On October 13, 2025, the World Health Organization announced that the Republic of Maldives had become the first country in the world to eliminate mother-to-child transmission (EMTCT) of HIV, syphilis, and Hepatitis B virus (HBV). This validation, endorsed by the WHO Director-General after rigorous review, means that the Maldives has reduced the transmission of all three infections from mothers to newborns to levels no longer considered a public health problem. Before this milestone, 19 countries (Cuba, Malaysia, Belarus, Sri Lanka, Armenia, Moldova, Namibia, Belize, Jamaica, Saint Vincent and the Grenadines, Dominica, Thailand, Anguilla, Antigua and Barbuda, Bermuda, Cayman Islands, Montserrat, St. Kitts and Nevis and Oman) had achieved single or dual elimination of HIV and/or syphilis. Yet, none had reached the combined benchmark of eliminating all three infections.
Vertical transmission
Vertical transmission refers to the transfer of infection from a parent to a child during pregnancy, childbirth, or breastfeeding. From a clinical standpoint, it is a biological event; from an ethical perspective, it is a profound social failure. A child who acquires an infection at birth carries a burden it did not choose, often shaped by gaps in awareness, access, or social protection. Preventing vertical transmission is not merely a medical obligation but an ethical one. Allowing a newborn to inherit a preventable infection is a collective injustice that societies must strive to end. Vertical transmission has long been an indicator of equity and social justice within health systems. Its elimination represents fairness across gender, geography, and class.
Three diseases, one goal
The three infections (HIV, syphilis, and HBV) share a common transmission pathway but have distinct biological consequences. HIV (Human Immunodeficiency Virus) can cross the placenta or spread during delivery and breastfeeding. Without treatment, up to 30% of infants of HIV-positive mothers become infected, but timely antiretroviral therapy can reduce this risk to below 2%. Syphilis, caused by Treponema pallidum, is transmitted when the bacterium crosses the placenta. Untreated maternal syphilis can result in miscarriage, stillbirth, or congenital infection, outcomes that are entirely preventable through early screening and penicillin treatment. HBV is transmitted mainly at birth. An infant exposed to HBV faces a 90% chance of developing chronic infection, which later predisposes the child to cirrhosis and liver cancer. When the HBV Immunoglobulin and HBV vaccine is administered within 12 and 24 hours, it can prevent almost all such transmissions. Together, these infections not only threaten physical health but also carrysignificant social stigma, often discouraging women (and later their infected newborns) from seeking timely testing or care.
How validation works
The WHO validation process is a structured, multi-level review designed to ensure accuracy and sustainability. Every country begins with a proposal sent by the Health Ministry to the WHO through a National Validation Committee (NVC), which compiles data, verifies records, and assesses testing, treatment, and vaccination coverage. The national report is then reviewed by a WHO Regional Validation Committee (RVC) that performs site assessments and audits laboratory quality. Finally, the Global Validation Advisory Committee (GVAC) reviews the regional findings and recommends certification to the WHO Director-General, who issues an official validation certificate. Even after recognition, countries must periodically prove that they continue to maintain elimination every three years for HIV and syphilis and every five years for Hepatitis B. This cyclical reassessment ensures that elimination remains a living public health standard rather than a one-time milestone.
Elimination targets
A country must meet strict 25 explicit targets for epidemiological impact and health system performance to qualify for validation based on impact, process, and viral load among mothers and infants.
Lessons for India
According to provisional 2024 estimates from the WHO South-East Asia Region, over 23,000 pregnant women were affected by syphilis, leading to the birth of more than 8,000 infants with congenital syphilis. Around 25,000 HIV-positive pregnant women required treatment to prevent transmission to their babies. Meanwhile, Hepatitis B remains a major concern, affecting over 42 million people across the region. T
The Maldives’ success offers hope that India and other countries can adapt to their scale. Replicating its approach across a nation of 1.45 billion people may not be pragmatic, but its principles are applicable. India can begin by targeting island regions such as Lakshadweep and the Andaman and Nicobar Islands, followed by other Union Territories and smaller states. Achieving elimination at the sub-district and district levels would allow India to expand towards a national milestone progressively. While the Maldives demonstrates feasibility, its population size and centralised system are unique. The lesson is not to imitate its structure but to emulate its discipline.
Language and sensitivity
India also offers an important conceptual contribution to global health communication. The WHO framework refers to vertical transmission as “mother-to-child transmission,” but India mandates, through both convention and government order, the use of “parent-to-child transmission.” This terminology recognises that responsibility for infection does not rest solely with mothers. In many cases, women may themselves be victims of sexual violence or infection acquired from a spouse/offender. The inclusive term reflects gender sensitivity and acknowledges that men, too, share accountability for transmission prevention. This linguistic shift is not semantic; it symbolises empathy. It ensures that public-health communication does not stigmatise mothers, who are already marginalised.
Global and moral imperative
The elimination of parent-to-child transmission is both a medical and ethical necessity. The message for India and the rest of the world is that triple elimination is technically feasible when health programmes are integrated, verified, and prioritised based on data. For the WHO, the Indian experience with inclusive terminology and multi-programme integration offers lessons in cultural adaptation and ethical framing. Preventing vertical transmission protects infants and the dignity of mothers and families. Each infection prevented is a life course altered, proving that prevention remains the most humane form of care.
(Dr. C. Aravinda is an academic and public health physician. The views expressed are personal. aravindaaiimsjr10@hotmail.com)
Published – October 15, 2025 02:42 pm IST
