 HIV infections/1000 LB, 7.1% HIV MTCT risk, and 11.11 intrauterine fetal demises (IUFD)/1000 pregnancies, with significant regional variation. With ideal access, we projected improved outcomes: 1.00 CS cases/1000 LB, 0.10 HIV infections/1000 LB, HIV MTCT risk of 2.4%, and 10.65 IUFD/1000 pregnancies. Increased testing drove the greatest improvements. Even with ideal access, only HIV infections/1000 LB met elimination goals. Achieving all targets required testing and treatment >95% and reductions in prevalence and incidence of HIV and syphilis. Conclusions.  Increasing access to care and HIV and syphilis antenatal testing will substantially reduce HIV and syphilis MTCT in Brazil. In addition, regionally tailored interventions reducing syphilis incidence and prevalence and supporting HIV treatment adherence are necessary to completely meet elimination goals.
authors.affiliation: Divisions of General Medicine.
authors.forename: Rodrigo
authors.initials: R
authors.lastname: Cerda
authors.affiliation: Communicable Diseases and Health Analysis Department, HIV, Hepatitis, Tuberculosis and Sexually Transmitted Infections Unit, Pan American Health Organization, Washington DC.
authors.forename: Freddy
authors.initials: F
authors.lastname: Perez
authors.affiliation: Fundação Oswaldo Cruz , Instituto Nacional de Infectologia Evandro Chagas , Rio de Janeiro , Brazil.
authors.forename: Rosa Maria S M
authors.initials: RM
authors.lastname: Domingues
authors.affiliation: Fundação Oswaldo Cruz , Instituto Nacional de Infectologia Evandro Chagas , Rio de Janeiro , Brazil.
authors.forename: Paula M
authors.initials: PM
authors.lastname: Luz
authors.affiliation: Fundação Oswaldo Cruz , Instituto Nacional de Infectologia Evandro Chagas , Rio de Janeiro , Brazil.
authors.forename: Beatriz
authors.initials: B
authors.lastname: Grinsztejn
authors.affiliation: Fundação Oswaldo Cruz , Instituto Nacional de Infectologia Evandro Chagas , Rio de Janeiro , Brazil.
authors.forename: Valdilea G
authors.initials: VG
authors.lastname: Veloso
authors.affiliation: Communicable Diseases and Health Analysis Department, HIV, Hepatitis, Tuberculosis and Sexually Transmitted Infections Unit, Pan American Health Organization, Washington DC.
authors.forename: Sonja
authors.initials: S
authors.lastname: Caffe
authors.affiliation: Divisions of General Medicine ; Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston.
authors.forename: Jordan A
authors.initials: JA
authors.lastname: Francke
authors.affiliation: Divisions of General Medicine ; Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston ; Divisions of Infectious Diseases ; Department of Health Policy and Management , Harvard School of Public Health , Boston, Massachusetts.
authors.forename: Kenneth A
authors.initials: KA
authors.lastname: Freedberg
authors.affiliation: Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston ; Divisions of Infectious Diseases.
authors.forename: Andrea L
authors.initials: AL
authors.lastname: Ciaranello
keywords: congenital syphilis; disease elimination; human immunodeficiency virus; infectious disease transmission; mathematical models; vertical transmission