Taking interventions
to scale
Any national strategy to prevent mother to child transmission
of HIV should be part of broader strategies to prevent the transmission
of HIV and STDs, to care for HIV-positive women and their families,
and to promote maternal and child health. The ability to make widely
available, and as soon as possible, the interventions to reduce HIV
transmission from mother to child depends on political will, affordability
of the interventions, and the strength of existing human resources and
infrastructures. Powerful means of effecting change lie in demonstrating
the success of interventions to reduce mother to child transmission
of HIV, as well as the costs of not acting to prevent this kind of transmission.
Three factors that affect the affordability of interventions
to prevent mother to child transmission are: (i) the cost of drugs;
(ii) the cost of safe alternatives to breastfeeding; and (iii) the cost
of HIV tests. WHO has added zidovudine for mother to child transmission
to the Essential Drug List. Glaxo-Wellcome has recently offered zidovudine
at substantially reduced prices. Further negotiations are planned to
minimise the cost of each of these components.
Service delivery, including voluntary HIV counselling
and testing, represents a further set of costs. In countries with well-functioning
health systems, the additional service delivery costs of interventions
to prevent mother to child transmission may be affordable. Other countries
may require more substantial investments in order to strengthen their
health infrastructure to allow for the incorporation of large scale
interventions. Where applicable, traditional health and community support
systems should also be fully utilised. Such investments will have a
broad beneficial effect on the health sector more generally and should
be encouraged.
Optimum context
The following parameters describe the optimum context
in which to implement effectively the interventions necessary to reduce
transmission of HIV from mother to child:
All women should have knowledge about HIV, and
should have access to the information necessary to make appropriate
choices about HIV prevention and about sexual and reproductive health
and infant feeding in the context of HIV.
HIV counselling should be available for pregnant
women and those contemplating pregnancy. Such counselling should address
the needs of pregnant women and women living with HIV, including reproductive
health issues such as family planning and safe infant feeding. Active
referral and/or networking for follow-up counselling, comprehensive
care, and social support should be available for the HIV positive woman
and her family.
Pregnant women, and those contemplating pregnancy,
should have access to voluntary HIV testing, to test results with the
least possible delay, requiring that appropriate laboratory services
be available to process such tests, and to counselling.
All pregnant women should have access to antenatal,
delivery and post-partum care, and to a skilled attendant at birth.
For the shorter zidovudine regimen to be effective, at least one antenatal
visit with follow up is needed before 36 weeks, and preferably before
34 weeks, of gestation. In order to benefit from this intervention,
women who access antenatal services prior to 36 weeks should have access
to HIV voluntary counselling and testing. Skilled care during delivery
is also needed; the shorter zidovudine regimen also involves administration
of zidovudine during labour and delivery.
There should be follow-up of children at least
until 18 months, especially for nutrition and for childhood illnesses.
Key principles
The following are some of the key principles that should
underpin the implementation of all interventions to prevent mother to
child transmission:
The right to protect oneself from HIV infection,
including through: (1) access to full information about HIV, including
information on mother to child transmission, information from relevant
research, and information concerning one's serostatus; and (2) access
to the means of prevention, such as condoms and relevant HIV/STD health
services. This requires the integration of HIV prevention, including
prevention of mother-to-child transmission, into existing systems, e.g.
education, health care (including traditional health care), and community
and women's development (non-governmental and community-based organisations,
traditional community leadership, etc.)
The right to decide whether or not, and when,
to bear a child. This requires access to information about family planning
and access to family planning services. It also requires community and
family acceptance of a woman's or a family's decisions.
The right to voluntary/ informed consent and confidentiality
in HIV testing, counselling and treatment, including choices made in
the context of mother to child transmission. This involves training
of health care workers, including traditional health care workers, in
providing informed consent and protecting confidentiality, and should
lead to voluntary, informed, and when possible, supported decision-making
on these and related issues.
The right to an environment which enables women,
parents and families to make choices that protect their health and that
of their loved ones, and to act upon these choices. This includes reducing
stigma and discrimination related to HIV and to mobilising communities
for support. It also includes improving access to health care, including
voluntary counselling and testing, antiretroviral treatment in pregnancy,
treatment for opportunistic infections, and to the conditions necessary
to use safe alternatives to breastfeeding.
The right to ethical research, including research
that does no harm, is conducted with informed consent and with the participation
of communities in research design and implementation, and involves the
dissemination of research results to affected communities.
Unresolved issues
The efficacy of zidovudine in preventing HIV transmission
to the child from an HIV positive mother who breastfeeds is currently
not known. Zidovudine may provide some degree of protection, although
probably less than the protection it provides to infants who are not
breastfed. Since the majority of HIV positive women facing transmission
from mother to child are women who breastfeed, it is critical to resolve
this issue. It is also necessary to learn more about the effect on the
morbidity and mortality of infants born to HIV positive women of introducing
alternatives to breastfeeding.
Nevertheless, the greatest reduction in mother to child
transmission of HIV is likely to occur when an integrated prevention
programme is implemented which combines the provision of zidovudine
and safe alternatives to breastfeeding. In some countries, it may prove
to be impractical to implement simultaneously access to zidovudine and
access to safe alternatives to breastfeeding. In these situations, the
implementation of one prevention component should not be delayed until
the other is feasible. Furthermore, if a woman chooses not to use both
zidovudine and safe alternatives to breastfeeding, she should still
have access to the intervention of her choice and should be supported
to carry out the use of this intervention safely and effectively.
Other unresolved issues involve the efficacy of even
shorter regimens of zidovudine than that used in the Thai study, and
the efficacy of interventions which do not require knowledge of serostatus,
such as Vitamin A supplementation and vaginal cleansing for prevention
of mother to child transmission. Results from ongoing research will
indicate whether or not these can be proposed as effective interventions
on their own, or only as measures complementary to an antiretroviral
regimen.
Additional research is also required on issues such
as factors influencing the uptake of voluntary testing and counselling,
not returning for HIV test results, adherence to the regimen, and acceptance
of interventions to prevent mother to child transmission.
The need for action
and support
A global effort is needed to promote the updating and
scaling up of interventions to prevent mother to child transmission
of HIV. Furthermore, there is an ethical imperative to support the introduction
of the shorter zidovudine regimen in countries in which trials have
been completed, and to encourage the initiation of such interventions
in countries which have the capacity and willingness to support them.
Recognising the urgency of the situation and at the same time the fact
that it will take time to mobilise new resources for these interventions,
it is recommended that a phased approach be taken in the introduction
of such interventions. Such an approach would tailor implementation
to utilise fully and immediately existing national and local capacities,
with a concrete plan to build on these initial efforts over time. Where
the capacity to implement these interventions is limited, efforts should
begin immediately to increase capacity, with a plan to introduce these
interventions as soon as possible.
Coordination mechanisms
Mechanisms are being established through UNAIDS, in
close collaboration with UNICEF and WHO, to coordinate and support efforts
for accelerated capacity-strengthening and technical development, and
to scale up the implementation of interventions to reduce mother to
child transmission. These mechanisms will facilitate the exchange of
information, mobilise resources, help to coordinate research, and resolve
remaining policy, programmatic and technical issues. Key actors are
presently discussing the nature and functioning of these coordination
mechanisms.