Time for "test and treat" in prevention of mother-to-child transmission programs in low- and middle-income countries.

Significant progress has been made in the prevention of mother-to-child transmission (PMTCT) of HIV. In 2008, an estimated 1.4 million pregnant women living with HIV in low- and middle-income countries (LMIC) gave birth and almost half of these accessed antiretroviral drugs to prevent HIV transmission to their infants, which ranged from single-dose nevirapine to full combination antiretroviral therapy (ART). Although this represents a significant increase in ART coverage, much more remains to be done in terms of HIV testing and counseling, establishment of ART eligibility, and postnatal treatment and care. In November 2009, the World Health Organization issued new PMTCT guidelines for LMIC, stressing the benefits of earlier initiation of ART during pregnancy and its continuation throughout the delivery and the breastfeeding periods. A key recommendation of these guidelines is to start ART for all HIV-positive pregnant women with a CD4 count below 350 cells/mm, irrespective of clinical stage. This makes access to CD4 testing more crucial than ever for the successful implementation of PMTCT programs, since clinical staging performs poorly in identifying pregnant women eligible for ART. However, there are still many barriers to accessing CD4 testing in remote health structures implementing antenatal care services, particularly in countries with a high HIV prevalence. In these settings, universal ART initiation among HIV-positive pregnant women, irrespective of CD4 cell count or clinical staging, is a potentially superior strategy for the prevention of vertical transmission and the improvement of mothers' health.