EMTCT Regional Framework

Elimination of
Elimination of New Paediatric HIV Infections and Congenital Syphilis in Asia-Pacific 2011-2015
New Paediatric
HIV Infections
and
Congenital
Syphilis
in
Asia-Pacific
2011-2015
UNICEF East Asia and Pacific Regional Office
Conceptual
19 Phra Atit Road
Bangkok 10200 Thailand
Framework
Tel: (66 2) 356-9499
Fax: (66 2) 280-3563 Monitoring and
E-mail: eapro@unicef.org
www.unicef.org/eapro Evaluation Guide
Elimination of
New Paediatric HIV Infections
and Congenital Syphilis in
Asia-Pacific, 2011-2015
Conceptual Framework
Monitoring and Evaluation Guide
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Conceptual Framework & Monitoring and Evaluation Guide
By Padmini Srikantiah
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Any part of this document may be freely reproduced with the appropriate acknowledgement.
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Printed in Thailand

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Acknowledgements
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as a key demonstration of regional commitment to working towards a generation free of HIV and Syphilis.
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Contents
Acknowledgements iii
Acronyms viii
PART 1: Conceptual Framework

Executive Summary 3
1. Background 5
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3. Guiding Principles 13
4. Elimination: Joint HIV/STI/MNCH Initiative 15
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5. Elements of the Framework 17
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6. Building Blocks: Priority Actions 21
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7. Key Next Steps 27
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References 31
PART 2: Monitoring and Evaluation Guide

1. Introduction 35
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3. Programmatic Targets and Indicators 43
Annex: Estimating Overall Targets with Spectrum 51
References 52
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PART 1
Tables
Table 1: 2L`.SVIHS0UP[PH[P]LZ-VJ\ZLKVU0TWYV]PUN4H[LYUHSHUK*OPSK/LHS[O
Table 2: Potential Contributions of Comprehensive PPTCT and ECS Efforts towards

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Table 3: /0=*VUNLUP[HS:`WOPSPZHUK45*/!*\YYLU[:JLUHYPVPU(ZPH7HJPÄJ9LNPVU 11
Table 4: 7YPVYP[`(J[PVUZ[V,TWSV`/PNOS`,MMLJ[P]L0U[LY]LU[PVUZMVY/0=:;07YL]LU[PVU

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Table 5: 6WLYH[PVUHS9LZLHYJO7YPVYP[PLZMVY77;*;HUK,*:PU[OL(ZPH7HJPÄJ9LNPVU
Table 6: +L]LSVWTLU[VMH*VTWYLOLUZP]L5H[PVUHS7;*;HUK*:,SPTPUH[PVU7SHU
Table 7: Cost-savings of implementing comprehensive PPTCT services in a concentrated

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Figures
Figure 1: Conceptual Framework for the Elimination of New Paediatric HIV Infections and
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Figure 2: The Eight Programmatic Targets Correlate to the Four Prongs of the
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PART 2
Figures
Figure 1: Conceptual Framework for the elimination campaign of mother-to-child

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Figure 2: *V\U[YPLZULLK[VZL[JVU[L_[HWWYVWYPH[L[HYNL[ZHUK[PTLSPULZ
Figure 3: The Eight Programmatic Targets Correlate to the Four Prongs of the
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Figure 4: :[Y\J[\YLVM:WLJ[Y\T4VKLS
vii
Acronyms
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ANC antenatal care
(9; HU[PYL[YV]PYHS[OLYHW`
(9= HU[PYL[YV]PYHS
(A; aPKV]\KPUL
CS congenital syphilis
CSW commercial sex worker
CTEI costing tool for elimination initiative
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ECS elimination of congenital syphilis
EID early infant diagnosis
FP family planning
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MDG Millennium Development Goal
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MSM men who have sex with men
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PITC provider initiated testing and counseling
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STI sexually transmitted infection
SW sex worker
UA Universal Access
UN United Nations
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UNFPA United Nations Population Fund
UNGASS United Nations General Assembly Special Session
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viii Conceptual Framework

PART 1
Conceptual Framework
Executive Summary
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about half of these infected children will die before their second birthday. Nearly all of these infections can be
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considered a realistic public health goal. Because similar strategies apply to the prevention of new paediatric HIV
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The Key Elements of the Framework are:
Vision
Women and children alive and free from HIV and syphilis
Goal
To eliminate new paediatric HIV infections and congenital syphilis and improve maternal and child health and
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Overall Targets ()`!

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Programmatic Targets:
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the elimination of new paediatric HIV infections and CS and the improvement of MNCH in the region.
4 Conceptual Framework
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1.1 Parents-to-Child Transmission of HIV and Congenital Syphilis
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prevent these outcomes.
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implementation of HIV PPTCT and CS services.
1.2 Comprehensive Approach to Prevention and Treatment
UN Comprehensive Approach to PPTCT

Countries can achieve dramatic reductions in new paediatric HIV infections through a comprehensive approach
to prevention and treatment;OLHWWYVHJOOHZMV\YRL`WYVUNZ!
Prong 1: Primary prevention of HIV among women of childbearing age.

Prong 2: Prevention of unintended pregnancies among women living with HIV.
Prong 3: Prevention of HIV transmission from a woman living with HIV to her infant.
Prong 4: Provision of appropriate treatment, care and support to women living with HIV and their children
and families.
Each prong plays a key role in preventing new paediatric HIV infections and improving maternal and child health
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all four prongs in order to achieve dramatic and sustained reductions in new paediatric HIV infections.
>/6.SVIHS:[YH[LN`MVY[OL,SPTPUH[PVUVM*VUNLUP[HS:`WOPSPZ,*:
0U>/6V\[SPULKHZPTPSHYJVTWYLOLUZP]LZ[YH[LN`MVY[OLNSVIHS,*:. The goal of the initiative is to
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1. Ensure advocacy and sustained political commitment;
2. Increase access to, and quality of, maternal and newborn health services;
3. Screen and treat pregnant women and partners; and
4. Establish surveillance, monitoring and evaluation systems.
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1.3 PPTCT, ECS and Improving Maternal, Neonatal and Child Health
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Efforts to prevent new paediatric HIV or CS infections rely heavily on the successful implementation of basic
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elimination efforts should be embedded within broader maternal and newborn mortality reduction strategies.
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5LVUH[HSHUK*OPSK/LHS[O745*/[OL/LHS[O0UP[PH[P]L/HUK[OL<5:LJYL[HY`.LULYHS»Z.SVIHS:[YH[LN`
MVY>VTLU»ZHUK*OPSKYLU»Z/LHS[O with the accompanying Commission on Information and Accountability
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.SVIHS4VTLU[\T[V0TWYV]L4H[LYUHSHUK*OPSK/LHS[O!2L`0UP[PH[P]LZ
Partnership for Maternal Neonatal and Child Health (PMNCH)
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of care across MNCH services in order for women and children to receive the care they need and lead healthy and
productive lives.
/LHS[O0UP[PH[P]L/
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JVU[YPI\[L[VYLK\JPUNJOPSKTVY[HSP[`4+.0U[OL/W\ISPZOLKN\PKHUJLVUHJVYLWHJRHNLVMPU[LY]LU[PVUZ
MVY45*/[OH[YLJVTTLUKZPU[LNYH[PVUVM/0=:;0ZLY]PJLZH[ÄYZ[SL]LSMHJPSP[PLZ
UN Secretary General’s Global Strategy for Women’s and Children’s Health with the accompanying Commission
on Information and Accountability
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to service delivery. The strategy endorses the delivery of a comprehensive integrated package of essential services
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Understanding concurrent MNCH initiatives helps place PPTCT and ECS targets in the context of broader
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initiatives. Comprehensive efforts to eliminate new paediatric HIV infections and CS may also contribute
[V^HYKZHJOPL]PUN4+.ZHUKTable 2.
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related MDGs
Millenium Development Goals (MDGS) and Targets Potential Contributions of PMTCT and ECS Elimination Initiative
MDG 4: Reduce Child Mortality - Strengthen MNCH practices to improve infant health
Target 4.A:9LK\JLI`[^V[OPYKZIL[^LLU HUK 9LK\JLU\TILYVMUL^/0=HUK*:PUMLJ[PVUZHUKPUMLJ[LK
[OL\UKLYÄ]LTVY[HSP[`YH[L infants to reduce morbidity and mortality
- Promote safe infant feeding practices
MDG 5: Improve Maternal Health 0UJYLHZLHJJLZZHUKX\HSP[`VM45*/ZLY]PJLZ

Target 5.A:9LK\JLI`[OYLLX\HY[LYZIL[^LLU 9LK\JL\UTL[ULLKMVYMHTPS`WSHUUPUN
HUK[OLTH[LYUHSTVY[HSP[`YH[PV - Primary prevention of HIV and syphilis in women
Target 5.B:(JOPL]LI`\UP]LYZHSHJJLZZ[V - Ensure treatment of HIV-infected women
reproductive health
MDG 6: Combat HIV/AIDS, Malaria and Other Diseases - Prevent spread of HIV and syphilis through primary prevention
Target 6.A:/H]LOHS[LKI`HUKILN\U[VYL]LYZL - Prevent vertical transmssion of HIV and syphilis
[OLZWYLHKVM/0=(0+: - Ensure treatment of women and children with HIV and syphilis
Target 6.B:(JOPL]LI`\UP]LYZHSHJJLZZ[V
[YLH[TLU[MVY/0=(0+:MVYHSS[OVZLÔVULLKP[
1.4 Towards Elimination of PTCT of HIV and CS: Evolution of Goals
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The updated 2010 WHO guidelines on ARV Drugs for Treating Pregnant Women and Preventing HIV Infection
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breastfeeding for HIV-infected women not in need of treatment.
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infections and improve maternal and child survival.
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new infections among young children 0U 5V]LTILY >/6 OLSK H NSVIHS [LJOUPJHS JVUZ\S[H[PVU VU
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1.5 Purpose of this Document
;OYV\NO[OL]PZPVUNVHSZ[HYNL[ZHUKI\PSKPUNISVJRZV\[SPULKPU[OPZKVJ\TLU[[OLMYHTL^VYRPZKLZPNULK[V
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PUMLJ[PVUZHUK*:HUK[OLPTWYV]LTLU[VMTH[LYUHSHUKJOPSKOLHS[OZ\Y]P]HSPU[OLJVU[L_[VM/0=:;0Z;OL
framework also serves as a tool to advocate for government endorsement of the elimination initiative at the
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syphilis. The intended audience for this document includes working groups within national health programmes
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(ZPH7HJPÄJ9LNPVU!
Current Scenario
2.1 HIV and Parents-to-Child Transmission: Epidemiology and Coverage
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WLYJLU[VM/0=L_WVZLKPUMHU[ZPU[OLYLNPVUYLJLP]LKHU`(9=WYVWO`SH_PZMVY77;*;. Closer examination of
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in the region.
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of HIV in exposed infants and facilitate prompt referral to care and treatment services. Available programme
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2.2 Congenital Syphilis: Regional Epidemiology and Screening Practices
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2.3 Maternal, Neonatal and Child Health: Key Indicators and Outcomes
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infections is potentially achievable with the further expansion of comprehensive and effective services.
Particularly in the broader context of improving overall maternal and child health and working towards achieving
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HIV and Parents-to-Child Transmission

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Maternal, Neonatal and Child Health

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to six months of age
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and PPTCT coverage.
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The development of this regional strategic framework for the elimination of paediatric HIV and CS was informed
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1. Optimise the Public Health Approach

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to provide the best proven standard of care on a large-scale with the optimal use of limited resources.
2. Adopt a rights-based approach, and ensure equity

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to make informed decisions regarding reproductive health and treatment options.
3. Mainstream gender
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role of male partners is critical. Efforts to expand PPTCT and ECS services should prioritise and enhance male
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4. Improve maternal, neonatal and child health

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5. Integrate services and collaborating with all relevant sectors

The long-term success of PPTCT and ECS programmes rely on appropriate integration within the health care
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involvement is essential to achieve elimination goals.
6. Ensure a country-led initiative based on local needs

Adaptation of the elimination framework at the country level should be driven by local epidemic needs and on
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countries should prioritise the implementation of select aspects of the framework.
7. Forward looking
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this framework to be truly forward-looking and to set aspirational goals. The availability of more effective
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realistically envisioning the elimination of new paediatric HIV infections and CS. It is an appropriate time to set
ambitious targets.
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4.1 Elimination: A Joint HIV/STI and MNCH Initiative
Based on these guiding principles and recognising the critical importance of an integrated approach towards
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4.2 Elements of the Elimination Framework
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YLNPVUJHUHKHW[[VKL]LSVWJV\U[Y`ZWLJPÄJWSHUZMVYHJVTWYLOLUZP]L77;*;HUK,*:YLZWVUZLFigure 1
Working toward a VISIONVM¸Women and children alive and free from HIV and Syphilis,” the dual GOALS of
[OLLSPTPUH[PVUPUP[PH[P]LHYL[V!
• Eliminate new paediatric HIV infections and congenital syphilis, and
• Improve maternal and child health and survival in the context of HIV/STI
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three OVERALL TARGETSMVY[OLLSPTPUH[PVUPUP[PH[P]L;OLZLHYL!
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The success of the elimination initiative ultimately relies on the implementation of a cohesive and
comprehensive response across multiple sectors of healthcare. The six cross-cutting BUILDING BLOCKS
outlined in the framework form the foundation of an effective response.
,UZ\YLcommitment to achieve goals
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,TWSV`highly effective interventionsMVY/0=:;0WYL]LU[PVUHUK[YLH[TLU[
0TWYV]Lcoverage and advocate for LX\P[HISLHJJLZZ
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0TWYV]Lmeasurement of programme performance and impact
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VISION: GOAL: OVERALL TARGETS: PROGRAMMATIC TARGETS:

Women and children alive To eliminate new 1. Reduce new 1. 50% reduction of HIV incidence
and free from HIV paediatric HIV infections paediatric HIV among women 15-49 years
and syphilis and congenital syphilis infections by 90% 2. Zero unmet need for family planning
and improve maternal 2. Reduce PTCT of HIV among women living with HIV
and child health and To <5% 90% of pregnant women access ANC
survival in the context 3. Reduce incidence of and skilled care at birth
of HIV/STI congenital syphilis to 90% of pregnant women know their
<0.5 per 1,000 live births HIV and syphilis status
90% HIV-positive mothers and
exposed infants receive effective ARVs
to reduce PTCT
90% syphilis sero-positive mothers
and exposed infants receive effective
treatment
LSPNPISL/0=WVZP[P]LWYLNUHU[
women remain on ART at 12 months
post-partum
/0=PUMLJ[LKJOPSKYLU
(0-14 years) receive ART
Ensure Enhance Employ Improve Promote Improve

COMMITMENT COMPREHENSIVE, HIGHLY EFFECTIVE COVERAGE and HEALTH MEASUREMENT
to achieve goals LINKED SERVICES INTERVENTIONS advocate for SYSTEMS of programme
between HIV/STI for HIV/STI EQUITABLE DEVELOPMENT performance and
and MNCH prevention and ACCESS and enhance impact
treatment COMMUNITY
INVOLVEMENT
BUILDING BLOCKS
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This section describes the rationale and implications of each of element of the Framework.
5.1 Vision
‘Women and children alive and free from HIV and syphilis’
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that both women and children are included as priority populations in PPTCT and ECS interventions.
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]PZPVU PZ PUJS\ZP]L VM PU[LY]LU[PVUZ [V WYL]LU[ /0=Z`WOPSPZ PU HSS ^VTLU WYL]LU[ [YHUZTPZZPVU VM PUMLJ[PVU [V
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children. The high value placed on the primary prevention of HIV or syphilis among women is particularly
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5.2 Goal
‘Eliminate new paediatric HIV infections and congenital syphilis and improve maternal and child health
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of eliminating new paediatric HIV and CS and improving maternal and child health and survival. PPTCT and
ECS interventions can be most effectively implemented as part of a comprehensive package of services for
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strengthened human resource capacity for the management of supplies and resources. The linked goals of
eliminating new paediatric HIV and CS infections and improving maternal and child health underscores the
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5.3 Overall Targets
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consider ambitious elimination targets for PTCT and CS in the context of improving maternal and child health.
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77;*;,*: HWWYVHJO MYVT WYPTHY` WYL]LU[PVU PU ^VTLU VM JOPSKILHYPUN HNL [V PU[LY]LU[PVUZ HPTLK H[
reducing vertical transmission and expanding treatment for women and children to improve survival.
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has been selected as an applicable goal for the elimination of new paediatric HIV infections in the region. In
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more appropriate target.
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The overall goal of the ECS initiative is to ensure that CS is no longer a public health problem. ECS will be
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measures to ensure that testing and treatment of all pregnant women is attained.
5.4 Programmatic Targets
Each of the eight programmatic targets outlined in this framework correlates to one of the four prongs of the
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AIDS. Prevention services should be implemented in any setting where women and their male partners access
antenatal services.
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per cent. Unintended pregnancies contribute to maternal morbidity and mortality which have a devastating effect
on the survival and wellbeing of both women and their children. It is essential to ensure that HIV-positive women
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YLK\JL\UTL[ULLKMVY-7[VaLYVHTVUNHSS^VTLUÔPJOPZHULZ[HISPZOLKNSVIHS[HYNL[MVY4+.)
-PN\YL! The Eight Programmatic Targets Correlate to the Four Prongs of the Comprehensive Approach to PPTCT
MATERNAL HEALTH
BEFORE PREGANCY PREGNANCY BIRTH
INFANCY, CHILDHOOD
PRONG 1: PRONG 2: PRONG 3: PRONG 4:

Prevent new HIV Prevent unintended Prevent vertical Provide care and
infections in women pregnancies in women transmission of treatment to women
of childbearing age with HIV HIV and syphilis and children with HIV
TARGET 1: TARGET 2: TARGET 5: TARGET 7:

50% reduction in HIV ZERO unmet need for /0=TV[OLYZ LSPNPISL/0=WYLNUHU[
incidence in women of FP among women and exposed infants women remain on ART at
childbearing age with HIV receive ARVs for PPCTC TVU[OZWVZ[WHY[\T
TARGET 6: TARGET 8:
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positive mothers and JOPSKYLU`LHYZ
infants receive treatment receive ART
TARGET 3: >90% pregnant women access ANC and skilled care at birth
TARGET 4: >90% pregnant women know HIV and syphilis status
Childbearing Women Women Living with HIV Pregnant Women Mothers and Children
with HIV with HIV
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The effectiveness of PPTCT and ECS interventions depends directly on the percentage of pregnant women who
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birth are key elements of the global MNCH agenda to reduce maternal mortality and achieve universal access to
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who receive the results of their HIV and syphilis serology tests. While women diagnosed in ANC settings can be
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cumbersome risk-assessment tools to guide selective HIV testing among ANC attendees has not been shown
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option for infant feeding. There are highly effective and inexpensive treatment options for the prevention of CS as
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A key feature of the elimination initiative is its focus on improving the health and survival of women and children
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exposed infants and ensuring that HIV-positive infants are promptly linked with treatment services. Developing
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be a critical component of measuring and achieving these programmatic targets.
5.5 Building Blocks
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particularly in the context of preventing HIV and syphilis in infants. The key priority actions for each building
block are discussed in detail in the next section.
1. Ensure commitment to achieve goals
2. Enhance comprehensive, linked services between HIV/STI and MNCH programmes
3. Employ highly effective interventions for HIV/STI prevention and treatment
4. Improve coverage and advocate for equitable access
5. Promote health systems development and enhance community involvement
6. Improve measurement of programme performance and impact
)\PSKPUN)SVJRZ!
Priority Actions
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essential to ensure the delivery of highly effective PPTCT and ECS interventions. This section outlines key
priority actions for each building block.
6.1 Building Block 1: Ensure Commitment to Achieve Goals
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development of successful operational plans for elimination. It is critical to ensure endorsement from ministries
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welfare services. Together these programmes and partners should work to develop regional and national targets
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45*/V\[JVTLZZ[YLUN[OLUOLHS[OZ`Z[LTZHUKYLK\JL[OLI\YKLUVM/0=HUKZ`WOPSPZ
Priority Actions:
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sectors and development partners involved in health and welfare.
,Z[HISPZOHUH[PVUHS;HZR-VYJLMVY[OLLSPTPUH[PVUVM7;*;HUK*:[V!
a. Formulate evidence-based national targets and timelines
b. Develop a national advocacy plan with the involvement of civil society
J +LÄULM\UKPUNYLX\PYLTLU[Z[VHJOPL]LNVHSZ
d. Ensure that the elimination of PTCT and CS is incorporated within broader health sector planning processes.
6.2 Building Block 2: Enhance Provision of Comprehensive, Linked Services
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6.3 Building Block 3: Employ Highly Effective Interventions
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interventions for prevention and treatment. Importance should be given to improving interventions in each of
[OLMV\YWYVUNZVM[OLJVTWYLOLUZP]LHWWYVHJO[V77;*;Table 3
7YPVYP[`(J[PVUZ!
1. Prong 1!Primary prevention of HIV and syphilis among women of childbearing age
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JVUJLU[YH[LK/0=LWPKLTPJZL[[PUNZVM(ZPH7HJPÄJ;OPZPZWHY[PJ\SHYS`YLSL]HU[MVY^VTLUPURL`HMMLJ[LK
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:PTPSHYS`:9/45*/ZLY]PJLZZOV\SKILLTWSV`LKHZHULU[Y`WVPU[MVY/0=WYL]LU[PVUMVYHSS^VTLUHUK
their male partners.
2. Prong 2!Prevention of unintended pregnancies among women living with HIV

The inclusion of FP services as part of routine care for HIV-positive women of childbearing age is critical to
reduce the number of unintended pregnancies among women living with HIV. Effective FP services for HIV-
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HUK^PSSJVU[YPI\[L[VIYVHKLYLZ[HISPZOLK4+.[HYNL[Z[VYLK\JL\UTL[ULLKMVY-7HTVUNHSS^VTLU
The implementation of routine FP services for women enrolled in HIV care and treatment should prioritise
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3. Prong 3: Prevention of HIV or syphilis transmission from a pregnant woman to her infant
0U VYKLY [V LMMLJ[P]LS` WYL]LU[ [OL ]LY[PJHS [YHUZTPZZPVU VM /0= WYLNUHU[ ^VTLU ^P[O /0= T\Z[ ÄYZ[ IL
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will enhance detection and treatment of sero-positive women and prevention of CS. Building capacity for
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4. Prong 4!Appropriate treatment, care to mothers living with HIV and their children
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treatment is essential to improve the health and survival of mothers with HIV and their exposed children.
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for all HIV-exposed infants.
6.4 Building Block 4: Improve Coverage and Advocate for Equitable Access
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Comprehensive Approach to PMTCT and ECS Priority Actions
Prong 1: • Integrate HIV and STI prevention for women of reproductive age
Primary prevention of HIV and syphilis among in any setting where women and their male partners access
women of childbearing age ANC services
• Strengthen HIV primary prevention services for male and female
2(7ZHUKLUOHUJL/0=JV\UZLSSPUNHUK[LZ[PUNMVYMLTHSL
WHY[ULYZVMTHSL2(7Z
• Ensure that PPTCT and STI counselling is part of harm reduction
PU[LY]LU[PVUZMVY^VTLUPURL`H[YPZRWVW\SH[PVUZPUJS\KPUN
PWIDs and SWs
• Prioritise male involvement in the primary prevention of HIV
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setting where HIV testing and counselling is provided
Prong 2: • Standardise the delivery of routine FP services for women

Prevention of unintended pregnancies among attending services in HIV care settings
women living with HIV ,UOHUJLTHSLPU]VS]LTLU[PUYV\[PUL:9/HUK45*/ZLY]PJLZ
Prong 3: • Prioritise expansion of routine HIV and syphilis testing in all

Prevention of HIV or syphilis transmission from ANC settings
a pregnant woman to her infant 0TWSLTLU[HUKL_WHUK\ZHNLVMOPNOS`LMÄJHJPV\ZJVTIPUH[PVU
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• Promote safe infant feeding practices and support adherence to
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Prong 4: ,HYS`*+HZZLZZTLU[MVY[YLH[TLU[LSPNPIPSP[`HUKWYVTW[SPURHNL
Provision of appropriate treatment and care to [V(9;MVY^VTLUÔVYLX\PYLP[MVY[OLPYVÛOLHS[O
mothers living with HIV and ,HYS`/0=KPHNUVZPZHUJV[YPTV_HaVSLPUL_WVZLKPUMHU[ZHUK
their children SPURHNL[VLHYS`(9;MVY/0=WVZP[P]LPUMHU[Z
0U(ZPH7HJPÄJJV\U[YPLZPTWYV]PUNHJJLZZ[V45*/HUK/0=:;0ZLY]PJLZPZVMWHY[PJ\SHYPTWVY[HUJLMVY^VTLU
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STI care and support.
Priority Actions:
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improve access and utilisation of timely ANC and skilled childbirth services.
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/0=:;0ZLY]PJLZWHY[PJ\SHYS`HTVUN2(7Z
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TLJOHUPZTZ[VHKKYLZZLJVUVTPJIHYYPLYZ[VHJJLZZHUK\[PSPZH[PVUPUJS\KPUN[OLL_WHUZPVUVMZVJPHS
insurance policies.
6.5 Building Block 5: Promote Health Systems Development and

Enhance Community Involvement
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ZLY]PJLZ HUK [V SPTP[Z PU [OL LMMLJ[P]LULZZ VM PU[LY]LU[PVUZ *VTT\UP[ÌHZLK HWWYVHJOLZ JHU LMMLJ[P]LS`
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;OLSHJRVMZ\MÄJPLU[O\THUYLZV\YJLZPZHJYP[PJHSIHYYPLY[VLMMLJ[P]LPTWSLTLU[H[PVUVM77;*;,*:ZLY]PJLZPU
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include the development of innovative task-shifting and task-sharing mechanisms for clinical service delivery
and supply management issues. Developing effective human resource solutions at the community and primary
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which can increase access to services and may contribute to improved adherence. Enhancing the involvement
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based approaches to support adherence to follow-up interventions are two other essential components of
strengthening the overall platform for the delivery of optimal PPTCT and ECS services.
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proportion of women access MNCH services through the private sector. Developing systematic partnerships
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a broader population.
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of services.
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follow-up care.
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management and programme evaluation.
6.6 Building Block 6: Improve Measurement of Performance and Impact
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[OYV\NO JHYLM\S HUHS`ZPZ VM UH[PVUHS HUK Z\IUH[PVUHS KH[H ;OPZ ^PSS HZZPZ[ WYVNYHTTLZ [V KLÄUL WYPVYP[`
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support. This analysis will also guide programmes to develop ambitious but realistic timelines for meeting
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PUKPJH[VYZ[OH[TLHZ\YL[OLWYVNYLZZVMJVTWYLOLUZP]LLSPTPUH[PVULMMVY[Z:LL(ZPH7HJPÄJ9LNPVUHS77;*;
,*:4VUP[VYPUNHUK,]HS\H[PVU.\PKL0UHKKP[PVU[VJVTTVUS`JVSSLJ[LKWYVJLZZPUKPJH[VYZP[PZLZZLU[PHS
[VPUJS\KL[OLYV\[PULTLHZ\YLTLU[VMV\[JVTLHUKPTWHJ[PUKPJH[VYZ0TWYV]LKJHWHJP[`MVY[OLJVSSLJ[PVU
THUHNLTLU[HUKHUHS`ZPZVMKH[H^PSSILYLX\PYLK[VZ\WWVY[YV\[PULWYVNYHTTLL]HS\H[PVU
The role of operational research is also critical to support optimal scale-up and expansion of comprehensive
PPTCT and ECS interventions. Well designed and conducted operational research and implementation science
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L]HS\H[PUNPUUV]H[P]LZ[YH[LNPLZ[VPTWYV]L[OLJV]LYHNLX\HSP[`HUKVW[PTHSKLSP]LY`VMPU[LNYH[LK:9/45*/
HUK/0=:;0ZLY]PJLZ:[\K`ÄUKPUNZZOV\SKIL\[PSPZLK[VZ[YLUN[OLULSPTPUH[PVUZ[YH[LNPLZHUKLUOHUJL[OL
sustainability of interventions.
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+LÄULIHZLSPULWYVNYHTTLWLYMVYTHUJLHUKNHWZMVY45*//0=HUK:;0ZLY]PJLZ
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impact of elimination efforts at the district and national levels.
)\PSKJHWHJP[`MVYKH[HTHUHNLTLU[HUKHUHS`ZPZ^P[OPU[OL45*/HUK/0=:;0ZLJ[VYZHUK
systematically track progress through strengthened monitoring mechanisms.
+L]LSVWYLNPVUHSHUKUH[PVUHSSL]LSVWLYH[PVUHSYLZLHYJOHNLUKHZMVJ\ZLKVU77;*;,*:HUK
PTWYV]LTLU[VM45*/V\[JVTLZPU[OLJVU[L_[VM/0=:;0Table 4
;HISL!6WLYH[PVUHS9LZLHYJO7YPVYP[PLZMVY77;*;HUK,*:PU[OL(ZPH7HJPÄJ9LNPVU
Eliminating New Paediatric HIV Infections and Congenital Syphilis Operational Research Priorities in the
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use of novel mobile communications technology
• Evaluate outcomes of routine integration of HIV prevention interventions in MNCH settings
• Identify successful models to increase male involvement in primary prevention of intimate partner transmission of
HIV in women
(ZZLZZPTWHJ[VMYV\[PUL-7PU[LY]LU[PVUZHTVUN/0=WVZP[P]L^VTLUVMJOPSKILHYPUNHNLPU/0=(9;JHYL
• Assess innovative strategies to increase utilisation of MNCH services by women from key affected populations
• Examine methods to increase male involvement in antenatal HIV testing
• Determine effective methods to expand routine rapid HIV and syphilis testing in all ANC settings
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(UHS`ZL[OLPTWHJ[VMSPURHNLZIL[^LLU45*//0=HUK:;0VU/0=HUK45*/V\[JVTLZ
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7.1 Country Level
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LSPTPUH[PVUNVHSZ)L`VUKZPTWS`Z[H[PUNLSPTPUH[PVUHZHNVHSUH[PVUHS/0=:;0HUK45*/WYVNYHTTLZ^PSS
have to determine strategic priorities and programming shifts that are necessary to achieve PPTCT and ECS
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programme performance. This is essential to identify programme needs and gaps.
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LMMVY[Z^PSSILPTWSLTLU[LKH[[OLÄLSKSL]LS5H[PVUHSLSPTPUH[PVUWSHUZZOV\SKILSPURLK^P[OIYVHKLY/0=:;0
:9/45*/HUK4+.WSHUZHUKNVHSZHUKJSLHYS`KLSPULH[LYVSLZHUKYLZWVUZPIPSP[PLZ[VLUZ\YLHJJV\U[HIPSP[`
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levels. Programmes should regularly monitor progress and conduct annual country reviews to measure
77;*;,*:V\[JVTLZHUK\ZLYLZ\S[Z[VN\PKLPTWYV]LTLU[[VJV\U[Y`SL]LSLSPTPUH[PVUZ[YH[LNPLZ
*YP[PJHSL]HS\H[PVUVMV\[JVTLZHUKPTWHJ[ZZOV\SKILJVUK\J[LKH[TPK[LYTHUKPU
7.2 Regional Level
High level advocacy

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endorsement at the highest levels. Emphasising the comprehensive nature of the initiative and its potential
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STI programmes and agencies within the region.
/HYTVUPZLK[LJOUPJHSZ\WWVY[HUKYLNPVUHSHJJV\U[HIPSP[`
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to countries to develop and revise national plans. This will also inform the development of a regional accountability
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Platform for exchange of data and lessons learned

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^^^HPKZKH[HO\IVYNLUYLNPVUHSWYVÄSLZWYL]LU[PVUVMWHYLU[[VJOPSK[YHUZTPZZPVU MVY JV\U[YPLZ [V ZOHYL
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4VIPSPZPUNULJLZZHY`YLZV\YJLZ
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accelerate the elimination initiative at country and regional levels. This will include providing support to country
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<:7YLZPKLU[Z,TLYNLUJ`7SHUMVY(0+:9LSPLM7,7-(9
;HISL!+L]LSVWTLU[VMH*VTWYLOLUZP]L5H[PVUHS7;*;HUK*:,SPTPUH[PVU7SHU
Developing a Country Plan for Elimination of New Paediatric HIV Infections and Congenital Syphilis
Assess Current Programme Performance Gaps

• Conduct critical analysis of HIV, STI and MNCH programme performance to facilitate greater understanding of
current practices, achievements and service gaps
Set Targets and Goals

• .\PKLKI`[OPZHUHS`ZPZKL]LSVWHTIP[PV\ZI\[YLHSPZ[PJJV\U[Y`ZWLJPÄJLSPTPUH[PVUNVHSZHUK[HYNL[ZÔPJO
include time-bound milestones
• Targets and timeline will vary according to many factors, including epidemiologic situation, public policies and basic
health service delivery infrastructure
Develop an Operational Plan

• 7SHUZOV\SKZ[H[LV]LYHSSNVHSZHUK[HYNL[ZKLÄULL_WLJ[LKV\[JVTLZHJYVZZHSSMV\YWYVUNZVM[OLJVTWYLOLUZP]L
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must be implemented to achieve each outcome
• Address cross-cutting issues of integration, linkages, equitable access and human resource capacity for each outcome
• Integrate within national strategic health plan and clearly link with broader MNCH and health goals
• Include an accountability section that clearly delineates roles and responsibilities, and facilitates assessment of
progress and challenges
• Develop an integrated monitoring and evaluation plan
Implement, Monitor and Evaluate

• Implement at the national, sub-national and community levels
• Critically evaluate programme performance, outcomes and impact through routinely collected programme and
target related indicators
• Plan periodic in-depth analyses of updated interventions, innovative service delivery models and linkages between
different health sectors
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and expanded PPTCT and ECS services for pregnant women in low prevalence settings.
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for HIV- exposed infants were also compared to the costs of HIV care and treatment for HIV-infected children.
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Elimination of PTCT and CS: The Need to Develop a Costed Plan

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the resources needed to achieve PPTCT and ECS goals in order to develop a fully costed country elimination
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HIV-exposed infants. Additional factors include the cost of expanding human resources and investments in
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of funding gaps will also allow programmes to more effectively mobilise resources and support.
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PMTCT Coverage Expected Number Total costs Total Costs Total

number of new of PMTCT costs of per new savings**
of new paediatric services paediatric paediatric
paediatric HIV (USD)* treatment HIV
infections* infections for 20 years infection
averted* (USD)* averted
(USD)
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long-term funding commitments by public and private entities are upheld and increased. The Task Force will
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through public-private partnerships.
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syphilis. Obstet Gynecol Int"
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PART 2
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Guide
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the comprehensive approach to HIV PPTCT is also applicable to the prevention of CS. The approach has
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Prong 1: Primary prevention of HIV among women of childbearing age

Prong 2: Prevention of unintended pregnancies among women living with HIV
Prong 3: Prevention of HIV transmission from a woman living with HIV to her infant
Prong 4: Provision of appropriate treatment, care and support to women living with HIV and their
children and families
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countries in the Asia-Pacific region have begun to consider a combined approach to the delivery and
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PPTCT Task Force has developed a Conceptual Framework for the Elimination of New Paediatric HIV
Infections and Congenital Syphilis in Asia-Pacific, 2011-2015;OPZMYHTL^VYRYLWYLZLU[ZHQVPU[HJ[P]P[`
VM[OL/0=:;0HUK45*/ZLJ[VYZPU[OL(ZPH7HJPMPJYLNPVU,SPTPUH[PVUVMUL^WHLKPH[YPJ/0=PUMLJ[PVUZ
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the context of HIV and STIs.
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The conceptual framework outlines a common systematic approach to the elimination of new paediatric
HIV and CS infections and improvement of maternal and child health in the context of HIV and sexually
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Working towards a Vision VM ¸Women and children alive and free from HIV and Syphilis,” the dual
GOALS of the elimination initiative are to
• Eliminate new paediatric HIV infections and congenital syphilis and
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The Overall TargetsVM[OLLSPTPUH[PVUPUP[PH[P]LHYL[V!

The framework further outlines eight key Programmatic TargetsFigure 1LHJOVMÔPJOJVYYLSH[LZ[VVUL

of the four prongs of the comprehensive approach to PPTCT9LJVNUPZPUN[OH[HJOPL]PUN77;*;HUK,*:
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A clear strategy to monitor and measure progress is necessary to support the regional PPTCT and ECS
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outlines a common Monitoring and Evaluation Framework for tracking progress towards the elimination
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• Proposes core indicators to measure progress towards each programmatic target.
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TVUP[VY[OL,SPTPUH[PVUPUP[PH[P]LHYLHSYLHK`JVSSLJ[LKL]LY``LHYHZWHY[VM[OL<UP]LYZHS(JJLZZ<(YLWVY[PUN
TLJOHUPZT MVY [OL HUU\HS /0= WYVNYLZZ YLWVY[ ¸;V^HYKZ <UP]LYZHS (JJLZZ! :JHSPUN \W WYPVYP[` /0=(0+:
PU[LY]LU[PVUZPU[OLOLHS[OZLJ[VY¹W\ISPZOLKI`>/6<5(0+:<50*,- VYHZWHY[VM[OL<5(0+:¸<5.(::
*VYL0UKPJH[VYZMVY4VUP[VYPUN[OL+LJSHYH[PVUVM*VTTP[TLU[VU/0=(0+:¹. Because improving MNCH
ZLY]PJLZPZ]P[HS[V[OLZ\JJLZZVM77;*;HUK,*:LMMVY[ZZL]LYHSVM[OLPUKPJH[VYZV\[SPULKPU[OPZN\PKLHYL
KPYLJ[S`YLSH[LK[V[OLJV]LYHNLVMIHZPJHU[LUH[HSHUKMHTPS`WSHUUPUN-7ZLY]PJLZHUKHYLYV\[PULS`JVSSLJ[LK
I`ZL_\HSHUKYLWYVK\J[P]LOLHS[O:9/HUK45*/WYVNYHTTLZH[UH[PVUHSHUKZ\IUH[PVUHSSL]LSZ
1.3 Monitoring and Evaluation Elimination: An opportunity to improve data systems
(Z ^P[O [OL PTWSLTLU[H[PVU VM JVTWYLOLUZP]L 77;*; HUK ,*: LMMVY[Z TVUP[VYPUN HUK L]HS\H[PVU VM
[OL LSPTPUH[PVU PUP[PH[P]L ^PSS YLX\PYL [OL JVSSHIVYH[P]L LMMVY[Z VM /0=:;0 HUK 45*/ ZLJ[VYZ ([ [OL
JV\U[Y`SL]LS/0=:;0HUK45*/WYVNYHTTLZ^PSSULLK[VKL]LSVWHJVUZLUZ\ZVUHJJ\YH[LIHZLSPULZ
HWWYVWYPH[L[HYNL[ZZ[YLUN[OLUJV\U[Y`JHWHJP[`[V\ZL/0=LZ[PTH[LZHUKWYVQLJ[PVUZTVKLSZ[VTVUP[VY
[OL ,SPTPUH[PVU [HYNL[Z ;OL PUP[PH[P]L WYV]PKLZ HU VWWVY[\UP[` MVY /0= :;0 HUK 45*/ WYVNYHTTLZ [V
Z[YLUN[OLU[OLX\HSP[`VML_PZ[PUNOLHS[OPUMVYTH[PVUZ`Z[LTZHUKI\PSKHKKP[PVUHSJHWHJP[`MVYTVUP[VYPUN
HUKL]HS\H[PVU;V[OH[LUK[OL(ZPH7HJPMPJ77;*;;HZR-VYJL[OYV\NOP[ZTLTILYHNLUJPLZHUKRL`
[LJOUPJHSWHY[ULYZ^PSSZ\WWVY[JV\U[YPLZPU[OLPYYLWVY[PUNYLX\PYLTLU[ZJVU[YPI\[L[VI\PSKPUNJHWHJP[`
MVYKH[HNLULYH[PVUJVSSLJ[PVUHUKPU[LYWYL[H[PVUH[[OLUH[PVUHSHUKZ\IUH[PVUHSSL]LSZHUKHZZPZ[JV\U[Y`
programmes to effectively use data to strengthen PPTCT and ECS interventions.
36 Monitoring and Evaluation Guide

-PN\YL ! *VUJLW[\HS -YHTL^VYR MVY [OL LSPTPUH[PVU JHTWHPNU VM TV[OLY[VJOPSK [YHUZTPZZPVU VM /0= HUK
*VUNLUP[HS:`WOPSPZPU(ZPH7HJPÄJ
VISION: GOAL: OVERALL TARGETS: PROGRAMMATIC TARGETS:

Women and children alive To eliminate new 1. Reduce new 1. 50% reduction of HIV incidence
and free from HIV paediatric HIV infections paediatric HIV among women 15-49 years
and syphilis and congenital syphilis infections by 90% 2. Zero unmet need for family planning
and improve maternal 2. Reduce PTCT of HIV among women living with HIV
and child health and To <5% 90% of pregnant women access ANC
survival in the context 3. Reduce incidence of and skilled care at birth
of HIV/STI congenital syphilis to 90% of pregnant women know their
<0.5 per 1,000 live births HIV and syphilis status
90% HIV-positive mothers and
exposed infants receive effective ARVs
to reduce PTCT
90% syphilis sero-positive mothers
and exposed infants receive effective
treatment
LSPNPISL/0=WVZP[P]LWYLNUHU[
women remain on ART at 12 months
post-partum
/0=PUMLJ[LKJOPSKYLU
(0-14 years) receive ART
Ensure Enhance Employ Improve Promote Improve

COMMITMENT COMPREHENSIVE, HIGHLY EFFECTIVE COVERAGE and HEALTH MEASUREMENT
to achieve goals LINKED SERVICES INTERVENTIONS advocate for SYSTEMS of programme
between HIV/STI for HIV/STI EQUITABLE DEVELOPMENT performance and
and MNCH prevention and ACCESS and enhance impact
treatment COMMUNITY
INVOLVEMENT
BUILDING BLOCKS
4LHZ\YPUN,SPTPUH[PVU;HYNL[Z
6]LYHSS;HYNL[Z!+LÄUP[PVUZ
6]LYHSS;HYNL[!9LK\JLUL^WHLKPH[YPJ/0=PUMLJ[PVUZI` WLYJLU[I`
;OL[HYNL[VMYLK\JPUNUL^WHLKPH[YPJ/0=PUMLJ[PVUZI` WLYJLU[YLMSLJ[Z[OLJVU[YPI\[PVUZVM[OL7YVUN
strategy for PPTCT and signifies the importance of a comprehensive approach. While it is recognised that
[OL WLYJLU[[HYNL[I`PZHZWPYH[PVUHSZPNUPMPJHU[WYVNYLZZ[V^HYKZ[OPZ[HYNL[JHUILTHKLHTVUN
countries in the Asia-Pacific region.
6]LYHSS;HYNL[!9LK\JLUL^WHLKPH[YPJ/0=PUMLJ[PVUZI` WLYJLU[
9LNPVUHS)HZLSPUL !UL^WHLKPH[YPJ/0=PUMLJ[PVUZ
Regional Target (2015): <2,200 new paediatric HIV infections
• Successful implementation of all prongs is required to achieve this Elimination target
• Momentous achievement in one of the prongs alone is not enough
6]LYHSS;HYNL[!9LK\JL7;*;VM/0=[V#WLYJLU[
;OL[HYNL[VMYLK\JPUN7;*;[VSLZZ[OHUWLYJLU[HKKYLZZLZLMMVY[Z[VLSPTPUH[L[OL]LY[PJHS[YHUZTPZZPVU
of HIV. This target directly addresses the public health issue of how well interventions are being provided
to prevent new infant infections in pregnant women already infected with HIV. The estimated risk of
[YHUZTPZZPVU^P[OV\[HU`PU[LY]LU[PVUPZHYV\UKWLYJLU[HYV\UKWLYJLU[^P[OV\[IYLHZ[MLLKPUN.
;OLYLNPVUHS[HYNL[PZ[VYLK\JL7;*;[VSLZZ[OHUWLYJLU[HUKHZ\I[HYNL[VM#WLYJLU[[YHUZTPZZPVU
in non-breastfeeding settings.
6]LYHSS;HYNL[!9LK\JL7;*;[V#WLYJLU[
Numerator: Number of infants born to HIV-infected mothers who are HIV-infected
Denominator: Number of all estimated HIV-positive pregnant women
• ;OLKLUVTPUH[VYPZUV[SPTP[LK[VVUS`PKLU[PÄLK/0=WVZP[P]LWYLNUHU[^VTLU
• In breastfeeding populations, PTCT should be assessed after cessation of breastfeeding
• The percentage of infants who are HIV-infected should decrease as the coverage of interventions for PPTCT
and the use of more effective regimens increases
6]LYHSS;HYNL[!9LK\JLPUJPKLUJLVM*:[V#WLYSP]LIPY[OZ
The target of reducing the incidence of CS addresses efforts to eliminate the vertical transmission of
syphilis . This target directly addresses the public health issue of how well interventions are being
provided to prevent new infant infections in women who are already syphilis sero-positive.
6]LYHSS;HYNL[!9LK\JLPUJPKLUJLVM*:[V#WLYSP]LIPY[OZ
Numerator: Number of infants born to syphilis sero-positive mothers who have CS
Denominator: Estimated number of live births in the past 12 months
• (JJVYKPUN[V[OLUH[PVUHSKLÄUP[PVUVMJVUNLUP[HSZ`WOPSPZ
• The percentage of infants who have congenital syphilis should decrease as the coverage of interventions for
ECS interventions increases
2.2 Measurement Methods for Overall Elimination Targets
There are several methods countries can use to measure annual progress towards elimination targets.
;OLZLPUJS\KLTVKLSSPUNPTT\UPZH[PVUJSPUPJZ\Y]L`ZOV\ZLOVSKHUKKLTVNYHWOPJZ\Y]L`ZHUKJVOVY[
analyses. The two key methods that are best applicable to the concentrated and low-level HIV epidemic
ZL[[PUNZPU(ZPH7HJPMPJJV\U[YPLZPUJS\KL!
1. 9L[YVZWLJ[P]LHUHS`ZPZVMJVOVY[KH[HZ\JOHZHU[LUH[HSJHYL(5*VYLHYS`PUMHU[KPHNUVZPZ,0+KH[H
2. 4VKLSSPUN\ZPUNWYVQLJ[PVUZVM[^HYLZ\JOHZ[OL:WLJ[Y\TWHJRHNL\ZLKI`[OL<5MVY/0=LZ[PTH[LZ
HUKWYVQLJ[PVUZ
;OLYLHYLHK]HU[HNLZHUKSPTP[H[PVUZ[VLHJOTL[OVK0[PZPTWVY[HU[[VYLJVNUPZL[OH[PUYLHSP[`JV\U[YPLZ
will need to analyse and triangulate data collected through multiple measurement methods to determine
HUK]HSPKH[L[HYNL[ZMVY[OLLSPTPUH[PVUPUP[PH[P]L-\Y[OLYTVYL[OLWYVJLZZVMKL[LYTPUPUN77;*;HUK,*:
targets should ideally be incorporated into existing programme exercises for HIV and STI estimations.
;OPZJHUWYVTW[Z[YLUN[OLUPUNVM[OLV]LYHSS/0=:;0LZ[PTH[PVUZWYVJLZZH[[OLJV\U[Y`SL]LSHUKIL[[LY
align PPTCT and ECS efforts with broader health goals.
(UHS`ZPZVM*VOVY[VY7YVNYHTTL+H[H
6UL ^H` [V KL]LSVW HUK TLHZ\YL [HYNL[Z PZ [V [Y` [V KPYLJ[S` TLHZ\YL [OL V\[JVTLZ VM ^VTLU HUK
children using programme data.
ANC cohort of HIV+ mothers:

0U [OPZ TL[OVK WYVNYHTTLZ ZLSLJ[ H YHUKVT ZHTWSL VM /0=WVZP[P]L ^VTLU MYVT (5* MPSLZ ÔV NH]L
IPY[OLHYSPLYLNPU[OLWHZ[TVU[OZHUKH[[LTW[[VKL[LYTPULV\[JVTLZ[OYV\NOKH[HHIZ[YHJ[PVU
HUKSPURPUNHUKPU[LUZP]LMVSSV^\W^P[OWVZ[WHY[\THUKJOPSKYLJVYKZ;OLZLHUHS`ZLZJHUWYV]PKLH
7;*;YH[LMVYHJVOVY[^P[OV\[JVTLKH[HHUK[OLU\TILYVMUL^WHLKPH[YPJ/0=PUMLJ[PVUZV\[VM[OL
JVOVY[ [LZ[LK /V^L]LY [OPZ TL[OVK KVLZ 56; WYV]PKL HU LZ[PTH[PVU VM [OL U\TILY VM /0=WVZP[P]L
women in need of PPTCT.
Analysis of EID Data:

Countries should also analyse EID programme data to calculate the number of HIV-exposed infants with
positive EID results. These findings can be combined with estimates of the number of infants lost to
follow-up to get a national estimate of number of new infant HIV infections in a given year.
(K]HU[HNLZ!
Conducting a cohort analysis can help to promote data linkages and longitudinal follow-up. The findings
YLMSLJ[WYVNYHTTLYLHSP[`HUKJHUN\PKLPTWYV]LTLU[ZPU[OLKLSP]LY`VMPU[LY]LU[PVUZHZ^LSSHZYLMPULTLU[
of programme targets and timelines.
3PTP[H[PVUZ!
;OLYLZ\S[ZVMJVOVY[HUHS`ZLZHYLIPHZLKHZ[OL`YLWYLZLU[VUS`[OVZLTV[OLYIHI`WHPYZÔVWYLZLU[
[VMHJPSP[PLZ;OPZPZWHY[PJ\SHYS`YLSL]HU[PU[OLJHZLVM,0+KH[HHUHS`ZPZÔPJOPZHWWSPJHISLVUS`ÔLYL
MHJPSP[`H[[LUKHUJLPZOPNO:PNUPMPJHU[H[[YP[PVUPZ[OLYLHSP[`PUTHU`ZL[[PUNZHUKWYVNYHTTLZ^PSSULLK[V
make assumptions for those who are lost to follow-up and those not captured in data. Findings of cohort
HUHS`ZLZZOV\SK[O\ZILPU[LYWYL[LK^P[OJH\[PVU(KKP[PVUHSS`Z\JOHUHS`ZLZJHUIL[PTLHUKYLZV\YJL
PU[LUZP]LWHY[PJ\SHYS`ÔLUL_[YHJ[PUNKH[HMYVTT\S[PWSLMHJPSP[PLZ
4VKLSSPUN\ZPUN7YVQLJ[PVU:VM[^HYL
This method uses HIV and STI surveillance data and programme data in a demographic model to estimate
YLZ\S[Z4VKLSSPUN^PSSHZZPZ[^P[OLZ[PTH[PVUVM[OL7;*;YH[LHZ^LSSHZU\TILYVMUL^WHLKPH[YPJ/0=
PUMLJ[PVUZ 4VKLSZ HYL JVUZ[Y\J[LK \ZPUN WYVQLJ[PVU ZVM[^HYL Z\JO HZ :WLJ[Y\T ÔPJO PZ \ZLK I` [OL
<5MVY/0=LZ[PTH[LZHUKWYVQLJ[PVUZO[[W!^^^\UHPKZVYNLUKH[HHUHS`ZPZ[VVSZZWLJ[Y\TLWW
See (UUL_L for a detailed description of Spectrum.). In partnership with national stakeholders and
<5 HNLUJPLZ /0= WYVNYHTTLZ PU TVZ[ JV\U[YPLZ PU [OL (ZPH7HJPMPJ YLNPVU OH]L HSYLHK` JVUK\J[LK
modelling and estimation exercises to assess HIV prevalence and trends. Efforts to set and measure
PPTCT elimination targets should be integrated with broader HIV estimation exercises and viewed as an
opportunity to refine and strengthen current measurements.

(K]HU[HNLZ!
There are advantages to using Spectrum to estimate PPTCT elimination targets as it is consistently
Z\WWVY[LK I` [OL <5 PU V]LY JV\U[YPLZ HUK [O\Z LZ[PTH[LZ MYVT T\S[PWSL JV\U[YPLZ HYL WYVK\JLK
\ZPUNHZ[HUKHYKPZLKHWWYVHJOYLSH[P]LS`LHZPS`-\Y[OLYTVYL<5(0+:>/6HUKWHY[ULYZ[YHPUHUKHZZPZ[
countries to produce country Spectrum files to model and estimate their HIV epidemic every two years.
3PTP[H[PVUZ!
/V^L]LY ZVTL JH]LH[Z L_PZ[ PU YLS`PUN VU TVKLSSPUN ;OL Z[YLUN[O VM [OL TVKLS PZ Z[YVUNS` PUMS\LUJLK
I` TVKLS HZZ\TW[PVUZ HUK [OL X\HSP[` VM [OL KH[H LU[LYLK -HJ[VYZ Z\JO HZ HKOLYLUJL HUK V\[JVTLZ
HYL VM[LU IHZLK VU YLZ\S[Z VM YLZLHYJO Z[\KPLZ ÔPJO TH` UV[ YLMSLJ[ [OL MPLSK YLHSP[PLZ VM WYVNYHTTL
implementation. Models may thus overestimate the impact of PPTCT interventions. As countries intensify
LMMVY[Z [V TLHZ\YL WYVNYLZZ [V^HYKZ LSPTPUH[PVU NYLH[LY LTWOHZPZ T\Z[ IL WSHJLK VU PTWYV]PUN HUK
validating routine data collected as well as capturing adherence to improve the input into models.
:L[[PUN*V\U[Y`ZWLJPÄJ,SPTPUH[PVU;HYNL[Z
The aspirational goals and target outlines in the regional PPTCT and ECS elimination framework should
prompt Asia-Pacific countries to develop ambitious national overall targets that remain guided by data
HUKWYVNYHTTLYLHSP[PLZ5H[PVUHS45*//0=HUK:;0WYVNYHTTLZHSVUN^P[OV[OLYRL`Z[HRLOVSKLYZ
HUK WHY[ULYZ T\Z[ KL]LSVW HTIP[PV\Z `L[ HJOPL]HISL JV\U[Y`ZWLJPMPJ LSPTPUH[PVU NVHSZ [HYNL[Z HUK
[PTLSPULZ>OPSLJV\U[YPLZZOV\SKZ[YP]L[V^HYKZ[OLZHTLLSPTPUH[PVUNVHSZPULHJONP]LU`LHYJV\U[Y`
ZWLJPMPJ[HYNL[ZTH`KPMMLYFigure 2
-PN\YL!*V\U[YPLZULLK[VZL[JVU[L_[HWWYVWYPH[L[HYNL[ZHUK[PTLSPULZ
Regional target for 2015

1
try
un
2
Co
ry
nt
ou
C
Progress towards Goal

Intervention Coverage
3
ntry
Cou
2007 2010 2015
While countries may strive towards the same elimination goals, in each given year, targets and timelines
will vary from country to country. Factors that will influence this include the epidemiological situation,
public policies, health service delivery infrastructure and the anticipated pace of scale-up.
5LJLZZHY`(UHS`ZLZ!
0UVYKLY[VN\PKL[OLZLSLJ[PVUVMHWWYVWYPH[LLSPTPUH[PVU[HYNL[ZHUK[PTLSPULZJV\U[YPLZZOV\SKJVUK\J[
HML^RL`HUHS`ZLZ!
1. Establish clear baselines

0UVYKLY[VKL]LSVWHWWYVWYPH[LJVU[L_[ZWLJPMPJ[HYNL[ZP[PZMPYZ[LZZLU[PHS[VL_HTPULJ\YYLU[KH[H
and practices to establish clear baselines. This includes determining baselines for each of the three
V]LYHSSLSPTPUH[PVU[HYNL[ZU\TILYVMUL^WHLKPH[YPJ/0=PUMLJ[PVUZ7;*;VM/0=YH[LHUKPUJPKLUJL
VM*:PU 0UHKKP[PVUP[PZPTWVY[HU[[VNHPUHJSLHY\UKLYZ[HUKPUNVM[OLIHZLSPULMVYLHJOVM[OL
LPNO[WYVNYHTTH[PJ[HYNL[Z;OPZWYVJLZZ^PSSYLX\PYLJSVZLL_HTPUH[PVUVML_PZ[PUNWYVNYHTTLKH[H
and should prompt improved data generation and collection for future reviews of elimination targets.
2. Critically review country programme data

Countries should examine epidemiological data to develop a clear and updated understanding of
the population in need of services. Programmes should further critically review the historical pace of
scale-up as well as current programme practices and coverage rates to identify key bottlenecks to
HJOPL]PUNLSPTPUH[PVU[HYNL[Z7YVNYHTTLZZOV\SKHSZVL_HTPULO\THUYLZV\YJLJHWHJP[`HUKNHWZ
as well as anticipated funding sources to comprehend what is achievable on an annual basis in terms
VMHJJLZZJV]LYHNLHUKX\HSP[`VM45*/77;*;HUK,*:PU[LY]LU[PVUZ
3. Model the Impact of Different Target Scenarios

7YVNYHTTLZ TH` \[PSPZL TVKLSSPUN ZVM[^HYL [V L_HTPUL KLTVNYHWOPJ HUK LWPKLTPVSVNPJ KH[H
PUJS\KPUN /0= WYL]HSLUJL HUK PUJPKLUJL [YLUKZ HUK SL]LSZ VM 45*/ /0= HUK :;0 ZLY]PJL JV]LYHNL
[V \UKLYZ[HUK ÔH[ SL]LS VM PTWHJ[ 7;*; YH[L VY U\TILY VM UL^ WHLKPH[YPJ /0= PUMLJ[PVUZ JHU IL
achieved at varying levels of coverage.
Setting a Target
-PUHSS` JV\U[YPLZ ZOV\SK [HRL PU[V HJJV\U[ [OL YLZ\S[Z VM HSS [OYLL HUHS`ZLZ [V KL]LSVW HTIP[PV\Z HUK
HJOPL]HISLUH[PVUHS[HYNL[Z[OH[HYL[PLK[VSVNPJHSWYVNYHTTPUNHUK[PTLSPULZ)HZLKVUJ\YYLU[IHZLSPULZ
[OLHU[PJPWH[LKWHJLVMZJHSL\WHUK[OLL_WLJ[LKPTWHJ[H[PUJYLHZPUNSL]LSZVMZLY]PJLJV]LYHNL/0=
STI and MNCH programmes should arrive at a consensus on overall elimination targets and appropriate
timelines for achieving these goals.
2.4 Measuring Elimination Targets: Proposal for Countries, 2011-2015
2011:
,Z[HISPZOJSLHYIHZLSPULZMVYLHJOVM[OLV]LYHSS[HYNL[ZHUKKL[LYTPULJV\U[Y`ZWLJPÄJ[HYNL[ZHUK[PTLSPULZ
(NYLL VU H Z[HUKHYK TL[OVK [V TLHZ\YL WVW\SH[PVUZ PU ULLK PUJS\KPUN /0= WYLNUHU[ ^VTLU HUK
syphilis sero-positive pregnant women.
• Measurement strategies in the Asia-Pacific region should take into account the need to measure hard
[VYLHJOWVW\SH[PVUZPUJS\KPUNRL`HMMLJ[LKWVW\SH[PVUZ2(7Z
2011-2014:
4VKLSLSPTPUH[PVU[HYNL[ZL]LY`VUL[V[^V`LHYZ^P[OJHYLM\S]HSPKH[PVUVMPUW\[KH[H
7LYPVKPJHSS`\ZLV[OLYTL[OVKZJVOVY[HUHS`ZLZ,0+KH[HHUHS`ZLZ[VHZZLZZ[HYNL[Z
0TWYV]LH]HPSHIPSP[`VMJVOVY[HUK,0+KH[HHZ^LSSHZJHZLYLWVY[PUNHUKOLHS[OMHJPSP[`Z\Y]L`KH[H
• Develop and refine outcome assumptions for populations without data.
• Validate estimates based on information from different sources and methods.
2015:
9LWLH[TVKLS^P[OYLMPULKPUW\[KH[HHUKHZZ\TW[PVUZ
• Directly measure new infections where possible AND estimate population with no data and model new
infections for this population.

Programmatic Targets
and Indicators
,SPTPUH[PVUVM7;*;VM/0=HUK*:YLX\PYLZHJVTWYLOLUZP]LHWWYVHJO[OH[HKKYLZZLZHSSMV\YWYVUNZVM
the comprehensive approach to PPTCT. Each of the eight programmatic targets outlined in the conceptual
MYHTL^VYR JVYYLSH[LZ [V VUL VM [OL MV\Y WYVUNZ VM [OL JVTWYLOLUZP]L HWWYVHJO [V 77;*; Figure 3
:L]LYHS VM [OLZL [HYNL[Z HSZV KPYLJ[S` JVYYLSH[L ^P[O IYVHKLY 45*/ WYVNYHTTL VIQLJ[P]LZ HUK HYL PU
SPUL^P[OLZ[HISPZOLK4+.[HYNL[ZYLSH[LK[VPTWYV]PUN[OLOLHS[OHUKZ\Y]P]HSVM^VTLUHUKJOPSKYLU
particularly in the context of HIV and STIs.
-PN\YL!;OL,PNO[7YVNYHTTH[PJ;HYNL[Z*VYYLSH[L[V[OL-V\Y7YVUNZVM[OL*VTWYLOLUZP]L(WWYVHJO[V77;*;
MATERNAL HEALTH
BEFORE PREGANCY PREGNANCY BIRTH
INFANCY, CHILDHOOD
PRONG 1: PRONG 2: PRONG 3: PRONG 4:

Prevent new HIV Prevent unintended Prevent vertical Provide care and
infections in women pregnancies in women transmission of treatment to women
of childbearing age with HIV HIV and syphilis and children with HIV
TARGET 1: TARGET 2: TARGET 5: TARGET 7:

50% reduction in HIV ZERO unmet need for /0=TV[OLYZ LSPNPISL/0=WYLNUHU[
incidence in women of FP among women and exposed infants women remain on ART at
childbearing age with HIV receive ARVs for PPCTC TVU[OZWVZ[WHY[\T
TARGET 6: TARGET 8:
Z`WOPSPZZLYV /0=PUMLJ[LK
positive mothers and JOPSKYLU`LHYZ
infants receive treatment receive ART
TARGET 3: >90% pregnant women access ANC and skilled care at birth
TARGET 4: >90% pregnant women know HIV and syphilis status
Childbearing Women Women Living with HIV Pregnant Women Mothers and Children
with HIV with HIV
7YVNYLZZ[V^HYKZHJOPL]PUNLHJOVM[OLZLWYVNYHTTH[PJ[HYNL[ZPZJYP[PJHSMVYJV\U[YPLZ[VYLHSPaPUNV]LYHSS
LSPTPUH[PVU NVHSZ 0U HKKP[PVU [V TLHZ\YPUN WYVNYLZZ [V^HYKZ H[[HPUPUN V]LYHSS LSPTPUH[PVU [HYNL[Z P[ PZ
[OLYLMVYL LX\HSS` PTWVY[HU[ [V TVUP[VY WYVNYLZZ [V^HYKZ YLHJOPUN LHJO VM [OLZL LPNO[ WYVNYHTTH[PJ
targets. The following tables outline one to two key measures for each of the eight programmatic targets.
7YVNYHTTH[PJ;HYNL[!9LK\J[PVUVM/0=0UJPKLUJL(TVUN>VTLU(NLK @LHYZ
7YL]LU[PVUVM/0=PU^VTLUVMYLWYVK\J[P]LHNLHNL SLHKZ[VHYLK\J[PVUPU^VTLUSP]PUN^P[O/0=ÔVTH`Z\IZLX\LU[S`NL[
WYLNUHU[YLK\JPUN[OLV]LYHSSU\TILYVMWV[LU[PHSM\[\YLWHLKPH[YPJ/0=PUMLJ[PVUZ
Measure of Target Numerator Denominator Method of Measurement
HIV incidence Number of new HIV infections Number of women The baseline incidence and reduction in
among women among women aged 15-49 years in aged 15-49 in the incidence in women of reproductive age (15-49)
HNLK `LHYZ a given calendar year given calendar year, should be modelled using the Spectrum software
UNGASS Indicator) excluding the female (see Annex 1)
HIV population in
that year
Additional Indicators for Programmatic Target 1
Indicator >OH[+VLZ0[4LHZ\YL 5\TLYH[VY +LUVTPUH[VY 4L[OVKVM4LHZ\YLTLU[
Percentage Assesses progress in implementing 5\TILYVM2(7 Number of Numerator and

of key at-risk HIV testing and counselling among respondents who 2(7ZPUJS\KLK +LUVTPUH[VY!
populations 2(7Z. This indicator should be have been tested for in the sample Behavioural surveillance
(KAPs) who calculated separately for each HIV during the last VYV[OLYZWLJPHSZ\Y]L`Z
received an HIV population that is considered at-risk TVU[OZHUKÔV ZHTWSLKMVYZWLJPÄJ2(7Z
test in the last 12 PUHNP]LUJV\U[Y`PUJS\KLZZL_ know their results can be used
months and who ^VYRLYZ:>WLVWSLÔVPUQLJ[
know their results KY\NZ7>0+TLUÔVOH]LZL_
UA/UNGASS ^P[OTLU4:4HUKWYPZVULYZ
indicator
Percentage of (ZZLZZLZTHSLPU]VS]LTLU[ÔPJO Number of pregnant Number of Numerator and

Pregnant Women is important in the prevention of women attending pregnant +LUVTPUH[VY!5H[PVUHS
attending ANC HIV infection. Measures percentage ANC whose male women programme records
whose partner of pregnant women attending partner was tested in attending ANC compiled from ANC
was tested for ANC whose male partner was [OLWHZ[TVU[OZ PU[OLWHZ[ registers
HIV in the last 12 [LZ[LKK\YPUN[OLPYMLTHSLWHY[ULY»Z months
months* WYLNUHUJ`PU[OLSHZ[TVU[OZ
UA Indicator
(S[LYUH[P]LS`WYVNYHTTLZTH`JOVVZL[VMVJ\ZVUWLYJLU[HNLVMKL[LJ[LK/0=WVZP[P]LWYLNUHU[^VTLUÔVZLWHY[ULY^HZ[LZ[LKMVY
/0=PU[OLSHZ[TVU[OZ;OLU\TLYH[VYPZ[OLU\TILYVMWYLNUHU[/0=WVZP[P]L^VTLUH[[LUKPUN(5*ÔVZLTHSLWHY[ULY^HZ[LZ[LKPU
[OLSHZ[TVU[OZHUK[OLKLUVTPUH[VYPZ[OLU\TILYVM/0=WVZP[P]LWYLNUHU[^VTLUH[[LUKLK(5*KL[LJ[LKPU[OLSHZ[TVU[OZ
7YVNYHTTH[PJ;HYNL[!9LK\JL<UTL[5LLKMVY-HTPS`7SHUUPUN[VALYV(TVUN>VTLU3P]PUN^P[O/0=
<UTL[ULLKMVY-7PZKLÄULKHZ[OLWYVWVY[PVUVM^VTLUVMYLWYVK\J[P]LHNL `LHYZÔVHYLTHYYPLKVYHYLPUH\UPVUÔVKVUV[
^HU[HU`TVYLJOPSKYLUVY^HU[[V^HP[H[SLHZ[[^V`LHYZILMVYLOH]PUNHIHI`HUK`L[HYLUV[\ZPUNJVU[YHJLW[PVU9LK\JPUN\UTL[
ULLK-7HTVUN^VTLUSP]PUN^P[O/0=YLK\JLZ[OLU\TILYVM\UWSHUULKWYLNUHUJPLZHTVUN/0=^VTLUJVU[YPI\[PUN[VHYLK\J[PVU
in potential new paediatric HIV infections.
Unmet need for Number of women of reproductive Total number Numerator and Denominator: Review of ART
family planning age living with HIV and attending of women of registries; exit interviews with HIV-positive
among HIV- HIV care and treatment services reproductive age women in care if through special survey;
positive women of who either have an unmet need for (15–49) living national programme records
reproductive age (15 FP or an unintended pregnancy at with HIV who are
`LHYZÔVHYL the time of the assessment attending HIV care
attending care and and treatment
treatment services services
Percentage of HIV The necessary conditions for Number of HIV Number of Numerator and
service delivery ensuring a minimum range of service delivery HIV service +LUVTPUH[VY!
points prepared contraceptive methods at HIV care points prepared delivery points 9LWYLZLU[H[P]LZ\Y]L`
to provide at least and treatment sites [VWYV]PKLOH]L assessed conducted annually or
three FP methods unexpired stocks (SSZP[LZPU every few years
and a trained JV\U[Y`VY
WYV]PKLYH]HPSHISL a selected
modern FP methods ZHTWSL

7YVNYHTTH[PJ;HYNL[!% VM7YLNUHU[>VTLU(JJLZZ(5*HUK:RPSSLK*HYLH[)PY[O
The effectiveness of PPTCT and ECS interventions critically depends on the proportion of pregnant women who access antenatal
services and receive skilled attendant services at the time of labour and delivery. These data are collected through the MDG
TVUP[VYPUNWYVJLZZ4+.;OLZLKH[HHYLVM[LUJVSSLJ[LKPUYV\[PULWYVNYHTTLTVUP[VYPUNHUKYLWVY[PUNZ`Z[LTZ+H[HHYLHSZV
JVSSLJ[LKWLYPVKPJHSS`PUOV\ZLOVSKZ\Y]L`ZPUJS\KPUN+LTVNYHWOPJHUK/LHS[O:\Y]L`Z+/:9LWYVK\J[P]L/LHS[O:\Y]L`Z9/:
-LY[PSP[`HUK-HTPS`:\Y]L`Z--:HUKHYLHSZVPUJS\KLKPU[OL4\S[PWSL0UKPJH[VY*S\Z[LY:\Y]L`Z40*:
Percentage of Number of women age 15-49 years Total number of Numerator and Denominator: Review of
pregnant women who were attended at least once by women aged 15-49 national programme data or representative
attended by skilled skilled personnel during pregnancy years with a live birth health survey (e.g. MICS)
personnel at in the 12 months preceding the in the 12 months
least once in the survey preceding the survey
antenatal period
Percentage Number of women age 15-49 years Total number of Numerator and Denominator: Review of
of deliveries with a live birth in the 12 months women age 15-49 national programme data or representative
attended by preceding the survey who were years with a live birth health survey (e.g. MICS)
skilled birth attended during childbirth by skilled in the 12 months
attendants health personnel preceding the survey
Percentage of Access to antenatal services among Number of women Total number Numerator and
pregnant women all women HNL `LHYZÔV of women age +LUVTPUH[VY! 9L]PL^VM
attended by were attended at `LHYZ national programme data
skilled personnel least four times by with a live or representative health
at least four any provider during birth in the Z\Y]L`LN40*:
times during the WYLNUHUJ`PU[OL TVU[OZ
antenatal period months preceding preceding the
the survey survey
7YVNYHTTH[PJ;HYNL[!% 7YLNUHU[>VTLU2UV^;OLPY/0=HUK:`WOPSPZ:[H[\Z
The effectiveness of PPTCT and ECS interventions critically depends on the proportion of pregnant women who receive the results of
[OLPY/0=HUKZ`WOPSPZZLYVSVN`[LZ[Z>VTLUKPHNUVZLKPU(5*ZL[[PUNZJHUILSPURLK[VLZZLU[PHS77;*;HUK,*:ZLY]PJLZHZ^LSS
HZ[VSPMLZH]PUN[YLH[TLU[MVY[OLPYVÛOLHS[O;OLZLKH[HHYLJVSSLJ[LKMYVTUH[PVUHSWYVNYHTTLZ[OYV\NO[OL<UP]LYZHS(JJLZZ<(
HUKVY<5(0+:YLWVY[PUNWYVJLZZLZ
Percentage of Number of pregnant women who were Estimated number Numerator: National programme records
pregnant women tested for HIV and received results of total pregnant aggregated from facility registers for ANC,
who know their during pregnancy, during labour and women in the last 12 labour and delivery and post-partum care.
HIV status results delivery, and during the post-partum months Denominator: Derived from a population
UA Indicator period (<72 hours), including those estimate*
with previously known HIV status in
the last 12 months
Percentage of 5\TILYVM^VTLUH[[LUKPUNÄYZ[ Number of women Numerator and Denominator: National

women accessing visit ANC services who were tested H[[LUKPUNÄYZ[]PZP[ programme records aggregated from facility
ANC services who for syphilis ANC services registers for ANC
were tested for
syphilis at
ÄYZ[(5*]PZP[
(UA Indicator)
*HUILVI[HPULKMYVTLZ[PTH[LZVMIPY[OZMYVT[OLJLU[YHSZ[H[PZ[PJZVMÄJL<UP[LK5H[PVUZ7VW\SH[PVU+P]PZPVUVYWYLNUHUJ`YLNPZ[YH[PVU
systems with complete data
Percentage of 6UZP[LH]HPSHIPSP[`VM/0=[LZ[PUNH[ Number of health Total number Numerator and

-VY ZL]LU
health VM [OL WYVNYHTTH[PJ
facilities [HYNL[Z
all health facilities that provideHKKP[PVUHS
ANC PUKPJH[VYZ
facilities providingHYL HSZV Z\NNLZ[LK+LUVTPUH[VY!
of health [V TLHZ\YL WYVNYLZZ
National
[V^HYKZ Z[H[LK
providing ANC NVHSZ ;OL IHZLSPUL ]HS\L MVY [OL [HYNL[Z PZ
ANC services that [OL `LHY
facilities HUK [OL [HYNL[ `LHY
WYVNYHTTLYLJVYKZ PZ
unless
servicesspecified
that otherwise. offer HIV testing on providing ANC e.g. list of facilities and
also provide site at the end of the available services
HIV testing and reporting period
counselling for
pregnant women
(UA Indicator)
Percentage of 6UZP[LH]HPSHIPSP[`VMZ`WOPSPZ Number of health Total number Numerator and

health facilities screening at all health facilities that facilities providing of health +LUVTPUH[VY! National
providing ANC provide ANC ANC services facilities WYVNYHTTLYLJVYKZ
services that also that offer syphilis providing ANC e.g. list of facilities and
provide syphilis screening on site available services
screening for at the end of the
pregnant women reporting period
7YVNYHTTH[PJ;HYNL[! /0=7VZP[P]L4V[OLYZHUK,_WVZLK0UMHU[Z9LJLP]LK,MMLJ[P]L(9=Z[V9LK\JL7;*;
Dramatic reductions in new paediatric HIV infections will not be possible unless pregnant women living with HIV and their exposed
PUMHU[ZYLJLP]LLMMLJ[P]L(9=YLNPTLUZ[VYLK\JL7;*;;OLZLKH[HHYLJVSSLJ[LKMYVTUH[PVUHSWYVNYHTTLZ[OYV\NO[OL<UP]LYZHS
(JJLZZ<(HUKVY<5(0+:YLWVY[PUNWYVJLZZLZ
Percentage of Number of HIV-infected pregnant Estimated number Numerator: National programme records
HIV-infected women who received ARV to reduce of pregnant HIV- aggregated from facility registers (ANC, labour
pregnant women PTCT during the preceding 12 infected women in and delivery, HIV care and treatment, post-
who received ARV months. This includes: the preceding 12 partum care site)
drugs to reduce 1) ART for eligible women months Denominator: Projection model such as
the risk of PTCT 2) Maternal triple ARV prophylaxis; Spectrum*
(UA Indicator) 3) Maternal AZT, and
4) Single-dose nevirapine only
(Disaggregate by ARV option)
Percentage of Number of infants born to HIV- Estimated number Numerator: National programme records
infants born to HIV infected women during the past 12 of live births to aggregated from facility registers(labour and
infected women months who were started on ARV pregnant HIV- delivery, HIV care/treatment, post-natal care)
who received prophylaxis to reduce peri-partum infected women in Denominator: Projection model such as
ARV prophylaxis PTCT the past 12 months Spectrum*
to reduce risk of
peri-partum PTCT
(UA Indicator)
Percentage of Progress in the prevention of PTCT Number of infants Estimated 5\TLYH[VYHUK+LUVTPUH[VY!

infants born to in breastfeeding populations by the born to HIV-infected number of Stand-alone or integrated
HIV-infected WYV]PZPVUVM(9=Z[VYLK\JL[OL ^VTLUÔVK\YPUN infants born to HIV-exposed infant register;
mothers who are risk of HIV transmission during the [OLWHZ[TVU[OZ HIV-infected reporting form
provided with breastfeeding period. are breastfeeding ^VTLU/0=
ARV (maternal or and protected by exposed
infant) to reduce HU(9=PU[LY]LU[PVU PUMHU[Z
the risk of HIV to reduce vertical who are
transmission transmission through breastfeeding
during IYLHZ[MLLKPUNUHTLS` during the past
breastfeeding either maternal or TVU[OZ
period PUMHU[(9=Z
4\S[PWS`[OLU\TILYVM^VTLUÔVNH]LIPY[OPU[OLWHZ[TVU[OZI`[OLTVZ[YLJLU[UH[PVUHSLZ[PTH[LVM/0=WYL]HSLUJLPUWYLNUHU[
^VTLUÔPJOJHUILKLYP]LKMYVT/0=ZLU[PULSZ\Y]LPSSHUJLPUHU[LUH[HSJHYLJSPUPJZPM:WLJ[Y\TWYVQLJ[PVUZHYL\UH]HPSHISL

7YVNYHTTH[PJ;HYNL[!% :`WOPSPZ:LYVWVZP[P]L4V[OLYZHUK,_WVZLK0UMHU[Z9LJLP]LK,MMLJ[P]L;YLH[TLU[
Dramatic reductions in congenital syphilis infections will not be possible unless syphilis sero-positive pregnant women and their
exposed infants receive effective treatment to reduce vertical transmission.
Percentage of Number of ANC attendees who Number of ANC Numerator and Denominator: National
ANC attendees tested positive for syphilis attendees who were programme data aggregated from health
who were positive tested for syphilis facility data (ANC register, reporting form)
for syphilis
UA Indicator)
Percentage of Number of ANC attendees with a Number of ANC Numerator and Denominator: National
ANC attendees positive syphilis serology who attendees with a programme data aggregated from health
positive for received at least one dose of positive syphilis facility data (ANC or labour and delivery
syphilis who benzathine penicillin 2.4 mU IM serology register; reporting form)
received
treatment
(UA Indicator)
Percentage of Number of infants born to syphilis Total number of Numerator and Denominator: National
infants born to sero-positive women who received live births to sero- Programme data aggregated from health
syphilis sero- syphilis treatment to reduce CS positive pregnant facility data (labour and delivery, post-partum
positive women women registers)
are treated
appropriately
There are no additional indicators for Programmatic Target 6.
7YVNYHTTH[PJ;HYNL[!% ,SPNPISL/0=7VZP[P]L7YLNUHU[>VTLU9LTHPUVU(9;H[4VU[OZ7VZ[7HY[\T
(RL`MLH[\YLVM[OLLSPTPUH[PVUPUP[PH[P]LPZP[ZMVJ\ZVUPTWYV]PUN[OLOLHS[OHUKZ\Y]P]HSVM^VTLUHUKJOPSKYLUPU[OLJVU[L_[VM/0=
:;0Z;OPZ[HYNL[\UKLYZJVYLZ[OH[77;*;PU[LY]LU[PVUZKVUV[LUKH[KLSP]LY`HUKLTWOHZPZL[OLPTWVY[HUJLVMSPURPUN/0=WVZP[P]L
mothers to lifelong treatment and care.
Percentage of Number of HIV-infected pregnant Estimated number Numerator and Denominator:

eligible HIV- women attending PPTCT services of HIV-positive ANC or other register for HIV-positive women,
positive mothers in the past 12 months assessed as pregnant women pre-ART or ART register depending on
still alive and eligible for ART (by either clinical or eligible for ART (by context; reporting form for special cohort
known to be on CD4 criteria) who were started and either clinical or CD4 analysis
treatment 12 remain on ART at 12-months post- criteria) in a given
months after ART partum year
initiation (among
estimated eligible
HIV-positive
mothers in a
given year)
Percentage of Coverage of eligibility assessment Number of HIV- Estimated Numerator!5H[PVUHS

HIV-infected MVY(9;HTVUN/0=PUMLJ[LK infected pregnant number of programme data aggregate
pregnant women WYLNUHU[^VTLULP[OLYI`JSPUPJHS women attending HIV-infected from health facility registers
assessed for ART Z[HNPUNJYP[LYPHVYI`*+[LZ[PUN services for PPTCT pregnant (5*VYV[OLYYLNPZ[LYMVY
eligibility through PU[OLWHZ[ women in /0=WVZP[P]L^VTLUWYL
either clinical months assessed for [OLWHZ[ (9;VY(9;YLNPZ[LY
staging or CD4 LSPNPIPSP[`MVY(9;I` months +LUVTPUH[VY! 7YVQLJ[PVU
testing either clinical staging TVKLSZ\JOHZ:WLJ[Y\T
(UA Indicator) VY*+[LZ[PUNVU
site or by referral
+PZHNNYLNH[L
by method of
HZZLZZTLU[
Percentage of *V]LYHNLVM(9;HTVUN/0= Number of HIV- Estimated Numerator and

eligible HIV- infected pregnant women who infected pregnant number of Denominator: National
infected pregnant YLX\PYL[YLH[TLU[MVY[OLPYVÛOLHS[O women attending HIV-infected programme data
women started on services for PPTCT in pregnant aggregated from health
ART [OLWHZ[TVU[OZ women eligible MHJPSP[`(5*WYL(9;(9;
Z[HY[LKVU(9;MVY MVY(9;PU[OL register or reporting form
their own health WHZ[TVU[OZ
7YVNYHTTH[PJ;HYNL[!% /0=0UMLJ[LK*OPSKYLU@LHYZ9LJLP]L(9;
(RL`MLH[\YLVM[OLLSPTPUH[PVUPUP[PH[P]LPZP[ZMVJ\ZVUPTWYV]PUN[OLOLHS[OHUKZ\Y]P]HSVM^VTLUHUKJOPSKYLUPU[OLJVU[L_[VM/0=
:;0Z;OPZ[HYNL[\UKLYZJVYLZ[OH[77;*;PU[LY]LU[PVUZKVUV[LUKH[KLSP]LY`HUKLTWOHZPZLZ[OLPTWVY[HUJLVMSPURPUN/0=PUMLJ[LK
children with lifesaving care and treatment.
Percentage of HIV- Number of children who are Estimated number Numerator: National programme records drawn
infected children receiving ART in accordance of children with from data collected in ART registers at facilities
(aged 0-14 years) with the nationally approved advanced HIV Denominator: Estimated by the method
who are currently treatment protocol (or WHO/ infection recommended by the UNAIDS/WHO
receiving ART UNAIDS standards) Reference Group on Estimates, Modelling and
(UA Indicator) at the end of the reporting period Projections using Spectrum software
Percentage of The extent to which infants born Number of infants Estimated 5\TLYH[VY! Collected from
infants born to to HIV-infected women are tested who received an number of databases held at Early
HIV-infected ^P[OPU[OLÄYZ[[^VTVU[OZVMSPML[V HIV test within HIV-infected Infant Diagnosis testing
women receiving KL[LYTPUL[OLPY/0=Z[H[\Z two months of pregnant laboratories
a virological test disaggregated by test results IPY[OK\YPUN[OL women giving +LUVTPUH[VY!7YVQLJ[PVU
for HIV within two YLWVY[PUNWLYPVK birth in the last TVKLSZ\JOHZ:WLJ[Y\T
months of birth disaggregated by TVU[OZ
(UA Indicator) test results Including
WVZP[P]LULNH[P]L
PUKL[LYTPUH[LHUK
YLQLJ[LKMVY[LZ[PUNI`
the laboratory. Infants
tested should only be
counted once. The
numerator should
only include the most
recent test result for
an infant tested in
[OLÄYZ[[^VTVU[OZ
VMSPMLHUKUV[HU`
earlier tests
^VTLUÔPJOJHUILKLYP]LKMYVT/0=ZLU[PULSZ\Y]LPSSHUJLPU(5*JSPUPJZPM:WLJ[Y\TWYVQLJ[PVUZHYL\UH]HPSHISL

Additional Indicators for Programmatic Target 8 JVU[PU\LK
Percentage of The extent to which infants born Number of infants Estimated The numerator is calculated
infants born to to HIV-infected women are tested who received an HIV number of from national programme
HIV-infected to determine their HIV status [LZ[I`TVU[OZ HIV-infected records compiled from
^P[OPU[OLÄYZ[TVU[OZVMSPML KPZHNNYLNH[LKPU[V! pregnant data collected in registers
women who
KPZHNNYLNH[LKI`! women who at facilities.
received an HIV HPUMHU[ZÔV gave birth in
test within 12 HLHYS`]PYVSVNPJHS[LZ[PUNI` received virological [OLWHZ[ The number of infants
months months of age; or [LZ[PUNILMVYL months. This a ÔV^LYL[LZ[LKUV[[OL
(UA Indicator) I]PYVSVNPJHS[LZ[PUNIL[^LLU months of age; and proxy measure U\TILYVM[LZ[ZWLYMVYTLK
HUKTVU[OZVMHNLHUKPUP[PHS IPUMHU[ZÔV^LYL of the number ZOV\SKILJV\U[LKHZ
HU[PIVK`[LZ[PUNIL[^LLU HUK tested virologically of infants born many infants may be tested
months. MVY[OLÄYZ[[PTL to HIV-infected several times.
IL[^LLUHUK women
months of age or Two methods can be
who had an antibody used to eliminate the
[LZ[MVY[OLÄYZ[[PTL KLUVTPUH[VY!
IL[^LLU HUK
months of age HHWYVQLJ[PVUTVKLS
such as that provided by
Both categories :WLJ[Y\TZVM[^HYL!\ZL
should be further [OLV\[W\[¸U\TILYVM
disaggregated by pregnant woman needing
HIV test results prevention of mother-to-
into seropositive or JOPSK[YHUZTPZZPVUVM/0=¹
seronegative. HZHWYV_`VY
Tested infants should IT\S[PWS`[OLU\TILYVM

be counted only women who gave birth in
once. The numerator [OLWHZ[TVU[OZÔPJO
should include only can be obtained from the
the initial test. JLU[YHSZ[H[PZ[PJZVMÄJL
or the United Nations
Population Division or
pregnancy registration
systems with complete
KH[HI`[OLTVZ[YLJLU[
national estimate of HIV
prevalence in pregnant
womenÔPJOJHUIL
derived from HIV sentinel
surveillance in antenatal
JHYLJSPUPJPM:WLJ[Y\T
WYVQLJ[PVUZHYL\UH]HPSHISL
If there are data on the

U\TILYVMSP]LIPY[OZ[OL`
ZOV\SKILHKQ\Z[LK[V
derive a better proxy.
5H[PVUHSLZ[PTH[LZVM/0=PUMLJ[LKWYLNUHU[^VTLUZOV\SKILKLYP]LKI`HKQ\Z[PUNZ\Y]LPSSHUJLKH[HMYVTZLU[PULSZP[LZH[HU[LUH[HSJSPUPJZ
HUKV[OLYZV\YJLZ[HRPUNPU[VJVUZPKLYH[PVUJOHYHJ[LYPZ[PJZZ\JOHZHNLKPZ[YPI\[PVUHUKY\YHSHUK\YIHUWH[[LYUZVM/0=WYL]HSLUJL
Additional Indicators for Programmatic Target 8 JVU[PU\LK
Percentage of -LLKPUNVM/0=L_WVZLKPUMHU[Z The numerators The number of 5\TLYH[VY! National

HIV-exposed KLYP]LKMYVTOYLJHSSTLHZ\YLK capture feeding HIV-exposed programme records
infants who at the time of the third dose of practices only for infants whose aggregated from stand-
are receiving KPWO[OLYPHWLY[\ZZPZHUK[L[HU\Z known HIV-exposed feeding alone or integrated HIV-
exclusive ]HJJPUL+7; infants who visit a practice has exposed registers
breastfeeding, health facility at or been assessed Denominator!;V[HS number
replacement HYV\UK+7;]PZP[ H[+7;]PZP[ of exposed infants whose
feeding or mixed and are disaggregated feeding was assessed
feeding at DPT3 HZMVSSV^Z!
visit (Infants will H!5\TILY
be aged around exclusively
three months) breastfeeding
(UA Indicator) I!5\TILY
receiving replacement
feeding
J!5\TILYYLJLP]PUN
mixed feeding
Percentage of The provision and coverage of Number of infants Estimated 5\TLYH[VY! National
infants born to HIV- JV[YPTV_HaVSLWYVWO`SH_PZMVY born to HIV-infected number of programme records
infected women HIV-exposed infants in line with women started HIV-infected aggregated from stand-
who are started international guidelines VUJV[YPTV_HaVSL pregnant alone or integrated HIV-
on co-trimoxazole prophylaxis within two women who exposed registers
prophylaxis within months of birth in the gave birth in +LUVTPUH[VY!7YVQLJ[PVU
two months of birth WHZ[TVU[OZ [OLWHZ[ TVKLSZ\JOHZ:WLJ[Y\T
(UA Indicator) months
^VTLUÔPJOJHUILKLYP]LKMYVT/0=ZLU[PULSZ\Y]LPSSHUJLPU(5*JSPUPJZPM:WLJ[Y\TWYVQLJ[PVUZHYL\UH]HPSHISL
Annex
,Z[PTH[PUN6]LYHSS;HYNL[Z^P[O:WLJ[Y\T
;OL:WLJ[Y\TZVM[^HYLJVTIPULZHYHUNLVML_PZ[PUNKLTVNYHWOPJHUKLWPKLTPVSVNPJHSWHYHTL[LYZLN
WVW\SH[PVUMLY[PSP[`HUKTVY[HSP[`YH[LZ^P[O]HYPV\ZJV\U[Y`KH[HHUKWYVNYHTTLPUW\[ZHUKHZZ\TW[PVUZ
LN /0= WYL]HSLUJL MYVT ZLU[PULS Z\Y]LPSSHUJL Z\Y]L`Z PU[LY]LU[PVU JV]LYHNL HUK P[Z LMMLJ[ VU /0=
PUMLJ[PVUZWYVNYLZZPVUMYVT/0=PUJPKLUJL[VTVY[HSP[`HUKWYV]PKLZHKLTVNYHWOPJWYVQLJ[PVUVM]HYPV\Z
/0= LZ[PTH[LZ PUJS\KPUN /0= PUJPKLUJL U\TILY VM UL^ HK\S[ HUK JOPSK /0= PUMLJ[PVUZ HUK LZ[PTH[LK
77;*;(9=ULLKZFigure 4
-PN\YL!:[Y\J[\YLVM:WLJ[Y\T4VKLS
Demographic Data Demographic and Epidemic Calculations Results

• Parents-to-child transmission • Number of HIV+
• Child model • New Infections
Programme Statistics • Adult model • AIDS deaths
• Need for ART
Epidemic Patterns • Need for PMTCT
Surveillance and Survey Data Prevalence/incidence trend
-YVT:WLJ[Y\T7YLZLU[H[PVU<5(0+:
;OLÄN\YLILSVÎYPLÅ`KLZJYPILZ[OLJHSJ\SH[PVUVM[OLU\TILYVMUL^JOPSKPUMLJ[PVUZPU:WLJ[Y\T
Infants born
with HIV
Age-specific Perinatal
Age fertility rates transmission
Births to Monthly
Women specific discounted for rates New child
HIV-positive transmission
15-49 HIV lower fertility depending HIV infections
women rate during
prevalence among HIV on ARV Number of
positive women regimen Infants born breastfeeding
months
without HIV (depending on
breastfed
infant feeding
method and
ARV regimen)
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women in the Asia-Pacific region.
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!PP

Elimination of
New Paediatric
HIV Infections
and
Congenital
Syphilis
in
Asia-Pacific
2011-2015
Conceptual
19 Phra Atit Road
Bangkok 10200 Thailand
Framework
Tel: (66 2) 356-9499
Fax: (66 2) 280-3563 Monitoring and
E-mail: eapro@unicef.org
www.unicef.org/eapro Evaluation Guide

EMTCT Regional Framework

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EMTCT Regional Framework

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Elimination of

UNICEF East Asia and Pacific Regional Office

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PART 1: Conceptual Framework

4. Elimination: Joint HIV/STI/MNCH Initiative 15

5. Elements of the Framework 17

6. Building Blocks: Priority Actions 21

7. Key Next Steps 27

PART 2: Monitoring and Evaluation Guide

3. Programmatic Targets and Indicators 43

Annex: Estimating Overall Targets with Spectrum 51

Table 1: 2L`.SVIHS0UP[PH[P]LZ-VJ\ZLKVU0TWYV]PUN4H[LYUHSHUK*OPSK/LHS[O 

Table 2: Potential Contributions of Comprehensive PPTCT and ECS Efforts towards

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Table 6: +L]LSVWTLU[VMH*VTWYLOLUZP]L5H[PVUHS7;*;HUK*:,SPTPUH[PVU7SHU 

Table 7: Cost-savings of implementing comprehensive PPTCT services in a concentrated

Figure 1: Conceptual Framework for the elimination campaign of mother-to-child

Figure 2: *V\U[YPLZULLK[VZL[JVU[L_[HWWYVWYPH[L[HYNL[ZHUK[PTLSPULZ 

Figure 4: :[Y\J[\YLVM:WLJ[Y\T4VKLS 

viii Conceptual Framework

Overall Targets ()`!

1.1 Parents-to-Child Transmission of HIV and Congenital Syphilis

1.2 Comprehensive Approach to Prevention and Treatment

UN Comprehensive Approach to PPTCT

Prong 1: Primary prevention of HIV among women of childbearing age.

MDG 5: Improve Maternal Health  0UJYLHZLHJJLZZHUKX\HSP[`VM45*/ZLY]PJLZ

1.4 Towards Elimination of PTCT of HIV and CS: Evolution of Goals

2.1 HIV and Parents-to-Child Transmission: Epidemiology and Coverage

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2.2 Congenital Syphilis: Regional Epidemiology and Screening Practices

HIV and Parents-to-Child Transmission

Maternal, Neonatal and Child Health

Infant Health  0UMHU[4VY[HSP[`9H[PV! WLYSP]LIPY[OZ 

1. Optimise the Public Health Approach

2. Adopt a rights-based approach, and ensure equity

4. Improve maternal, neonatal and child health

5. Integrate services and collaborating with all relevant sectors

6. Ensure a country-led initiative based on local needs

4.1 Elimination: A Joint HIV/STI and MNCH Initiative

4.2 Elements of the Elimination Framework

VISION: GOAL: OVERALL TARGETS: PROGRAMMATIC TARGETS:

Ensure Enhance Employ Improve Promote Improve

5.3 Overall Targets

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5.4 Programmatic Targets

PRONG 1: PRONG 2: PRONG 3: PRONG 4:

TARGET 1: TARGET 2: TARGET 5: TARGET 7:  

TARGET 4: >90% pregnant women know HIV and syphilis status

5.5 Building Blocks

6.1 Building Block 1: Ensure Commitment to Achieve Goals

6.2 Building Block 2: Enhance Provision of Comprehensive, Linked Services

6.3 Building Block 3: Employ Highly Effective Interventions

2. Prong 2!Prevention of unintended pregnancies among women living with HIV

Comprehensive Approach to PMTCT and ECS Priority Actions

Prong 2: • Standardise the delivery of routine FP services for women

Prong 3: • Prioritise expansion of routine HIV and syphilis testing in all

6.5 Building Block 5: Promote Health Systems Development and

6.6 Building Block 6: Improve Measurement of Performance and Impact

7.1 Country Level

7.2 Regional Level

High level advocacy

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Figure 4: :[Y\J[\YLVM:WLJ[Y\T4VKLS

Overall Targets ()`!

MDG 5: Improve Maternal Health 0UJYLHZLHJJLZZHUKX\HSP[`VM45*/ZLY]PJLZ

;OLYLHYLHULZ[PTH[LK TPSSPVUWYLNUHUJPLZHUU\HSS`PU[OL(ZPH7HJPÄJYLNPVU0U VUS`WLYJLU[VM

Infant Health 0UMHU[4VY[HSP[`9H[PV! WLYSP]LIPY[OZ

º9LK\JLUL^WHLKPH[YPJ/0=PUMLJ[PVUZI` WLYJLU[MYVTH IHZLSPUL»

TARGET 1: TARGET 2: TARGET 5: TARGET 7:

Assess Current Programme Performance Gaps

Set Targets and Goals

Develop an Operational Plan

Implement, Monitor and Evaluate

9H[LZ!

Universal coverage:

The framework further outlines eight key Programmatic TargetsFigure 1LHJOVM^OPJOJVYYLSH[LZ[VVUL

TARGET 1: TARGET 2: TARGET 5: TARGET 7:

Percentage of (ZZLZZLZTHSLPU]VS]LTLU[^OPJO Number of pregnant Number of Numerator and

Percentage of 6UZP[LH]HPSHIPSP[`VM/0=[LZ[PUNH[ Number of health Total number Numerator and

Percentage of 6UZP[LH]HPSHIPSP[`VMZ`WOPSPZ Number of health Total number Numerator and

Percentage of *V]LYHNLVM(9;HTVUN/0= Number of HIV- Estimated Numerator and

Tested infants should IT\S[PWS`[OLU\TILYVM

Percentage of -LLKPUNVM/0=L_WVZLKPUMHU[Z The numerators The number of 5\TLYH[VY! National