LETTERS
Contraception is the best kept secret for prevention of mother-to-child HIV transmission
Tricia Petruney; Elizabeth Robinson; Heidi Reynolds; Rose Wilcher; Willard Cates1
Family Health International, 2224 E Hwy 54, Durham, NC 27713, United States of America
We commend Stringer et al. for addressing the importance of developing and implementing a monitoring and evaluation model for measuring the effectiveness of prevention of mother-to-child HIV transmission (PMTCT) programmes.1 We also recommend broadening our PMTCT lexicon and developing additional metrics for preventing both HIV acquisition by uninfected women and unintended pregnancies among HIV-infected women.
The terms "PMTCT" or "PMTCT programmes" are almost exclusively used to refer to programmes that provide antiretroviral prophylaxis for HIV-infected pregnant women. This is the case despite the 2002 WHO and United Nations' recommendation of the following comprehensive approach for PMTCT programmes:
primary prevention of HIV infection;
preventing unintended pregnancies among HIV-infected women;
preventing HIV transmission from HIV-infected women to their children; and
providing care for HIV-infected mothers and their infants.2
Most PMTCT guidelines and programmes focus almost solely on the third approach: identifying HIV-infected pregnant women and providing antiretroviral prophylaxis. Fortunately, programmes that provide care and treatment for HIV-positive mothers and their infants are rapidly expanding and have their own monitoring and evaluation indicators. Unfortunately, far less attention is given to preventing vertical HIV transmission by preventing HIV acquisition by uninfected women or preventing unintended pregnancies to HIV infected women, despite their demonstrated contribution to PMTCT.3
We propose that we broaden our PMTCT lexicon to include the comprehensive PMTCT approach. A truly comprehensive PMTCT programme includes:
preventing HIV acquisition (in HIV-negative women);
preventing pregnancies in HIV-infected women who do not wish to become pregnant;
preventing HIV transmission (in the discordant maternal/child dyad); and
providing care for HIV-infected mothers, their infants and their families.
To complement our expanding lexicon, we need to evaluate the comprehensive PMTCT approach. This requires the measurement of each component. The absence of indicators for the prevention of HIV acquisition, for the fertility intentions of HIV-infected women, and for unintended pregnancies among HIV-infected women is a critical gap.
If the goal, set at the United Nations General Assembly Special Session on HIV/AIDS, of reducing infections in infants by 50% by 2010 is to be met, all four elements of the WHO/UN PMTCT strategy need to be implemented, assessed and measured for impact. 
References
1. Stringer EM, Chi BH, Chintu N, Creek TL, Ekouevi DK, Coetzee D, et al. Monitoring effectiveness of programmes to prevent mother-to-child HIV transmission in lower-income countries. Bull World Health Organ 2008; 86:57-62. PMID:18235891 doi:10.2471/BLT.07.043117
2. Strategic approaches to the prevention of HIV infection in infants. WHO meeting report, Morges, Switzerland, March 2002. Geneva: WHO; 2003. Available from: http://www.who.int/hiv/pub/mtct/en/StrategicApproachesE.pdf [accessed on 29 April 2008] .
3. Sweat MD, O'Reilly KR, Schmid GP, Denison J, de Zoysa I. Cost-effectiveness of nevirapine to prevent mother-to-child HIV transmission in eight African countries. AIDS 2004;18:1661-71. PMID:15280777 doi:10.1097/01.aids.0000131353.06784.8f
1 Correspondence to Willard Cates (e-mail: wcates@fhi.org).