European Journal of Public Health, Vol. 16, No.

2, 123–127
Ó The Author 2006. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved.
doi:10.1093/eurpub/cki150
......................................................................................................
Infectious Diseases
......................................................................................................
Prevention of mother-to-child transmission of
HIV infection: Ukraine experience to date
Ruslan Malyuta1, Marie-Louise Newell2, Mikael Ostergren1, Claire Thorne2,
Nadezhda Zhilka3

Background: Despite the availability of effective interventions for the prevention of mother-to-child
transmission (PMTCT), questions remain regarding implementation of programmes in settings with
limited resources. This article sets out to describe the first 2 years of the implementation of the national

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PMTCT programme in Ukraine. Methods: National data sources and data from a cohort of pregnant HIV-
infected women delivering in 13 centres in Ukraine since 2000 were analysed. Results: Interventions for
prevention of MTCT have been implemented as a national programme within Ukraine’s well developed
infrastructure for maternal and child health. Implementation of an ‘opt-out’ model of counselling and
HIV testing in antenatal clinics resulted in a 97% uptake of women who agreed to be HIV tested. In 2002,

91% of HIV-positive pregnant women received ARV prophylaxis (mainly single-dose nevirapine or
short-course zidovudine) for PMTCT. The MTCT rate has decreased from 30% in 2000 to 10% in 2002.
The need to scale-up prevention interventions in pregnant women with risky behaviour and late access
to medical services was identified in a review of the national programme in 2003. Conclusions: Further
implementation of a comprehensive approach for the prevention of HIV infection in infants, including
more extensive ART regimen, as recommended by WHO, would help Ukraine to achieve the strategic goal
of virtual elimination of HIV infection in infants by 2010.

Keywords: antiretroviral, HIV infection, infants, pregnant, prevention, prophylaxis, Ukraine

..........................................................................................

ertical transmission is the main source of HIV infection in
V children with an estimated 2000 vertically-acquired HIV
infections occurring daily globally, mostly in sub-Saharan
Africa. Eastern Europe and Central Asia currently have the fast-
est growing epidemic in the world.1 Effective interventions for
prevention of mother-to-child transmission (PMTCT) of HIV
infection exist and where freely available, MTCT rates of 1–2%
are achievable.2–4 The challenge is to provide available, access-
ible and affordable interventions to overcome the rapid increase
in new HIV cases among children in countries with limited
resources. The WHO Regional Office for Europe with other
UN co-sponsors developed a Regional Strategic Framework
for Prevention of HIV Infection in Infants.5 The goal set for
the European region is virtual elimination (less than one HIV
infected infant per 100 000 live births, and <2% of infants born
to HIV-infected women acquiring HIV infection) of new HIV
paediatric cases by 2010.
Ukraine was the first Eastern European country facing a dra-
matic spread of HIV/AIDS, which, in contrast to the HIV epi-
demic in African countries, has been driven by illicit injection
drug usage (IDU).6,7 Incidence of HIV infection among IDUs
has remained stable during the last 5 years, with 4000 cases
officially registered annually, but has declined from 79%, in
1995–1998 to 58% in 1999–2002 among newly registered
cases, with concomitant increases in heterosexually acquired
cases. Risky sexual behaviour and low awareness of HIV pre-
.............................................................
1 World Health Organization Regional Office for Europe,
Copenhagen, Denmark
2 Institute of Child Health, University College, Centre for Paediatric
Epidemiology, London, UK
3 Ministry of Health, Department of Mother and Child Health,
Kiev, Ukraine
Correspondence: Ruslan Malyuta, MD, Medical Officer, Child and
Adolescent Health and Development, World Health Organisation,
Regional Office for Europe, Scherfigsvej 8, DK-2100 Copenhagen,
Denmark, tel: þ45 39171329, fax: þ45 39171852,
e-mail: rmalyuta@yahoo.com
vention methods have contributed to the further spread beyond
the IDUs to the general heterosexual population. By December
2003 more than 61 000 HIV-infected people had been registered
in Ukraine, with more than 290 000 people living with HIV/
AIDS, including 70 000 women. Over 7000 deliveries to HIV-
infected women have been registered since 1997, and 2500 in
2003 alone. The prevalence of HIV among pregnant women in
Ukraine is currently an estimated 0.5%, but is >1% in some
regions (Ukrainian AIDS Center, 2003 unpublished data).
The National Programme to Fight HIV/AIDS was adopted in
1992. Prevention of HIV infection in infants became an integral
part of this programme in 2001 and the implementation of the
PMTCT programme was reviewed in mid-2003 by the Ministry
of Health with experts from WHO, UNICEF and other inter-
national and national organizations. This article sets out to
describe the first 2 years of the implementation of the
PMTCT programme in Ukraine using national data sources
and data from a cohort of pregnant HIV-infected women deliv-
ering in 13 centres in Ukraine since 2000.
Methods
Reproductive and maternal and child health-care services in
Ukraine are implemented at a district level within a network
of 466 antenatal clinics and 91 maternity houses. Out of 400 000
annual deliveries, the vast majority (99%) occur at maternity
houses with supervision from trained health-care professionals
(obstetrician, midwife, neonatologist). About two-thirds of
women access antenatal care in the first trimester, but 10%
of women receive no antenatal care.8 Despite a halving since
1995, abortion remains a major fertility control method, with an
incidence of 828 per 1000 live births in 2002.
Description of the programme
The PMTCT programme has been integrated into existing
maternal and child health care services, supervised by the
124 European Journal of Public Health
Department of Health Care for Mothers and Children, with
close collaboration from HIV/AIDS-specific services. The pro-
gramme also includes development of legislative norms and
regulations and training modules for health-care workers and
policy makers. In 2001, the first national training module on
PMTCT for health-care workers was initiated.
Antenatal testing and rapid testing at delivery
Access to voluntary counselling and testing is available in ante-
natal clinics for all pregnant women. HIV testing is free of charge
and included in the routine package of antenatal screening tests,
including syphilis and viral hepatitis, with an ‘opt-out’ strategy.
HIV enzyme-linked immunosorbent assay (ELISA) screening
tests are performed in 69 laboratories, with confirmation testing
in seven referral laboratories. HIV screening is performed
twice during pregnancy; positive results are confirmed by
two ELISA tests; western blot is used if ELISA results are incon-
clusive. Antenatal testing is provided with informed consent,
and the right of women to refuse the HIV test is discussed
during counselling. Pretest counselling is conducted by mid-
wives and obstetricians, who ideally have undertaken a special
counselling training course. Women with positive tests are
referred to a specialist within their local AIDS centre, where
they receive post-test counselling, including information on
the laws pertaining to HIV-positive individuals in
Ukraine, and preventing transmission of HIV to partners and
infants. Women are encouraged to invite their partners for
HIV counselling and testing. Since 2001, in three pilot
regions, women without antenatal care presenting in labour
are offered rapid HIV testing (using Multispot HIV-1/HIV-2
rapid test kits); this strategy was implemented nationally in
2003.
Management of HIV-infected women: before,
during and after delivery
HIV-infected women have about eight routine antenatal visits,
the same as uninfected women. An HIV-infected woman can
deliver at any maternity service; alternatively, she can choose
to be followed at the PMTCT reference centre, where staff are
more experienced. Women are cared for by reproductive health
specialists or local gynaecologists together with an HIV specialist
from the AIDS centre.
Ukraine implemented ARV prophylaxis of MTCT on a large
scale in 2001. Protocols included maternal course of zidovudine
from 36 weeks gestation until delivery9 and/or single-dose
nevirapine for mother and infant.10 ARV drugs were provided
by donations from pharmaceutical companies and international
charity organizations.
As a result of concerns regarding the potential increased risk
of infectious complications after delivery,11,12 elective Caesarean
section (CS) was not adopted as a standard of care for HIV-
infected pregnant women in the national PMTCT protocol. In
2002 the CS rate was 12.4% among infected women, comparable
to the 12.1% in the general population. Follow-up of infants
born to HIV-infected mothers is provided by local paedia-
tricians with the HIV specialist from the AIDS centre.
The programme supplies free milk formula for children
born to HIV-infected mothers, with funding from local
budgets. Owing to the limited resources, early RNA or DNA
PCR diagnosis of infant HIV status is not currently widely
available. Diagnosis of HIV is based on an ELISA test at 18
months of age.
Monitoring of the programme
The implementation of the PMTCT programme is monitored
by the Department of Mother and Child Health of the Ministry
of Health, with the Republican Centre for the Prevention
and Fight Against HIV/AIDS. The following indicators are rou-
tinely collected in the health institutions: proportion of all
women receiving VCT during pregnancy, proportion of preg-
nant women identified as HIV infected, number of deliveries
among infected women, mode of delivery, proportion of
infected pregnant women receiving ARV prophylaxis for
MTCT, HIV status of infants born to infected mothers and
method of infant feeding.
In mid-2003 the Ministry of Health reviewed the first 2 years
of implementation of the PMTCT programme with expert par-
ticipation from WHO, UNICEF, and other international and
national organizations. Assessment included field visits in urban
and rural areas in four regions with high, mid and low preval-
ence, and desk review of available Federal documents and
studies; evaluation included organizational framework, policy
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and protocols, human resources and quality of service, manage-
ment systems and supplies and community awareness, mobil-
ization, and support. The review assessed achievements to date
and also identified constraints and feasible solutions to these
constraints, and these, together with recommendations for
future directions, will be incorporated in the national multi-
sectoral program for 2005–2011.
Cohort of HIV-infected pregnant women
Data on 860 women identified as HIV-infected through ante-
natal testing or rapid testing during labour delivering between
January 2000 and January 2004 were prospectively collected in
13 maternity hospitals in Southern Ukraine. The selection of
Odessa (n ¼ 7), Simferopol (n ¼ 1) and Mycolaiv (n ¼ 5) was
based on their high HIV prevalence. All HIV-infected women
were invited to participate in the study, with verbal consent.
Information relating to socio-demographic and clinical charac-
teristics and mode of acquisition was collected by the woman’s
clinician. Data management and analysis were carried out in
Microsoft Access.
Results
Antenatal HIV testing
Implementation of the antenatal HIV testing strategy resulted
in a significant increase in the proportion of pregnant women
agreeing to be tested from 32% in 1998 to 97% in 2003 (x2trend >
1000; P < 0.001) (Figure 1). In 2002, 12% (253/2022) of infected
pregnant women were identified during labour or soon after
delivery. In the cohort study, information on the timing of
diagnosis was available for 777 (90%) women, of whom
142 (18%) were identified as HIV-infected before the pregnancy,
521 (67%) as a result of antenatal testing and 114 (15%) through
rapid testing during labour.
100%
90%
80%
Pregnancies
70%
60%
50%
40%
30%
20%
10%
0%
1998 1999 2000 2001 2002 2003 Year
Passed HIV test Didn't pass HIV test
Figure 1 Trends in HIV testing during pregnancy and delivery,
1998–2003.
 PMTCT in Ukraine 125

Table 1 Maternal information on the 860 mother–child 1800

pairs in the cohort study 1600
1400

No. of deliveries
n (%) 1200
1000
Maternal age, years (n ¼ 837)
............................................................. 800
Median 25.1 600
............................................................. 400
Range 14–41
............................................................. 200
Ethnicity (n ¼ 843) 0
............................................................. 1998 1999 2000 2001 2002 2003 Year
White 828 (98)
............................................................. No ARV prophylaxis Received ARV prophylaxis
Oriental 5
.............................................................
Asian 5 Figure 2 Use of antiretroviral prophylaxis for PMTCT,
............................................................. 1998–2003.
Black 1

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.............................................................
Other 4
............................................................. Characteristics of HIV-infected pregnant
Marital status women
.............................................................
Single 128 (15) Within the cohort study, most women were young, married or
.............................................................
Married 374 (43)
cohabiting, and nulliparous (Table 1). Although over one-third
............................................................. of women were IDUs themselves or had sexual partners with a
Cohabiting 318 (37) history of IDU, the largest group were women who most likely
.............................................................
had acquired the infection heterosexually, and did not specify
Divorced/widowed 12 (1)
............................................................. belonging to any high-risk group (Table 1).
Missing 28 (3)
.............................................................
Parity (n ¼ 828) Prophylactic antiretrovirals
.............................................................
0 484 (58) Figure 2 shows the dramatic increase in receipt of ARV prophy-
............................................................. laxis among HIV-infected pregnant women and their infants
1 255 (31)
............................................................. over time, from <10% in 1999 to 91% in 2002 (x2trend ¼ 1164;
2 61 (7) P < 0.001). Of the 782 women receiving prophylaxis in 2001,
............................................................. 336 (43%) received short-course zidovudine prophylaxis and
$3 28 (3) 446 (57%) single-dose nevirapine, while in 2002 among the 1219
.............................................................
Previous termination of pregnancy (n ¼ 829)
women receiving prophylaxis, the proportion receiving
............................................................. zidovudine increased to 713 (59%), with the remaining 506
0 477 (58) (42%) receiving single-dose nevirapine or a combination of
.............................................................
two courses. In the cohort study, single-dose nevirapine for
1 172 (21)
............................................................. the mother and neonate was the most commonly used prophy-
2 94 (11) laxis (Table 2).
.............................................................
$3 86 (10)
............................................................. Mode of delivery
Mode of acquisition of HIV infection
............................................................. In 2002, the elective CS rate in the centres in the cohort study
IDU 74 (9) was 32% (87/274), significantly higher than the remaining
.............................................................
IDU and IDU sexual partner 168 (20) deliveries nationally (78/1060; 7%) (x2 ¼ 119.4; P < 0.001).
............................................................. These differences reflect the fact that, although national guide-
IDU sexual partner 163 (19) lines did not recommend use of elective CS to prevent MTCT,
.............................................................
Other high risk sexual partner 55 (6)
several pilot medical centres and university clinics had already
............................................................. started the broader use of elective CS for HIV-infected women in
Blood transfusion 4 order to test the feasibility and safety of this intervention in
.............................................................
Ukraine.
Occupational exposure 3
.............................................................
Unspecified risk group 393 (46)
............................................................. The neonatal and post-natal periods
Timing of last injecting drug use (n ¼ 242) Data from the cohort study show good perinatal outcome
.............................................................
Ex-user 103 (42) among the mother–child pairs enrolled with regard to prema-
............................................................. turity and birth weight (Table 2). Non-breast-feeding of the
IDU in pregnancy 86 (36) child is not stigmatizing in Ukraine and 99% of HIV-positive
.............................................................
Last IDU timing unspecified 53 (22) women choose to formula feed. In the cohort study, only four
women (0.5%) opted to breast feed their infants; all were aware
of their infection status.
In 2002, a total of 392 020 (96%) pregnant women were tested
for HIV antenatally or during labour, of whom 2022 (0.5%) Discussion
were found to be infected, a prevalence of 5.16 per 1000 preg-
nant women. Of the 2022 infected pregnant women, 1334 (66%) The MTCT rate in Ukraine decreased from 27.5% in 2000 to
had a live birth and 211 (10%) continued their pregnancy and 10% in 2002,13 reflecting the success of the national PMTCT
delivered the next year. Four hundred and seventy-seven (24%) programme, which is partly attributable to its coordinated effort
terminated their pregnancies (358 per 1000 live births). in preventive, clinical and social activities, involving a variety
126 European Journal of Public Health
Table 2 Cohort study: obstetric and perinatal information
n (%)
Mode of delivery (n ¼ 859)
.............................................................
Vaginal 546a (64)
.............................................................
Emergency CS 23 (3)
.............................................................
Elective CS 280 (33)
.............................................................
Gestational age, weeks
.............................................................
Median (range) 39 (27–42)
.............................................................
<37 weeks 85 (10)
.............................................................
Birthweight, g (n ¼ 854)
.............................................................
Median (range) 3080 (1200–4400)
.............................................................
$2500 g 740 (87)
.............................................................
<2500 g 114 (13)
.............................................................
Proportion (%) of women who were ‘missed’ by antenatal
care and were first tested HIV-positive at the time of
delivery in 13 clinical sites
.............................................................
Median (range) 18 (5–43)
.............................................................
Prophylactic ARV (n ¼ 702)
.............................................................
Maternal SC ZDV þ neonatal ZDV 24 (3)
.............................................................
Maternal SC ZDV þ SD NVP 133 (19)
.............................................................
SD NVP only (mother and infant) 498 (71)
.............................................................
SD NVP þ neonatal ZDV 47 (7)
a: Three forceps deliveries
SC ¼ short course (median from 34 weeks gestation); SD ¼
single dose; ZDV ¼ zidovudine; NVP ¼ nevirapine
of stakeholders. Furthermore, the focus on supporting NGOs
working in HIV prevention, care and support of people living
with HIV/AIDS, and reducing the epidemic’s negative impact
has been very important. Cooperation between the Ministry of
Health and UN agencies is an important asset to the programme
and the UN has facilitated consolidation of the efforts of NGOs
and international donor agencies. In 2003 Ukraine received a
US$92 million grant from Global Fund to Fight AIDS, TB and
Malaria (GFATM). Simultaneously, ARV generic drugs became
registered in Ukraine, allowing the opportunity for scaling up
ARV treatment programmes.
Improving access to prophylactic MTCT interventions was
facilitated by the integration of the programme into the pre-
existing health-care system and the optimal selection of health
care institutions providing services to HIV-infected women and
their families. The selected antenatal testing and counselling
‘opt-out’ strategy has proved to be effective elsewhere.14
Although this approach is beneficial, with HIV testing becoming
a routine antenatal procedure, avoiding stigmatizing any
particular group, and a high testing uptake, it has limitations.
In a recent study among HIV-infected pregnant women and
mothers, more than half were tested antenatally without
informed consent and/or pre-test counselling:15 three-quarters
received post-test counselling, but in about half of cases this
provided incomplete information, often in a way that women
found difficult to understand. The plan is thus now to improve
and expand the provision of quality counselling and antenatal
testing, with the aim of offering voluntary HIV testing and
counselling to all pregnant women, whilst providing continuous
monitoring and evaluation. Non-return for test results has
been a limiting factor in the optimal implementation of some
PMTCT programmes in Africa,16,17 but here, almost 100% of
women who were tested for HIV returned for their test results
(data not shown), reflecting the organization of HIV testing
within the antenatal care.
Many HIV-infected women in Ukraine are also socially dis-
advantaged18 and/or have co-morbidities. A significant propor-
tion do not receive antenatal care, often presenting in labour
with unknown HIV status. This represents a challenge for HIV
diagnosis and administration of PMTCT interventions, and
potentially higher risk of transmission to infant. Data from
the cohort study indicate that overall around one-fifth of
women were first tested as HIV-positive at the time of delivery.
Around one-third of the women in the cohort study had a IDU
history, and at least one-third of these were actively using drugs
during pregnancy. The actual numbers could be higher, but due
to the stigma associated with IDU it may have been under-
reported as a mode of acquisition, as we relied on self-report,
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clinical observation and drug withdrawal symptoms in the
infant for information on IDU. Pregnant women who are inject-
ing street drugs are a hard to reach group with regard to inter-
ventions for PMTCT.18 Chaotic lifestyle, poor health-seeking
behaviour and stigma related to drug addiction frequently
results in late presentation to the health-care system, often in
advanced labour. Rapid testing provided an opportunity for
administration of nevirapine to the mother in 50% of cases
and post-exposure prophylaxis for 75% of infants. There is a
demand to develop special services for IDU pregnant women
to improve their adherence to ARV medications.19 Pilot projects
with substitution treatment in Ukraine are planned for 2005,
including one among IDU pregnant women. A high rate of
infant abandonment has been documented among HIV-positive
IDU women,20 and in the cohort study here, 28 (30%) of the 97
children born to active IDUs were abandoned by their parents
soon after delivery, reflecting poor access to family planning
services and use of contraception by this group.
In 2004, the Ukraine Ministry of Health adopted new guide-
lines on use of ARV during pregnancy, based on WHO recom-
mendations.5 Implementation of these guidelines will allow
pregnant women to receive ARV drugs for her own health
needs as well as for PMTCT. Although overall the elective CS
rate among HIV-infected women in Ukraine was relatively low,
in certain pilot centres up to one-third of infected women are
now being delivered by elective CS. National guidelines are
currently being updated regarding mode of delivery among
pregnant HIV-infected women, and elective CS is to be recom-
mended as the first choice method with the informed consent
of the woman.21–25 The multidisciplinary approach taken in the
management of pregnant HIV-infected women enabled their
access to services including the diagnosis and treatment of
reproductive tract infections, contraception and follow-up of
their HIV disease.
Despite relatively high prevalence of HIV infection among
pregnant women, Ukraine is still faced with a lack of capacity
for early diagnosis of HIV infection in infants using virological
methods. This creates an obstacle for appropriate care of the
HIV-infected child, including decisions related to initiating
antiretroviral therapy and/or other appropriate treatment for
infected children. With the support from GFATM, the Ministry
of Health is planning to implement PCR diagnosis in referral
laboratories.
As cohort data presented here suggest, a large proportion of
infected women in Ukraine have acquired HIV heterosexually
but do not report having partners with high-risk behaviours.
This reflects the shift in the epidemic towards the general het-
erosexual population, and is consistent with the high incidence
of sexually transmitted infections in Ukraine.6,26
UNAIDS estimates that unless urgent measures to fight the
epidemic are implemented, 1.5 million people will be living with
HIV/AIDS in Ukraine, two-thirds of them of reproductive age,
by 2010. The challenges of the HIV epidemic as it applies to

women and children are varied. It is necessary to mobilize the
support of policy makers, health-care workers and the public,
and to move from a vertical to a horizontal structure of care.
Access to testing and counselling services must be universal, and
the quality of services of a high standard. Large-scale imple-
mentation of psychosocial support for HIV-infected pregnant
women with involvement of volunteers from NGOs is needed.
Currently, members of the ALL-Ukrainian Network of People
Living with HIV/AIDS are actively involved in development of
national programmes for care and support of HIV-positive
people. This organization helps to improve access to prophyl-
axis interventions among marginalized and vulnerable women
and to prevent stigmatization and discrimination of persons
affected by HIV.
The goals of the next PMTCT programme go beyond decreas-
ing the MTCT risk to a minimum, and aim to achieve the
strategic goal of virtual elimination of HIV infection in
infants. In order to achieve this goal a comprehensive approach
is needed and a four-pronged strategy has been suggested,
including primary prevention of HIV infection in women, con-
traception and family planning in HIV-infected women, pre-
vention of MTCT, and care and support for HIV-infected
women and their family members.5
The health-care system in Ukraine is similar to many former
Soviet countries. Implementation of HIV prevention in infants
with the same model as in Ukraine could have a positive impact
on prevention of the spread of HIV epidemic among infants
in these countries.
Key points
 The aim was to describe the implementation of the
prevention of mother-to-child transmission of HIV
(MTCT) programme in Ukraine in 2001–2002.
 The programme provides universal access to antenatal
testing and provision of short-course zidovudine pro-
phylaxis and single-dose nevirapine.
 There has been rapid uptake of interventions and
MTCT rates declined substantially, from 30% in 2000
to 10% in 2002.
 Improved access/uptake of interventions among
women from vulnerable groups with late presentation
to the health services is a challenge.
 A comprehensive approach is needed to achieve the UN
goal of virtual elimination of HIV infection in infants
by 2010.
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