Preventing
Mother-to-Child Transmission of HIV/AIDS in Developing Countries: What You Need
to Know
Hi, my name
is [PRESENTER NAME]. IÕm [PRESENTER ROLE]. Welcome to ÒPreventing
Mother-to-Child Transmission of HIV/AIDS in Developing Countries: What You Need
to Know.Ó
If a woman is
HIV positive and becomes pregnant, there are varying risks that her child will
contract HIV during the pregnancy, more commonly during childbirth, or while
breastfeeding. If an HIV positive woman takes no steps to protect her child
from HIV and does not breastfeed, there is a 15-30% chance that her child will
contract HIV. If she also breastfeeds, the risk of transmission increases to
20-45%.
However, if
an HIV positive woman follows her doctorÕs instructions, including the use of appropriate
antiretroviral medications (ARVs), it is possible to markedly reduce the risk
of HIV transmission. If you are pregnant or thinking about having a baby, the
information in this video could save your childÕs life, so please watch the
whole video and listen carefully.
Pregnant
women in developing resource-poor settings who are HIV positive often do not
have access to the medical treatments and nutrition available in developed
countries. This video talks about additional ways pregnant HIV positive women
in developing resource-poor settings can decrease the risk of transmission of
the virus to their baby. There is a separate video on this site for pregnant
HIV positive women in developed countries who generally have access to health
care services and antiretroviral medications.
If you know
you are pregnant or are thinking about having a baby, see a doctor. The next
step to protecting your baby from transmission is to find out if you are HIV
positive. You may be HIV positive and not know it. All pregnant women should be
tested for HIV, no matter how far along they are in their pregnancy.
Governments and Non-Governmental Organizations typically provide free HIV
testing.
In a
developed country, a doctor may recommend that a pregnant woman start taking
antiretroviral medications immediately if she is not already on them. A doctor
is especially likely to recommend this if the woman is showing symptoms of
clinical AIDS, her CD4 cell (or immune cell) count is low, or the amount of
virus in her body is high. Going on ARVs can improve a womanÕs own health as
well as reducing the chance that her child will contract HIV during pregnancy,
or, more commonly, during childbirth. If a pregnant woman is already on ARVs,
her doctor will likely keep her on them, except for efavirenz (also known as
Stocrin or Sustiva), which has been shown to cause problems for a developing
fetus. Even if a doctor doesnÕt recommend that a pregnant woman start ARVs
immediately, they will recommend going on ARVs after the first trimester. The
reason for this is to minimize the effects of ARVs on a fetus while it is in
the most critical early developmental stages in the womb. If a doctor
prescribes ARVs, itÕs extremely important to take every dose of the medications
on schedule. A separate video on this web site called ÒAdherence for LifeÓ
explains more about why taking every dose of ARV medications on schedule is so
important.
The likelihood
of going on ARVs if you are pregnant and HIV positive in a developing country
will vary depending upon what part of the world you live in. In a developing
country there is a limited number of ARVs used in pregnancy and for a shorter
course. Often, this regimen is not the optimal for protecting the baby but is
often the only resource available, and it is much better for the baby than
doing nothing. Efforts are being made to increase the availability of the best
antiretroviral medications to people in the developing world.
According to the World Health Organization,(quote) ÒAll the controlled clinical trials on MTCT [Mother to Child Transmission] prevention have demonstrated the short-term safety and tolerance of short-course ARV regimens used for a limited period of time in pregnancy and/or in the infant for preventing MTCT [Mother to Child Transmission]. However, information is still lacking on the effects of short courses of ARV drugs to prevent MTCT on the long-term health of the infected mother (and that of her infant) or on future ARV treatment options, but research is ongoing.Ó (end quote) The important thing for an HIV positive pregnant woman to understand is that following her doctorÕs advice and the current guidelines, including the use of ARVs where available, is the best way for her to prevent mother to child transmission of HIV.
There is
evidence that the risk of mother-to-child HIV transmission may be lower if the
child is delivered via a scheduled Caesarian section rather than by a natural
vaginal delivery. However, if a woman is on ARVs and her viral load – or
amount of virus in the body – is less than 1,000, vaginal delivery is as
low a risk as Caesarian section – approximately 1%. Of course, Caesarian
sections carry their own increased risks of infection for the mother and
possible respiratory complications for the child. Caesarian sections are only
an option when trained medical personnel and sterile medical treatment
facilities are available. In the developing world, Caesarian sections are
usually not an available or safe option due to the lack of access to trained
personnel and/or facilities and the high risk of infection due to unsanitary
conditions.
ARVs
During and After Labor and Delivery
Every HIV
positive woman should receive intravenous AZT during delivery, once her water
has broken, but this is not usually available in developing countries.
Alternatively, oral ARVs are given to the mother during delivery and to the
infant after delivery. In developing countries, there is still much work to be
done to provide pediatric (or child) dosages of ARVs to those infants most in
need.
Concerns have
been raised that when a mother takes a single dose of ARV medication to reduce
the risk of mother-to-child transmission, she is at an increased risk of
developing a resistant strain of the HIV virus, making it more difficult to
treat her in the future. Though itÕs true that a woman who takes a single dose
of nevirapine has an increased risk of developing an HIV strain with resistance
to some HIV medications, the overall risk to the mother is small while the
benefit to the child is great, so where better treatment regimens are not
available, single-dose nevirapine is still recommended to reduce the risk of
mother-to-child transmission of HIV. More recently, it has been shown that
adding a short course of additional ARVs to the single dose of nevirapine can
reduce the risk of the mother developing resistance. Therefore, this treatment
is preferred whenever possible. Evaluating these issues is complicated. The
best answer of course is to try to make top-quality ARV treatment readily
available to all who need it. Until then, women should talk to their doctor
about what options they actually have and try to get access to the best
treatment possible.
If the mother
is HIV positive and breastfeeds her baby, there is a risk of mother-to-child
transmission of HIV. In the worldÕs poorest regions, when comparing
breastfeeding versus the use of infant formula, breastfeeding is often
necessary despite the risk of HIV transmission because the water can be unsafe
to drink and formula is scarce. It has also been shown that mixing the use of
formula and breastfeeding is worse for the baby than either exclusive
breastfeeding or exclusive use of formula.
All babies
born to HIV positive mothers should be tested to determine whether they are HIV
positive. Babies born to HIV positive mothers are tested for HIV differently
than adults. Adults are tested by looking for antibodies to HIV in their blood.
A newly born infant keeps antibodies from its mother, including antibodies to
HIV, for many months after birth. Therefore, an antibody test given before the
baby is 1 year old may be positive even if the baby does NOT have HIV. For the
first year, babies are tested for HIV by looking for the virus, and not by
looking for antibodies to HIV. When babies are more than 1 year old, they no
longer have their motherÕs antibodies and can be tested for HIV using the
antibody test. If after the 1st year the baby tests negative they are
considered HIV negative.
If your child
turns out to be HIV positive, talk with your doctor about what treatments are
right for them. In the developing world, with the appropriate treatment and
nutrition, HIV positive infants may be able to live a very healthy life.
Being
pregnant and HIV positive in a developing country can pose many risks for your
child. Knowing your HIV status is the first step toward reducing your childÕs
risk of contracting HIV. Hopefully in the future every pregnant HIV positive
mother in developing countries will have the same access to health services and
treatment as most women in the developed world. In the meantime, as a woman in
a developing country, by doing the best you can with the resources available to
you to prevent the transmission of HIV to your child, you can play an important
part in the fight against HIV. This is [PRESENTER NAME].
REFERENCES
http://www.who.int/hiv/pub/mtct/guidelines/en/
ÒAntiretroviral Drugs for Treating Pregnant Women and
Preventing HIV Infection in Infants: Guidelines on Care, Treatment and Support
for Women Living with HIV/AIDS and their Children in Resource-Constrained
SettingsÓ
http://www.aidstruth.org/cohen-hivnet012.php
HIV
TRANSMISSION: Allegations Raise Fears of Backlash Against AIDS Prevention
Strategy
Science
24 December 2004
Vol.
306. no. 5705, pp. 2168 - 2169
by Jon Cohen
http://www.aidsnews.org/2004/12/nevirapine-ap.html
Nevirapine Misinformation: Will It Kill?
by John S. James
http://www3.niaid.nih.gov/news/newsreleases/2005/332005_nevirapine.pdf
Reports on nevirapine threaten public health
NATURE MEDICINE VOLUME 11 | NUMBER 3 | MARCH 2005
p. 245