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In 2003 about 630,000 children under 15 became infected with HIV1, mainly through mother to child transmission (MTCT). About 90% of these MCTC infections occurred in Sub-Saharan Africa and the effects are dramatic.2 AIDS is beginning to reverse decades of steady progress in child survival. But effective and feasible interventions to reduce mother-to-child transmission are now available and could save the lives of 300,000 children each year.3 Children at riskHIV can be transmitted to an infant during pregnancy, labour and delivery or breastfeeding. The risk of transmission varies between 15% and 30% among infants who are not breastfed. A number of factors influence the risk of infection, particularly the viral load of the mother at birth, the higher the load, the higher the risk. Breastfeeding increases the risk of transmission by 10-15%.4 Find out more about HIV, AIDS & pregnancy. Mother-to-child transmission (MTCT) in the developed world has been virtually eliminated thanks to effective voluntary counselling and testing, access to antiretroviral therapy (ART), safe delivery practices (including elective caesarean sections), and the widespread availability and safe use of breast-milk substitutes. Preventing MTCT (PMTCT)A three-fold strategy is needed to prevent MTCT, that is to prevent babies from acquiring HIV from their infected mothers.
The Use of Antiretroviral DrugsIn 1994 a drug regime using zidovudine (AZT) was shown to reduce MTCT by about two thirds in the absence of breastfeeding. But at an average cost of US$1,000 per pregnancy, this regime was far too expensive for use in resource poor countries. Then in 1998 studies in Thailand showed that a simpler drug regime, a one month course of zidovudine late in pregnancy, could halve the rate of HIV transmission so long as the women also avoided breastfeeding. Other studies showed that even if the women breastfed their infants, the rate of MTCT was still cut by a third. In 1999, a study in Uganda showed that one dose of nevirapine to the mother at the onset of labour, followed by another dose given to the infant after delivery, was highly effective in reducing MTCT. This "short course" regimen only costs about US$4. There are now other "short course" regimes involving zidovudine, or a combination of zidovudine and lamivudine.6 PMTCT and BreastfeedingA number of studies have shown that the protective effect of the various drug regimens is diminished when babies continue to be exposed to HIV through breastfeeding.7 This underlines the substantial risk of HIV transmission during breastfeeding which can greatly erode the short-term benefit of drugs to prevent MTCT of HIV. Up to 20% of infants born to HIV-positive mothers may acquire HIV through breastfeeding. An HIV-positive mother should be counselled on the risks and benefits of different infant feeding options and should be helped to select the most suitable option for her situation. The use of infant formula can be problematic, and it may be neither feasible or safe. However, breastfeeding may cause the child to become HIV positive, which may also result in illness and death. The use of infant formula means the baby is not receiving the special vitamins, nutrients and protective agents found in breast milk. And the cost of infant formula often puts it beyond the reach of poor families in reource poor countries, even when the products are widely available. Many women also lack access to the knowledge, potable water and fuel needed to prepare replacement feeds safely, or simply have no time to prepare them. If used incorrectly - mixed with unsafe water, for example, or over-diluted - a breast milk substitute can cause infections, malnutrition and even death. Furthermore, if a mother chooses not to breastfeed in settings where breastfeeding is the norm, this may draw attention to her HIV status and invite discrimination, violence or abandonment by her family and community. For HIV-positive women who choose to breastfeed, exclusive breastfeeding (as opposed to "mixed feeding" - breastfeeding mixed with bottle feeding of water or formula, or providing other foods) is recommended for the first months of an infant's life, and should be discontinued once an alternative form of feeding becomes feasible. This is because mixed feeding may increase the risk of HIV infection. Indirect evidence suggests that keeping the period of transition from exclusive breastfeeding to alternative feeding as short as possible may reduce that risk. Unfortunately, the best duration for this is not yet known and may vary according to the infant's age and/or the environment.8 International Initiatives to Prevent Mother to Child Transmission of HIVThere are a number of large scale international initiatives to prevent MTCT of HIV. These include:
President Bush's International Mother and Child HIV Prevention InitiativeOn June 19th 2002, President Bush announced a new $500 million International Mother and Child HIV Prevention Initiative, seeking to prevent the transmission of HIV from mothers to infants and to improve health care delivery in Africa and the Caribbean. Through a combination of improving care and drug treatment, and building healthcare delivery capacity, the initiative has the target of reaching up to one million women annually and reducing mother to child transmission by forty percent within five years or less in twelve African countries and the Caribbean.9 The initial countries are: In Africa: Botswana, Cote d'Ivoire, Ethiopia, Kenya, Mozambique, Rwanda, South Africa and Uganda. In the financial year 2004, Namibia, Nigeria, Tanzania, and Zambia are also to included. In the Caribbean: Guyana, Haiti and regional efforts through the Caribbean Regional Epidemiological Centre. There have however been some delays in the implementation of this program, with the program in Guyana only being officially launched in September 2003.10 USAID's Efforts to Prevent Mother-to-Child Transmission of HIVThe U.S. Agency for International Development has been committed since 1999 to helping the millions of women and families already infected, reduce the likelihood of transmitting HIV to their infants. USAID focuses on a comprehensive approach to preventing Mother to Child Transmission which includes improvement of antenatal services, HIV voluntary counselling and testing services, short-course antiretroviral prophylaxis for HIV infected pregnant women, counselling and support for safe infant feeding, and strengthened health, family planning, and safe motherhood programs.11 USAID provides a comprehensive package of PMTCT interventions: In Africa: Ghana, Kenya, Malawi, Rwanda, South Africa, Uganda, Zambia. In the Caribbean: Haiti, Jamaica. In Eastern Europe: Romania, Ukraine. A number of these countries are the same ones where the Bush Initiative is taking place, and it is not clear to what extent there is an overlap. The Elizabeth Glaser Paediatric AIDS Foundation Call to Action ProjectThe Elizabeth Glaser Paediatric AIDS Foundation initiated the Call to Action Project in September 1999 to help reduce mother to child transmission of HIV in the developing world.12 In three years the project had expanded to over 370 locations in 17 countries. The countries are: Angola, Cameroon, Congo, Dominican Republic, Georgia, Honduras, India, Kenya, Malawi, Russia, Rwanda, South Africa, Tanzania, Thailand, Uganda, Zambia and Zimbabwe. The UN Interagency Task Team on MTCTThe UN Interagency Task Team on MTCT involves UNICEF, UNFPA, WHO, the World Bank and the UNAIDS Secretariat, working with the governments of various developing countries to set up MTCT programmes. As of 2004, support is being provided to 226 programme sites in 16 countries. The countries are Belarus, Botswana, Burundi, Cambodia, Cote d'Ivoire, Honduras, India, Kenya, Malawi, Myanmar, Rwanda, Tanzania, Uganda, Ukraine, Zambia, and Zimbabwe. It is planned that support will be extended to Cameroon, Central African republic, Mozambique, Namibia, Nigeria and Vietnam.13 Between April 1999 and July 2002, the support provided by this program reached almost 600,000 pregnant women in antenatal care centres. Treatment with antiretroviral drugs was provided to more than 12,000 HIV positive women.14 References
Last updated October 6, 2004 |