The burden of HIV, syphilis, and hepatitis B in India
Effective prevention, testing, and treatment tools exist for preventing mother-to-child transmission of HIV, syphilis, and hepatitis B (HBV). However, siloed health systems and verticalization of disease programs often create missed early intervention opportunities.
The state of West Bengal, with technical support from the William J. Clinton Foundation (WJCF), an affiliate of the Clinton Health Access Initiative (CHAI), is pioneering a triple elimination (TE) initiative to reduce HIV, syphilis, and hepatitis B transmission from mother to child. This ambitious initiative aims to improve maternal health, child survival, and overall healthcare efficiency by addressing these three diseases simultaneously.
The goal is clear: ensure that every mother knows her status and can be linked to follow-up care and that every baby is born free from life-threatening infections. We are working to protect babies from infection during pregnancy, childbirth, and breastfeeding, giving them “Healthy Beginnings, Hopeful Futures.”
Facilitating triple elimination
Despite available prevention and treatment tools, the current rate of 11 out of every 100 HIV-infected mothers transmitting the virus to their babies exceeds the national target of reducing transmission to 2-5 per 100. The triple elimination program in West Bengal is generating evidence toward reducing this transmission and creating an impetus for other states to follow suit.
To support the implementation of this initiative, the state government of West Bengal established a dedicated State Task Force (STF). Working alongside the task force, WJCF facilitated a situational assessment to identify opportunities to implement TE protocols in four pilot districts. In December 2023, WJCF supported the State in disseminating the findings to key stakeholders and formalizing an integrated TE strategy. The strategy was co-created by State and District Health Departments, the World Health Organization, USAID, development partners, and private health associations. In response to the findings, the government and key stakeholders signed the “Kolkata Commitment,” formalizing the State’s TE pilot and securing partner support for implementing the strategy by 2025-26.
Lessons learned from the pilot
Since the pilot began in April 2024 across four health districts, valuable lessons from the field have been documented, showing significant progress in several areas:
- Process and policy improvements: Clear operating procedures and job aides are critical to simplifying the processes for healthcare workers. Syphilis treatment, previously available at only six district hospitals, has now been expanded to 57 health centers, demonstrating that decentralizing services is feasible and can enable greater access to treatment among pregnant women.
Devika,* a public health nurse from South 24 Parganas in West Bengal explained how these improvements have increased access: “We now conduct deliveries for HIV, and hepatitis B positive pregnant women and treat Syphilis cases here. Before this, it was being done at district hospitals only. Pregnant women would often hesitate in accessing (treatment) services back then, because of the long distances, and the need for multiple trips to the district hospital.”
2. Supply chain: Guidelines to reinforce standardized practices for storage, distribution, transportation, and commodities use ensure seamless planning and utilization of essential products across districts and blocks.
3. Human resources and capacity: Extensive and integrated multi-disease training is needed to ensure that health workers are skilled enough to screen, document, and refer patients. The program provided extensive training to over 700 healthcare providers across 2,000+ health facilities.
Devika shared, “The training has simplified the process. Primary health facilities are now more informed, and we have new job aides to help with screening, documentation, and referrals.”
4. M&E and governance: Strong monitoring and evaluation systems are necessary to ensure program implementation and sustainability. The taskforce developed a data tool that, for the first time, allows comprehensive tracking of pregnant women and mother-infant pairs across all three diseases simultaneously. This has enhanced visibility for decision-makers at the district and state levels. Additionally, the taskforce helped establish stronger integrated (cross-program) governance systems at the state, district, and block levels to ensure the program stays on track. Nodal officers at the district level have been capacitated with additional responsibilities to oversee and coordinate efforts, ensuring the successful management and progress of the initiative to eliminate mother-to-child transmission.
Key outcomes from the triple elimination pilot
The program has made remarkable progress in reducing mother-to-child transmission of HIV, syphilis, and HBV in the four pilot districts. The pilot reached over 200,000 pregnant women and identified 538 with HIV/ syphilis/ HBV (from April 1, 2024 – March 20, 2025).[1]
In addition:
- The role of routine antenatal screening: For the first time, the program had an improved mechanism to identify and document cases of co-infection among pregnant women during routine antenatal screening.
- Benefits of behavioral risk screening: Introducing behavioral risk screening in antenatal care identified an additional 425 pregnant women ‘at-risk’ of infection. Health workers triaged them for rescreening services in the third trimester, with two identified reactive for HIV and syphilis.
- Magnified focus on syphilis MTCT: The program saw a ~1.9x increase in the number of pregnant women reported with syphilis (~112), with a ~2.4x increase in treatment linkage rate (~ 83 percent) because of a focus on syphilis MTCT. 98 percent of these women completed treatment, with a 92 percent survival rate of exposed infants. More than 90 percent of eligible newborns received Benzathine Penicillin as prophylactic treatment.
- High coverage of HIV and HBV MTCT services: 91 percent of HBV-exposed infants received both the hepatitis B birth dose and immunoglobulin, while 91 percent of HIV exposed infants received antiretroviral prophylaxis.
A nurse holding up the Triple elimination job aide for labour rooms placed in a CEmONC labour room in West Bengal.
Aishwarya**, a mother of one from Cooch Behar, West Bengal who tested positive for syphilis, reflects on her screening and treatment experience: “The healthcare workers told me about mother-to-child transmission, and I was terrified for my child. Multiple people, including ASHA didi* (*a local colloquial reference for an elder sister) reassured me and kept checking on me throughout the process. She told me that my baby would be safe if I got the complete treatment. Today, my baby does not have the disease I had, and I am very grateful for it.”
A healthier future for all
West Bengal’s triple elimination journey highlights the importance of integrating care now for HIV, syphilis, and HBV for a healthier tomorrow. The results speak for themselves—more women are receiving treatment, resulting in better childbirth outcomes and more babies born infection-free.
The program’s goal is to expand coverage to all of West Bengal and eliminate mother-to-child transmission of these diseases by 2025-26. This will require ongoing collaboration, investment in healthcare infrastructure, and unwavering dedication to the cause. However, the progress so far shows that this goal is within reach.
[1] Program data – April 1, 2024 – March 20, 2025
* Name changed for privacy reasons
** Name changed for privacy reasons
