A triple impact approach to reduce mother-to-child transmission

July 21, 2023 by Ha Nguyen

PATH, The Hepatitis Fund, and the City of Geneva have teamed up on an innovative approach to combat hepatitis B, HIV, and syphilis in Vietnam.

A health provider and client at Dien Hanh Commune health station in Dien Chau District, Nghe An Province. Photo: Nguyen Thai Ha/PATH.

A health provider and client at Dien Hanh Commune health station in Dien Chau District, Nghe An Province. Photo: Nguyen Thai Ha/PATH.

Mothers who are infected with hepatitis B virus (HBV), HIV, or syphilis can pass these viruses to their babies during pregnancy, childbirth, or while breastfeeding—called mother-to-child transmission. Each year, more than 180,000 newborn babies in the Asia-Pacific region are infected with HBV, 13,000 are infected with syphilis, and 1,400 are infected with HIV through mother-to-child transmission.

Since 2019, Vietnam has endorsed the World Health Organization’s global triple elimination initiative, which seeks to eliminate mother-to-child transmission (EMTCT) for HBV, HIV, and syphilis.

Mother-to-child transmission can often be prevented through simple and effective interventions. For example, adequate diagnosis and treatment of chronic HBV during pregnancy can reduce mother-to-child transmission of HBV by more than 95 percent and break the cycle of transmission across generations. Additionally, vaccinating newborns against HBV in the first 24 hours after birth, plus an additional two doses at 1 month and 6 months of age, can prevent children from getting HBV even if their mothers were HBV-positive during pregnancy.

Screening mothers for all three diseases—HBV, HIV, and syphilis—is a crucial first step to link mothers to lifesaving treatments and treatments that can help prevent mother-to-child transmission of these diseases. However, screening pregnant women for these diseases is not a standard component of maternal, newborn, and child health (MNCH) or antenatal care services in Vietnam. As a result, there is a gap in understanding of the true incidence of HBV, HIV, and syphilis among pregnant women in Vietnam.

PATH teamed up with partners to demonstrate a scalable and cost-effective model for preventing mother-to-child transmission of HBV, HIV, and syphilis among pregnant women through early screening and treatment, supporting national and global triple elimination goals.

Partnering for integrated testing and treatment

Together with The Hepatitis Fund and the City of Geneva, and with additional co-financing from private-sector partners, PATH deployed a decentralized, integrated, and coordinated model of combined universal screening for HBV, HIV, and syphilis in Nghe An—Vietnam’s largest province by area, with a total population of more than 3.5 million people.

Launched in 2022, this three-year initiative aims to showcase effective approaches for integrating early screening and treatment of HBV, HIV, and syphilis within MNCH services alongside enhanced HBV vaccination at birth and hepatitis B immunoglobulin (HBIG) provision. The model is currently being implemented at commune health stations, private health facilities, and district hospitals in two districts of Nghe An, where uptake of HBV, HIV, and syphilis testing among pregnant women is low.

Building the triple EMTCT model required a three-pronged approach.

First, PATH trained and supported health staff at 12 sites to offer information and testing for all three diseases to pregnant women and then rapidly link those who test positive to treatment and follow-up care.

Second, PATH worked with private-sector diagnostics suppliers (such as Abbott and AMV Group) and service providers (such as Medlatec and Thai Hoa Lab) to deploy different approaches for more effective and efficient diagnosis and treatment. This included using dual HIV/syphilis test kits, testing for all three diseases with one blood sample, and offering a hepatitis B e-antigen diagnostic test where HBV DNA testing is not available.

Third, the project engaged pregnant women to promote early screening for HBV, HIV, and syphilis as a critical measure to prevent transmission to their babies and subsequently improve their child’s health and well-being early on.

Question and answer booklet to provide information to pregnant women on HIV and the triple elimination of mother-to-child transmission model.

Question and answer booklet to provide information to pregnant women on HIV and the triple elimination of mother-to-child transmission model.

Early screening has saved lives

Before the project launched, most facilities only offered HBV, HIV, and syphilis screening in the third trimester of pregnancy or right before delivery, which can be too late to prevent mother-to-child transmission.

Now, equipped with training and resources for efficient and effective diagnosis, participating facilities have screened more than 93 percent of women in the first or second trimester.

“In the first quarter of the project, most of the pregnant women getting tested were between 22 and 25 weeks of pregnancy, but by the second quarter, the majority were between 13 and 14 weeks of pregnancy. This is the best period for early screening and treatment as it enables those with reactive test results to be counseled and started on treatment, and ensures newborns receive preventive care immediately,” said Dr. Tran Thi Huong, a health provider who works at a primary health care clinic in Dien Chau District.

Since the project launched, the clinic where Dr. Tran Thi Huong works has organized several communication sessions on HBV, HIV, and syphilis that promoted free testing and care.

By integrating and decentralizing HBV, HIV, and syphilis testing within antenatal care services pregnant women routinely seek, the triple EMTCT model has saved lives. Between July 2022 and June 2023, nearly 2,700 women learned their HBV, HIV, and syphilis status, and 21 women were linked to lifesaving treatment for HBV.

Phuong Vo* was one of these women.

When Phuong received HBV testing and was diagnosed right before going into labor, she was worried. She learned from her doctor that infants born to HBV-infected mothers are at very high risk of acquiring HBV infection at or around the time of birth.

However, her doctor—who had received training through the project—quickly jumped into action. Following the delivery, they provided her newborn with its first hepatitis B vaccine and HBIG doses within 12 hours of birth.

A health care worker speaks with a client about HBV, HIV, and syphilis at Dong Hieu Commune health station in Thai Hoa Town. Photo: Ha Nguyen/PATH.

A health care worker speaks with a client about HBV, HIV, and syphilis at Dong Hieu Commune health station in Thai Hoa Town. Photo: Ha Nguyen/PATH.

Today, Phuong is receiving treatment to prevent liver cancer and cirrhosis that can result from chronic HBV infection as well as close follow-up care from health staff to monitor her baby’s HBV status. Phuong’s baby is 1 of 36 newborns that has received a lifesaving HBV vaccination and HBIG dose at birth with support from the project.

“HBV birth-dose vaccination and HBIG for infants born to mothers living with HBV are essential interventions to reduce incidence of HBV. In combination, these interventions reduce the risk of mother-to-child HBV transmission to just 1 in 20,” said Dr. Bao Ngoc Vu, PATH Vietnam Senior Technical Director, HIV, TB, and Viral Hepatitis. “This intervention is impactful in preventing new infections and averting premature deaths as it did for Phuong and her baby.”

Toward integrated, person-centered care

Evidence generated from implementing the triple EMTCT model in Nghe An will be used to establish a comprehensive evidence base to advocate for financing and programming toward universal access to HBV, HIV, and syphilis screening and care. This includes integrating HBV, HIV, and syphilis screening as a core part of Vietnam’s MNCH and primary health care services and ensuring its coverage in social health insurance structures.

PATH is now working to source additional funding through private and public sources to expand the triple EMTCT model to an additional district of Nghe An.

PATH is also supporting additional models to integrate and bundle care to increase health care access and uptake among underserved populations. For example, the PEPFAR-funded USAID/PATH STEPS project provides a comprehensive package of HIV, viral hepatitis, sexually transmitted infection, and other health care services through community-led, one-stop-shop clinics in Hanoi and Ho Chi Minh City that primarily serve gay men and transgender people.

Additionally, PATH and private-sector partners are working together to introduce innovative diagnostics that will further improve health care access and convenience, including HIV self-testing and partner testing; all-in-one multiplex testing for HBV, HIV, and syphilis; and point-of-care HBV viral load testing.

The triple EMTCT model is building momentum toward improving access to these simple yet lifesaving tools.

With earlier screening and expanded access to diagnostics and treatment, pregnant women in Vietnam are part of the movement to end mother-to-child transmission of HBV, HIV, and syphilis. Providing pregnant women with the need-to-know information and appropriate treatment early on is a simple and effective way to improve well-being among mothers and their children—one approach, triple the impact.

*Client name has been changed to protect their privacy.