The aim of this report is to discuss the effectiveness of existing preventative methods in mother-to-child-transmission (MTCT) of the HIV disease (Human Immunodeficiency disease),
MTCT transmission is defined as the transmission of the HIV virus from the infected mother to the baby, usually during pregnancy, labour and delivery or via breastfeeding 2, 3. In estimation, 590,000 infants are infected with the HIV virus through MTCT, in which, 90% of the MTCT infections occurred in African nations or other poorly developed countries. This is mainly due to the inability of third world countries to implement preventative interventions that could prevent MTCT 3, 4, 5. In the absence of treatment and preventative measures, 15-30% of infants will become infected during pregnancy and labour, and an extra 5-20% will become infected via breastfeeding 2, 3. Therefore, infant HIV infections can be prevented if effective and efficient preventative strategies are put into practice (figure 1) 6.
Figure 16: This is the process required for effective prevention of MTCT (PMTCT). The process of PMTCT is a three-fold process which includes: effective testing in pregnant women, providing and administering antiretroviral drugs and finally giving guidance to mothers on safer infant feeding strategies 1, 6.
PMTCT measures can effectively determine which women require assistance. The UN interagency Task Team has devised a four-component strategy in MTCT: (1) prevent HIV infection in all people, especially prospective parents; (2) Decreasing the number of unintentional pregnancies in HIV infected women; (3) prevent MTCT through pregnancy, safer method of delivery and breastfeeding; and (4) provide care and support for HIV positive women and their immediate relatives 2, 7.
HIV Testing in HIV Positive Pregnant Women
HIV testing involves taking blood from the individual, and screening the specific blood sample for the HIV virus (and sometimes other infections) 8, 9. Implementing HIV testing in health clinics has proven to be inexpensive and cost-effective, therefore allowing more and more women to discover their HIV status, in which PMTCT measures can be taken10. Routine HIV is available in two different types: opt-out and opt-in. The opt-out routine test involves testing of HIV in all pregnant women, in which they can specifically decline a HIV test. On the basis of a positive result, the individual will receive counseling, in which appropriate advice and treatment will be given 8, 9.
On the contrary, in the opt-in routine test, information of the availability of a HIV test is provided to women, and will be given if requested for one. This way of a routine test has shown to be less effective compared to opt-out due to women feeling fear for example 9, 11. However, studies have shown that the percentage of acceptance of routine tests is significantly higher if offered to pregnant women with counseling 6, 9, 12. Mandatory testing is an alternate way of testing, which involves the removal of informed consent from the pregnant women and leaves them with no choice, but to have the HIV test as they are bound to the law. This way of testing can favorably promote pregnant women from accessing health care services, and therefore lead to increased rates of MTCT 9.
The shortage of clinic resources such as: HIV testing kits and healthcare staff that could potentially provide counseling. A probable solution for this is to organize more reliable routes to provide testing kits 6. Accessibility to health clinics can lay as a further barrier to many women, especially in third world countries where far distances are required to be travelled by women who live in rural areas, which, in turn, there are limited access to transport and the cost of transport can be unaffordable. Opening clinics for longer hours and providing free transport can overcome these barriers 13. Furthermore, many women fear that if their HIV status is revealed then this will follow onto discrimination by members of their community 6.
Antiretroviral drugs in PMTCT
Antiretroviral drugs need to be taken daily by women who have reached the advanced stages of HIV infection, not only for their own health, but for PMTCT, as the risk of MTCT is significantly higher at this stage 13, 15. It is very common for newborn babies to also be given antiretroviral treatment in order to reduce the risk of MTCT even further by administering the drugs within the first few weeks of life. MTCT can also be effectively reduced if pregnant women, who don't yet need drugs, are provided with a short course of medication 13, 15.
Nevirapine is given in the form of a single dose to both the mother (in the onset of labour) and the child (post delivery), making it the most simplest, easiest and cheapest form of antiretroviral drug to administer 6. This is evident in a study carried out in Uganda, which also found this drug to reduce transmission by approximately 50%13, 16. Since such a simple procedure is required to administer Nevirapine, staff can be easily trained to provide the drug, and in turn, will reduce the burden of healthcare professionals, which can prove to be very useful in underdeveloped countries due to the lack of resources, especially trained staff. On the contrary, Nevirapine treatment can encourage resistance to other drugs (e.g. efavirenz) in both mother and infant, as seen in approximately a third of women who take the single dose of Nevirapine 17, 18. This subsequently will expose both mother and infant to other infectious diseases, which are more complex to treat 18. Furthermore, the supplying of a drug that is only 50% effective still leaves the potential of many babies being infected with HIV 6.
Moreover, long-term courses of drugs have shown to be the most effective at PMTCT, but at the same time most difficult to administer 19. Reasons for this include: the lack of resources in supplying the drugs, the requirement of frequent visits to the clinic by women for collection of drugs, sticking to and maintaining daily treatment, and acquiring considerable side effects of drugs 6. An alternative to this, which is still very effective in reducing PMTCT even further, is providing women with a combination of drugs, usually three antiretroviral drugs (AZT and 3TC with Nevirapine) in different regimens (Table 1), which, in turn, will also prevent HIV resistance 2, 6; yet although more effective, can prove to be a more expensive, difficult to administer and less practical in underdeveloped countries 2. Therefore, Nevirapine remains as the only cost-effective drug, which can be easily implemented with minimum supervision, most appropriate for third world countries.
Point/time of administration
High Recommend-ation
Alternative Recommend-ation
Low Recommend-ation
Minimum Recommend-ation
Pregnancy
AZT after 28 weeks
AZT after 28 weeks
-
-
Labour
single dose nevirapine; AZT+3TC
single dose nevirapine
single dose nevirapine; AZT+3TC
single dose nevirapine
For mother post- natal
AZT+3TC each for 7 days
-
AZT+3TC each for 7 days
-
For infant post-natal
single dose nevirapine; AZT for 7 days
single dose nevirapine; AZT for 7 days
single dose nevirapine
single dose nevirapine
Table 1: Showing four existing regimen guidelines recommended by the World Health Organisation (WHO) 19, 20.
Safer Infant Feeding Strategies
The HIV virus has the ability to be transmitted through breast milk, thus alternative methods of feeding is recommended. Studies show, MTCT can be increased by 40% alone by HIV positive women breast feeding their infants 3. The advice given to HIV positive women in developed countries is to abstain from breastfeeding as this reduces the risk of HIV transmission. However, in third world countries, replacement feeding isn't feasible. Reasons for this include: increased costs for feeding formulas, and another factor is the availability of safe water, which when consumed by infants can potentially lead to infections or even death, leaving some mothers with no choice but to breastfeed only, solely depending on their personal health (HIV) circumstances 21, 22.
Breastfeeding can also be exclusively administered by HIV-positive women to their infants who choose to breastfeed only and not give their child anything else to consume, including water 23, 24. This way the baby will receive all the vital vitamins, nutrients and protective agents that are not present in feeding formulas 21. This is a more practical way of feeding infants, especially for mothers in third world countries as it has no cost, and at the same time reduces the risk of MTCT 22. However, the tables can turn if 'mixed feeding' is introduced. This involves providing the infant with other foods and liquids in combination with breast milk, leading to damaging effects in the infants' digestive system, therefore, considerably increasing HIV transmission (MTCT) from breast milk in entering bodily tissues 21, 22. Besides, transmitting the HIV virus, breastfeeding can also infect infants with HIV resistance that has been acquired by the mother through certain antiretroviral drug therapies 6, 25.
Moreover, as is with other PMTCT strategies, safer infant feeding strategies also cause problems to some women. Certain locations in the world seize the norm of breastfeeding, and women who don't abide by this, by maybe using feeding formulas, as a result could reveal their HIV status and, in turn, face discrimination by their surrounding community 22. In due course, MTCT can be avoided effectively by 100%, if abstinence from breast feeding is undertaken by HIV-positive mothers 23. Therefore, the absolute decision can only be made by the mother and depending on her health status; replacement feeding should purely be used if it is 'acceptable, feasible, affordable, sustainable, and safe', which is a recommended guide for which councillors should use as a basis for assessment of mothers when offering advice 26.
Conclusion
To conclude, the existing PMTCT have proven to be quite valuable and effective in reducing MTCT in both developed and underdeveloped countries. However, developments in certain areas still need to be made in order to sustain, and decrease the number of MTCT around the world. MTCT can only be combated with drastic steps if the HIV status of women is revealed, quickly and effectively through HIV testing. Training and educating of staff on the subject of the importance of confidentiality and using the correct drug regimes and training staff so they could acquire certain skills such as: HIV testing, counselling, and communication. Combining these skills will help in increasing trust between the healthcare provider and user and make women more comfortable in giving and receiving information and making them more adherent to treatment, especially long-term treatment. If more funding was increased, better antiretroviral treatment (combining drugs), alternate feeding foods, transport to clinics and HIV testing kits will be available, which will decrease MTCT and drug resistance. Overall, it can be said that abstinence from breast feeding is still the best way in PMTCT. However, counselling mothers on the grounds of acceptability, feasibility, affordability, sustainability and safety can help them make right and sensible decisions that can benefit their own and their child's health and well-being. Improving all PMTCT programmes along with the three step strategy will significantly decrease the number of MTCT cases in third world countries.
