ZKKL Academic Sharing | The Three-Tiered Prevention Framework for Mother-to-Child Transmission of HIV/AIDS

1. New Implications of the Three-Tiered Prevention of Mother-to-Child Transmission

In a broad sense, AIDS Tertiary prevention encompasses preventing infection in uninfected populations, ensuring early diagnosis and treatment for those who are infected to curb further transmission, and improving the quality of life and extending the lifespan of people living with HIV/AIDS (PLWHA).

Meanwhile, tertiary prevention of mother-to-child transmission (MTCT) is seldom addressed; current preventive measures still rely on the “Four‑Pronged Strategy” promoted by the WHO in 2003—namely, preventing infection among couples of reproductive age, providing antenatal care and screening to determine pregnancy outcomes, implementing clinical interventions during the perinatal period, and offering supportive care and assistance. However, this approach no longer aligns with the characteristics of today’s epidemic. The “Four‑Pronged Strategy” was developed when AIDS had not yet spread widely into the general population, and the baseline burden of infection among women of reproductive age and pregnant women remained relatively low. It focused on clinical interventions for specific periods and populations centered on marriage and childbearing, without concrete measures to prevent infection among couples of reproductive age, thus limiting its primary preventive impact. Under the new circumstances, the MTCT tertiary prevention strategy must place greater emphasis on upstream prevention. Primary prevention entails school‑based, systematic, and mandatory health education and behavioral interventions led by the education sector, aimed at protecting all uninfected individuals—especially adolescents. Secondary prevention involves targeted, sustained, and comprehensive interventions coordinated by relevant government agencies and supported by society at large, ensuring early diagnosis and treatment for various high‑risk and priority groups, thereby reducing the incidence of new infections among women of reproductive age. Tertiary prevention consists of scientifically grounded, precision‑driven clinical interventions provided by medical institutions, offering infected pregnant women individualized services such as early counseling, prompt diagnosis, and timely pharmacological prophylaxis to achieve effective transmission interruption. Among these, primary prevention serves as the first line of defense against MTCT, representing a population‑wide, upstream approach that plays a crucial role in reducing new HIV infections, particularly among women of reproductive age. This aligns with and maintains continuity with the broader three‑tiered prevention framework for AIDS, while differing significantly from the “Four‑Pronged Strategy.”

2. Targeted at junior high school students

By taking school-based systematic, universal, and compulsory education as the entry point to address the root causes, this approach serves as primary prevention for mothers who have not yet been infected.

2.1 The Urgency of Primary Prevention As of December 31, 2015, China had 336,382 living HIV-infected individuals and 241,041 AIDS patients, with a combined total of 182,882 deaths. According to a 2014 study published in The Lancet, the number of living AIDS patients in China was estimated at 840,000, while AIDS-related deaths had increased 180-fold over the past two decades—exceeding the total number of fatalities from traffic accidents. In some regions, the epidemic is even more severe: the number of provinces with more than 10,000 PLWHA rose from five in 2013 to fifteen in 2014, with Yunnan, Guangxi, and Sichuan accounting for over 45% of the national total. Taking into account underreporting, concealment, and low testing rates, at least 56% of infections remain undetected. By 2003, the cumulative number of AIDS cases in China had already reached 1.04 million, growing annually by more than 20%; moreover, approximately 80% of cases occurred among adolescents aged 15–24, and about half of those infected were unaware of their status. Sexual education in Chinese schools lags far behind, while Western liberal attitudes toward sexuality have steadily infiltrated, leading to increasingly serious social problems such as premarital sexual activity, unintended pregnancies, and a trend toward younger ages of HIV infection. Among student cases, the proportion of those aged 20–24 rose from 20.3% in 2006 to 49% in 2011; from 2011 to 2015, the net annual growth rate of HIV infections among students under 24 was 35% (excluding increases attributable to expanded testing), with over 65% occurring in the 18–22 age group and more than 96% transmitted through sexual contact. Currently, every province in China has reported student infections, with cases rising from 527 in 2008 to 1,154 in 2011 and 2,695 in 2014. At the end of 2013, five provinces had more than 100 student cases; by the end of 2014, this number had grown to thirteen, including Beijing, with the youngest case being just 14 years old. In Guangzhou, 48 schools have confirmed the presence of students living with HIV, with one school reporting over ten cases. Furthermore, 34.4% of female students and 27.7% of male students report having a steady partner, more than 50% of students support premarital sex, and 30.1% have engaged in sexual activity—of whom 37.3% had their first experience before age 18, and 61.2% between ages 19 and 21, with the youngest participant only nine years old. Only 5.6% have ever utilized voluntary counseling and testing (VCT) services, and a significant portion of students engage in sexual activity without protection. These data underscore the urgent need to accelerate nationwide efforts to implement mandatory, comprehensive AIDS education and behavioral interventions in junior high schools.

2.2 The Necessity of Primary Prevention The level of governmental attention and the measures implemented play a crucial role in preventing the spread of AIDS. At present, China operates an AIDS prevention and control coordination system led by the State Council, coordinated by the National Health and Family Planning Commission, and implemented across multiple departments. However, this system suffers from fragmented responsibilities, difficulties in interagency collaboration, and a widespread tendency to prioritize testing and treatment over public awareness‑raising. As a result, sustained, routine AIDS health education remains challenging to advance. Among urban students in China, the rate of comprehensive knowledge about AIDS stands at only 70%, with knowledge of PMTCT at 78% and awareness of non‑transmission routes below 60%; moreover, the correct use of condoms is reported at just 17%. The primary sources through which students acquire AIDS‑related information are media such as the internet, television, newspapers, and magazines. Although these channels enjoy broad reach, the quality of information varies considerably, failing to ensure scientific rigor or accuracy and sometimes even conveying misleading or negative messages. Furthermore, such communication is largely one‑way, lacking feedback mechanisms and systematic evaluation. In rural areas, the situation is even more dire: for instance, in Liangshan, Sichuan, the overall level of AIDS‑related knowledge is merely 34%, likely due in part to the predominance of Chinese‑language materials in health‑education efforts. Meanwhile, regions with high HIV/AIDS prevalence—such as impoverished ethnic minority areas and rural communities where local dialects are widely spoken—are concentrated in provinces like Yunnan, Sichuan, Guangxi, and Xinjiang, where educational resources remain relatively limited. Approximately 59.1% of premarital young women in China have a junior high school education, while working youth, migrant laborers, socially marginalized individuals, and even sex workers and drug users constitute key populations for AIDS prevention and control. To address these challenges, the Ministry of Education has issued a series of relevant policy documents; since 2004, China has promulgated as many as 248 policy‑level documents on AIDS prevention and control, including 38 specifically addressing health education. Nevertheless, most of these initiatives have not been integrated into formal compulsory education curricula, and there is a lack of complementary, institutionalized frameworks to ensure their sustained implementation, leaving AIDS education in schools largely superficial and perfunctory.

2.3 The Specificity of Primary Prevention Junior high school students represent a population that rapidly transitions among family, school, and society, and they are in the tumultuous adolescent period marked by dramatic changes in both physical and psychological development. They exhibit strong tendencies toward imitation and curiosity, yet lack stability and self‑discipline; their values and worldview often lag behind the maturation of their sexual physiology. As a result, they are easily confused by the ever‑changing social norms—particularly regarding sexual attitudes and behaviors—and struggle to resist the allure of harmful information, which can further lead them to experiment with and imitate risky practices. Without access to knowledge and skills in reproductive health care, relief from sexual tension, mental health maintenance, contraception, HIV/AIDS prevention, and protection against sexual harm, they are highly vulnerable to premature, irrational, unprotected, or even transactional sexual activity, as well as to substance abuse and limited access to HIV/AIDS prevention information and services—factors that constitute significant risk factors for HIV infection among school‑aged youth and adolescents in the community. As a behavioral disease, the prevention of HIV transmission hinges on changes in behavior, and establishing new patterns of conduct is generally easier than modifying existing ones. Schools serve as primary vehicles for knowledge dissemination, offering greater concentration, systematic organization, seriousness, and receptivity compared with media such as the internet, television, and radio. For junior high students who have yet to experience sexuality, school‑based education often proves far more effective than peer‑led or community‑based programs aimed at those with prior sexual experience. Moreover, once students acquire and internalize HIV prevention knowledge, they can generate a ripple effect, extending its reach to their families, communities, broader society, and peers. In light of this population’s socio‑psychological characteristics, implementing school‑based, universal primary prevention—primarily targeting junior high students—represents the most cost‑effective and efficient strategy for preventing and controlling HIV/AIDS.

2.4 Feasibility of Primary Prevention Awareness is the foundation for changes in behavior and attitudes, and prioritizing adolescents as a key target group in health education has been one of the crucial lessons learned by countries worldwide in their long-term fight against AIDS. According to surveys, health education can raise adolescents’ knowledge of AIDS from a baseline of 39.2% to 98.9%. Junior high schools, with their well‑structured teaching systems, experienced educators, comprehensive facilities, relatively low financial burdens, concentrated populations, fixed venues, and ease of management and post‑intervention evaluation, enjoy significant advantages. Teachers wield authority among students, who trust them and are accustomed to receiving guidance; thus, a systematic and holistic health education program at this level could, in theory, ensure that every adolescent receives AIDS‑related health education. Moreover, sex education grounded in junior high school not only helps students develop an accurate understanding of safe sexual practices, AIDS, and the relationship between the two, but also does not encourage premature or excessive sexual activity. Consequently, as the primary setting for adolescents’ learning and daily life, junior high schools should rightfully assume the critical responsibility of delivering the first lesson in AIDS prevention. The United States was the first country to enshrine the importance of AIDS health education in secondary schools through national legislation. Employing standard educational formats—classroom instruction, class discussions, and post‑lesson assessments—the curriculum focuses on fundamental knowledge about AIDS, its modes of transmission, consequences of infection, and preventive measures, delivered as regular, credit‑bearing courses. As a result, by 1999, 90.2% of U.S. middle and high school students had received systematic AIDS‑prevention education—a key factor explaining why, despite the country’s relatively permissive sexual culture, HIV infection rates among young people remain comparatively low. In regions such as the Middle East, Arab countries, and Bangladesh, schools likewise place great emphasis on AIDS prevention education, a trend bolstered by years of efforts to integrate AIDS awareness into school curricula. In June 2015, Cuba became the world’s first country certified by the World Health Organization as having eliminated mother‑to‑child transmission of HIV.

3. For all persons

By focusing on key areas—namely, education rooted in social traditions, delivered in small, incremental steps, and sustained over time—we can implement secondary prevention measures for mothers who may be at risk of infection.

3.1 Promotion of Social Health Education In China, AIDS health education remains led by the health authorities, with limited participation from other government departments and social organizations. Coupled with constraints in human resources and funding, interventions can only be concentrated on high-risk groups, leaving the general population—particularly the mobile population—largely out of reach. China’s mobile population has reached 260 million, predominantly aged 15–34, with generally low levels of education and weak awareness of AIDS and other sexually transmitted infections; for example, among unmarried female migrant workers, awareness stands at just 23%. The government should establish mechanisms for procuring services, providing financial support, and offering incentives, while strengthening its backing for non-governmental organizations (NGOs) and opening up more public resources to civil society. At present, China has fewer than 400 NGOs involved in AIDS prevention and control, yet most remain unapproved and unregistered with the civil affairs authorities, still in a phase of defining their roles and exploring viable approaches—whereas even a small country like Bangladesh boasts 235 legally recognized NGOs. From a grassroots perspective, NGOs focus less on quantifiable metrics such as the number of condoms distributed or the frequency of outreach campaigns, and instead prioritize addressing pressing issues that often escape governmental attention—such as care for people living with HIV/AIDS, their social standing, and access to healthcare—thereby demonstrating greater effectiveness than government efforts in health education. Only through the concerted engagement of all sectors of society, delivering sustained, incremental, and context‑specific health education and behavioral interventions across diverse populations and over time, can HIV transmission among women of reproductive age and mother-to-child transmission be minimized.

3.2 Social Monitoring and Free Testing Support As of December 31, 2015, China had reported a total of 143,583,117 HIV antibody tests, with 115,465 newly reported PL-WHA cases. The annual number of antibody tests increased from 19.68 million ten years earlier to 111 million in 2013, while the number of newly identified and reported PL-WHA cases rose from 47,600 per year to 90,100 per year. Testing is a critical tool for identifying PL-WHA and monitoring the epidemic; it also serves as a key entry point for timely notification, follow-up, and treatment, thereby reducing secondary transmission. China was among the first to adopt testing‑based identification of PL-WHA as a core control strategy, implementing a real‑name registration system that contributed to a 63% decline in AIDS mortality and a 31.4% reduction in new HIV infections between 2005 and 2013, making this approach a major global model for AIDS control. However, due to stigma and other factors, late diagnosis remains prevalent among PL-WHA, accounting for 33.1% of all detected cases, with most individuals being identified through clinical visits. Medical institutions remain the primary source of HIV testing in China; yet, given the country’s overall low‑prevalence status, expanding clinical testing has proven inefficient in detecting cases, falling far short of the effectiveness of community‑based testing—such as VCT—targeted at key populations. In 2013, medical facilities nationwide detected only 6 new positive cases per 10,000 patient visits, compared with 114 cases identified through VCT clinics. Currently, free VCT uptake stands at just 64.5%, while high fees for provider‑initiated HIV testing and counseling (PITC) and weak linkages between services result in elevated missed‑diagnosis and loss‑to‑follow‑up rates. We recommend strengthening PITC within medical settings, particularly by raising awareness of proactive testing among staff in STD clinics, dermatology departments, and infectious disease units. Outside healthcare facilities, the government should delegate free VCT services to NGOs, supporting and fully leveraging their social engagement to improve accessibility and uptake. At the same time, it is essential to refine a scientifically sound national AIDS surveillance system and information management platform, focusing resources, policies, programs, and technical assistance on high‑prevalence areas to ensure early and widespread detection among women of childbearing age, thus optimizing opportunities for PMTCT.

3.3 Social Interventions for Other Modes of Transmission According to online interviews and other data released by the National Health and Family Planning Commission on December 1, 2014, HIV transmission through drug use and blood transfusion in China has been brought under significant control, with corresponding rates declining from 44.2% and 29.2% during 1985–2005 to 5.3% and 0.04% in 2013. However, sexual transmission remains uncontrolled, rising from 11.6% to 91.5% in 2014, and even exceeding 96% among young people. Among them, heterosexual and homosexual transmission account for 66% and 25%, respectively; in rural areas such as Guizhou and Guangxi, heterosexual transmission exceeds 90%. The prevalence of HIV among MSM in China ranges from 33% to 47%, approaching the 60% levels seen in Europe and North America, with a striking 65.53% reporting six or more sexual partners. Sexual transmission has clearly become the primary mode of HIV transmission in China, characterized by a pronounced trend toward younger ages and covert transmission patterns, thereby complicating prevention efforts. Current prevention and control strategies and interventions have limited effectiveness. Dr. Bernhard Schwartländer, WHO Representative in China, noted that intra‑household sexual transmission leading to spousal infections is also on the rise. Pre‑exposure prophylaxis (PrEP), one of the WHO’s recommended key interventions, has demonstrated some efficacy in preventing sexual transmission among MSM. By interrupting sexual transmission, it is possible to reduce infections among women of childbearing age and mother-to-child transmission; however, this will require broad‑based, sustainable measures that address both symptoms and root causes.

3.4 Social Care and Free Medication Interventions On April 23, 2016, with the launch of the “Internet Plus” initiative for AIDS in Shanghai, China entered an era of electronic and network‑based care and support for people living with HIV/AIDS (PLWHA). It is crucial to provide all PLWHA with diverse forms of ongoing social support and care, along with free antiretroviral therapy (ART) throughout the entire treatment course, while striving to improve treatment adherence and reduce social stigma. Research indicates that although antiretroviral therapy cannot cure HIV, it can suppress viral replication, lower viral load, and promote immune reconstitution; however, its efficacy depends on factors such as age at initiation of treatment, baseline CD4+ T‑cell count, and adherence—lower age, lower CD4+ counts, and better adherence correlate with better outcomes. As of December 31, 2015, nationwide, 471,140 adult and 6,066 pediatric AIDS patients had received ART, with 382,139 adults and 4,617 children currently undergoing treatment. Over the past decade, the implementation of the “Administrative Measures for Free or Reduced‑Cost Drug Treatment of AIDS and Common Opportunistic Infections” and the “Four Frees and One Care” policy has provided critical policy support for controlling the AIDS epidemic in China, raising the survival rate from 22% in 2004 to 54% in 2013. Nevertheless, China’s healthcare financing framework still has shortcomings in addressing AIDS‑related risks, with limited social support; annual per‑capita spending on AIDS prevention and control ranges from RMB 0.29 to 0.95, accounting for only 0.98% to 2.49% of basic public health expenditures. Moreover, the growth rate of funding lags far behind the epidemic’s annual increase of over 30%, leaving PLWHA burdened by substantial costs, particularly for non‑antiretroviral therapies. The AIDS epidemic in China is concentrated primarily in impoverished regions, where poverty itself is a major driver of transmission; conversely, AIDS exacerbates poverty, with the incidence of illness‑induced poverty among PLWHA reaching 36.9% to 44.9%. Poverty also undermines medication adherence, compromising treatment effectiveness—for example, in Liangshan, Sichuan, the overall treatment success rate falls below 50%. It is recommended to further enhance treatment adherence among PLWHA by expanding support for community health service centers, organizations of people living with HIV, and grassroots groups.

4. Targeting pregnant and postpartum women

By taking the hospital’s scientific rigor, precision, and remedial education as checkpoints to implement preventive measures, as… Tertiary prevention when the mother is already infected.

4.1 Targeted Health Education After more than a decade of development, China’s PMTCT program has achieved qualitative and quantitative leaps in both organizational management and technical services, earning recognition and appreciation from the international community. Nevertheless, numerous challenges remain, including insufficient coverage, inadequate capacity for comprehensive interventions at the primary care level, under‑identification or delayed diagnosis of HIV‑infected pregnant women, and, in particular, limited access to health education. According to surveys, among rural women of childbearing age in high-prevalence areas, awareness of general AIDS knowledge stands at 67%, while awareness of PMTCT‑related topics—such as choices regarding pregnancy outcomes, prevention methods, infant feeding practices, and policies on preventive services—remains below 45%. In low‑prevalence areas and rural settings, the situation is even worse: overall AIDS knowledge awareness is 46.9%, and PMTCT‑related knowledge awareness is only 22.4%. Moreover, nearly 90% of pregnant women are concerned about the relationship between breastfeeding and mother-to-child transmission; in some regions, HIV prevalence among pregnant women and those undergoing premarital health checks exceeds 1%, yet more than 40% receive a definitive diagnosis only during labor or postpartum. The extent to which pregnant women receive health education directly influences their utilization of PMTCT interventions and is pivotal to the success of these efforts. In addition to routine public awareness campaigns via television, print media, and the internet, it is essential to deliver targeted education and guidance in a broad and in-depth manner through channels such as premarital schools, antenatal classes, hospital orientation sessions, informational bulletin boards, mobile text messages, and standard educational materials distributed when registering for prenatal care. By ensuring that all pregnant women receive scientifically sound, precise, and remedial educational interventions at each critical stage—premarital screening, prenatal care, and delivery—awareness levels can be raised, and adherence to mother‑to‑child transmission prevention measures can be improved.

4.2 Centralized and Precise Counseling and Testing Conducting timely, proactive, and widely accessible free, centralized early‑stage counseling and testing for specific groups of women—such as premarital, prenatal, and antenatal care—is a critical component of PMTCT. However, in China, maternal and child health institutions serve both as the main providers of PMTCT and as the primary entities delivering maternal and infant health services and basic public health care. Internally, departments with different functions must integrate their services, while externally, coordination and collaboration are required with disease control agencies, general hospitals, township health centers, and other institutions. Yet, a unified information‑sharing mechanism has not yet been fully established among these stakeholders, creating significant barriers to early counseling, testing, and monitoring for pregnant and postpartum women. Surveys indicate that in low‑prevalence rural areas, the HIV antibody testing rate among pregnant and postpartum women is 57.9%, with only 14.7% tested during the first or second trimester, and just 11.8% having received VCT services. Leveraging the three‑tier maternal and child health network, it is possible to strengthen PITC targeted at women of childbearing age and their partners, and to provide one‑on‑one, personalized counseling and guidance to infected pregnant and postpartum women and their families during the early stages of diagnosis and throughout pregnancy. Such efforts would enable them to fully understand the risks of MTCT, available prevention measures, and national support policies, thereby facilitating informed decisions about pregnancy outcomes or the selection of safer delivery facilities and delivery methods. This, in turn, can improve adherence to timely, standardized medication regimens and ensure full compliance with preventive interventions, effectively reducing obstetric risks.

4.3 Standardized Treatment of Free Items Blocking antiretroviral therapy (ART) can reduce the risk of mother-to-child transmission (MTCT) and is a critical factor determining the success or failure of prevention of mother-to-child transmission (PMTCT). Standardized ART can lower MTCT rates by approximately 68%; when combined with interventions such as safe delivery and formula feeding, MTCT rates can be reduced to below 2%. In China, the free ART program for HIV-infected pregnant women and their infants has been progressively implemented, expanding from coverage in 271 counties (cities, districts) in 2005, to 1,156 in 2010, and 1,638 in 2014, achieving nationwide coverage by 2015. However, shortcomings remain in terms of scientific rigor, rationality, and timeliness. Moreover, most infected women of reproductive age live in rural areas and often seek hospital care only near term; early initiation of treatment and adherence to regimens both require improvement. Additionally, pediatric formulations of ART are still lacking, with infant dosing typically relying on adult‑formulated medications, resulting in low rates of appropriate use. Consequently, the overall impact of ART on reducing MTCT remains limited. Therefore, it is essential to further optimize referral pathways within primary‑care maternity facilities to ensure unified management and the provision of free, early, comprehensive, and individualized ART, while strengthening support measures to enhance medication adherence.

4.4 Safe Rib-Block Analgesia for Labor It is generally believed that perinatal transmission accounts for 23% of mother-to-child transmission (MTCT) during pregnancy, 12% postpartum, and more than 60% during labor; thus, the success or failure of obstetric interventions plays a decisive role in the effectiveness of PMTCT. Although domestic guidelines do not yet recommend cesarean section as an indication for HIV-positive women in resource‑limited settings, studies have shown that elective cesarean delivery performed before labor onset or prior to premature rupture of membranes can reduce perinatal HIV transmission by 55% to 80% compared with other modes of delivery. In theory, vaginal delivery could also prevent MTCT if traumatic procedures such as episiotomy, artificial rupture of membranes, vacuum extraction, and intrapartum scalp monitoring were entirely avoided; however, most primary‑level maternity facilities find it difficult to eliminate these invasive practices, and there are significant variations among providers in their ability to shorten the second stage of labor, prevent excessive uterine contractions, protect the perineum, and perform antenatal vaginal cleansing. Consequently, the actual safety of vaginal delivery remains a matter of debate. To achieve safer maternal care, it is essential to increase the rate of deliveries at designated hospitals at or above the county level and to advance the timing of delivery appropriately, ensuring adequate referral processes and thorough preparation for childbirth, thereby reducing the risk of intrapartum transmission.

4.5 Postpartum Feeding Practices for Transmission Prevention Breastfeeding has long been widely promoted as the optimal feeding method for infants, serving as a cornerstone of child health and survival strategies and offering substantial benefits in reducing the incidence and mortality of infectious diseases among infants. However, HIV has been detected in the breast milk of infected pregnant and postpartum women at rates as high as 58%, with mother-to-child transmission (MTCT) rates reaching 10% to 15%. Breastfeeding is the first—and consistently scrutinized—risk factor demonstrably associated with MTCT. A comprehensive assessment of factors such as acceptability, affordability, sustainability, and the availability of relevant knowledge and skills is essential; feeding practices should be tailored to local contexts and individual circumstances. In principle, formula feeding is recommended, breastfeeding should be avoided, and mixed feeding must be strictly prohibited. Antiretroviral therapy (ART) can reduce the risk of HIV transmission via breast milk from approximately 35% to below 5%. For those who, despite difficulties with formula feeding, choose exclusive breastfeeding, thorough counseling and guidance are imperative, emphasizing the critical importance of maintaining ART for both mother and infant throughout the period of feeding. Additionally, HIV is sensitive to heat and loses viability within 30 minutes at 56°C in vitro; thus, the feasibility of subjecting breast milk to high‑temperature treatment before feeding warrants further investigation.

4.6 Improved Adherence and Follow-up Support Follow-up is a critical component of AIDS prevention and control as well as PMTCT. Since China implemented quantitative management of PLWHA in 2008, the follow-up intervention rate in high-prevalence areas has risen from 55.7% to 94.7% by 2014; the CD4+ T‑cell testing rate among newly reported and untreated PLWHA has increased from 48.4% to 88.3%; and the HIV testing rate among spouses or steady partners has climbed from 48.3% to 91.1%. However, due to shortages of dedicated follow-up personnel, inadequate compensation and incentive mechanisms, and insufficient inter‑agency coordination, substantial regional disparities persist. In some areas, the child loss‑to‑follow‑up rate remains as high as 22%, with 49% of children lost before six months of age. Referral rates, full-course follow-up rates, adherence rates, and overall follow-up quality all require further improvement. As fee reductions for diagnosis and treatment become increasingly widespread, counseling and testing uptake, along with the rate of formula feeding, continue to rise, and obstetric technologies grow ever more sophisticated, diagnosis and ART are no longer the primary challenges or bottlenecks in PMTCT efforts. Instead, the pressing issues now lie in enhancing follow-up skills, reducing loss‑to‑follow‑up, and maximizing follow-up quality, dynamic monitoring coverage, and adherence to the full course of preventive interventions. Effective counseling and social support are closely linked to maintaining strong adherence to prevention measures among HIV‑infected pregnant and postpartum women. At the same time, follow-up content and procedures should be streamlined and optimized, follow-up models refined, and contact information collected at registration made as comprehensive as possible—incorporating multiple channels such as QQ numbers, WeChat IDs, family contacts, and even third‑party points of contact.

5. The Significance of Tertiary Prevention in MTCT

The routine, comprehensive implementation of a three-tiered prevention strategy—school–community–hospital—will have a positive and far-reaching impact on AIDS control and PMTCT in China, carrying significant practical importance. This is reflected in the following aspects: ① The model adopts a tiered approach to prevention, addressing individuals at three distinct stages—those who are not yet infected, those at risk of infection, and those already infected—while taking into account both the biological characteristics of HIV and the psychological and social dimensions of AIDS. It aligns with the biopsychosocial model of medicine and represents a novel initiative suited to the current context. ② This model effectively shifts the preventive focus upstream, re‑integrating AIDS prevention and PMTCT efforts and restoring their inherent interdependence. By breaking the current fragmented separation between the two, it emphasizes a prevention‑oriented system that prioritizes source‑level interventions, thereby enhancing overall efficiency and conserving resources. ③ The model fully meets the requirement of inclusive, all‑encompassing prevention, ensuring complete coverage of healthy populations, high‑risk groups, and people living with HIV, while tailoring interventions to specific needs. This approach is consistent with the principles of infectious disease control: protecting susceptible populations, interrupting transmission pathways, and containing sources of infection. ④ The model clarifies the respective responsibilities of national authorities and civil society organizations, returning education to schools and prevention to hospitals. It reverses the current situation in which medical institutions—primarily engaged in clinical care—are effectively serving as the main educators for this incurable condition, while educational agencies—focused on outreach and awareness‑raising—remain passive bystanders in the prevention of a disease amenable to education. This integrated approach addresses both symptoms and root causes, while also helping to conserve already scarce healthcare resources.

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