Two steps forward, one step back

As the global community moves forward in implementing the 2030 Agenda for Sustainable Development, it is important that we learn from past challenges, especially those related to effectively reaching the people who are furthest behind.

We greatly appreciated the commentary by Drs. Wu and Hawkes (1) on our article on the Global burden of maternal and congenital syphilis in 2008 and 2012: a health systems modelling study (2) and fully agree that political will is instrumental in achieving dual elimination of mother-to-child transmission (MTCT) of HIV and syphilis. Our colleagues remarked on the “upsurge in global and national interest in controlling MTCT of syphilis that was spurred by its close alignment with the similar global goal of eliminating MTCT of HIV” (1). This interest and alignment was directly linked to evidence of continued congenital syphilis burden and the ability of countries to measure progress toward elimination. As is described in their commentary, inclusion of three core indicators into the Global AIDS Response Progress Reporting (GARPR) database in 2008 allowed, for the first time, measurement of outcomes and monitoring of national and regional progress in eliminating MTCT of syphilis, as has been done for many years in eliminating MTCT of HIV (2,3). That body of evidence, based upon country-reported data, allowed (quoting Wu and Hawkes) “accountability if national governments deem the global commitment as legitimate and comply with it” (1,4).

Our colleagues were particularly concerned about the marked disparity in progress in Sub-Saharan Africa, the region that is most affected by syphilis as well as HIV, compared with other regions of the world. From 2009 to 2013, in 21 prioritized African countries, coverage of antenatal care services increased to 83%, HIV testing coverage increased to 45%, and treatment coverage of pregnant women with HIV increased to 68% (5). However, syphilis testing coverage in pregnant women declined from 57% to 38% in these countries. Seeking a solution to this dilemma, Wu and Hawkes drew attention to the case of China, where in 2010 the joint efforts of the policy communities working on HIV and syphilis were able to influence national decision makers to reframe the two infections, HIV and syphilis, together as “threatening the physical and mental health of a large number of women” (1,6). China’s approach, using program and cost-effectiveness data to influence decision makers, is one that could be used by other countries to achieve elimination of MTCT of HIV and syphilis (7). Based on success of this integrated model promoting quality antenatal services that support women and children’s health, China initiated prevention of MTCT of hepatitis B through an expanded program aimed at triple elimination of HIV, syphilis and hepatitis B (8).

It was therefore more than disheartening to learn—just as member states attending the June 2016 United Nations (UN) General Assembly High-Level Meeting on Ending AIDS committed to “taking all appropriate steps to eliminate new HIV infections among children… (and) dual elimination with congenital syphilis” (1,9)—that decision makers at UNAIDS have elected to discontinue collection of six critical indicators in the Global AIDS Monitoring (formerly GARPR) surveillance system that are needed to measure country and global progress toward elimination of MTCT of HIV (Table 1) (10,11). Lack of country-reported data on HIV testing in pregnancy and perinatal transmission will cripple the ability of the global health community and affected countries to measure ongoing progress in PMTCT, the flagship program that has forged the way to “Getting to Zero”. This lack of indicator data is anticipated to particularly affect Sub-Saharan Africa, which accounts for most MTCT transmission of HIV but has made such remarkable progress over the past decade. We worry that the disparities noted by Wu and Hawkes in program coverage for HIV and syphilis screening and treatment among pregnant women and infants may diminish further beyond already low levels.

The dual elimination of MTCT of HIV and syphilis specifically addresses Sustainable Development Goals (SDGs) 3 and 5 and has broad reaching impacts across all SDGs given their inherent focus on gender equality and the empowerment of women and girls. Integration of HIV and reproductive health services such as prenatal syphilis screening is a pragmatic and cost-effective approach to achieving maternal and child health goals, and has been found particularly effective in areas where access to health care may be limited (3,7). Lack of funding for reproductive health services (including prevention of sexually transmitted infections) greatly affects women and children. Losing critical MTCT of HIV indicators will inhibit realization of the dual elimination goals by making it more difficult to assess progress, identify areas that need improvement and demonstrate the cost-effectiveness of integrated approaches that have been proven effective in countries such as China. As pointed out by Wu and Hawkes, unification of efforts and alignment of global goals requires sustained political commitment, but this is unlikely to come without reliable data upon which to measure progress.

Acknowledgments

Funding: None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Journal of Public Health and Emergency. The article did not undergo external peer review.

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at http://dx.doi.org/10.21037/jphe.2017.05.06). The findings and conclusion in this report are those of the author(s) and do not necessarily represent the official position of the Centers for Disease Control and Prevention.The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

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References

1. Wu D, Hawkes S. Eliminating mother-to-child transmission of syphilis: the need for more consistent political commitment. J Public Health Emerg 2017;1:19. [Crossref]
2. Wijesooriya NS, Rochat RW, Kamb ML, et al. Global burden of maternal and congenital syphilis in 2008 and 2012: a health systems modelling study. Lancet Glob Health 2016;4:e525-33. [Crossref] [PubMed]
3. UNAIDS. Global plan towards the elimination of new HIV infections among children by 2015 and keeping their mothers alive. Joint United Nations Programme on HIV/AIDS (UNAIDS), Geneva (2011). Available online: http://www.unaids.org/en/media/unaids/contentassets/documents/unaidspublication/2011/20110609_JC2137_Global-Plan-Elimination-HIV-Children_en.pdf
4. Taylor A, Alfoén T, Hougendobler D, et al. Nonbinding Legal Instruments in Governance for Global Health: Lessons from the Global AIDS Reporting Mechanism. J Law Med Ethics 2014;42:72-87. [Crossref] [PubMed]
5. World Health Organization. Global update in the health sector response to HIV, 2014. (World Health Organization), Geneva (2014). Available online: http://www.who.int/hiv/pub/global-update.pdf
6. Ministry of Health, People's Republic of China. Report on Women and Children's Health Development in China (2011). Available online: http://unpan1.un.org/intradoc/groups/public/documents/apcity/unpan051019.pdf
7. Owusu-Edusei K Jr, Tao G, Gift TL, et al. Cost-effectiveness of integrated routine offering of prenatal HIV and syphilis screening in China. Sex Transm Dis 2014;41:103-10. [Crossref] [PubMed]
8. Wu D, Hawkes S, Buse K. Prevention of mother-to-child transmission of syphilis and HIV in China: What drives political prioritization and what can this tell us about promoting dual elimination? Int J Gynaecol Obstet 2015;130:S32-6. [Crossref] [PubMed]
9. United Nations General Assembly, Political Declaration on HIV and AIDS: On the Fast-Track to Accelerate the Fight Against HIV and to End the AIDS Epidemic by 2030. 08 June 2016. Available online: http://www.unaids.org/en/resources/documents/2016/2016-political-declaration-HIV-AIDS
10. UNAIDS. Global AIDS Response Progress Reporting 2016. Construction of core indicators for monitoring the 2011 United Nations Political Declaration on HIV and AIDS. Joint United Nations Programme on HIV/AIDS (UNAIDS), Geneva (2016). Available online: https://aidsreportingtool.unaids.org/static/docs/GARPR_Guidelines_2016_EN.pdf
11. UNAIDS. Global AIDS Monitoring 2017. Indicators for monitoring the 2016 United Nations Political Declaration on HIV and AIDS. Joint United Nations Programme on HIV/AIDS (UNAIDS), Geneva (2017). Available online: http://www.unaids.org/sites/default/files/media_asset/2017-Global-AIDS-Monitoring_en.pdf