of MTCT: Interventions
activities to control the HIV/AIDS epidemic
has shown that a range of interventions can reduce the risk of
mother to child transmission of HIV/AIDS by up to 50 per cent.
The primary effort is being directed to trying to prevent HIV/AIDS
infection in women, young women in particular. In addition, three
key interventions are being used to help to prevent mother to
child transmission of HIV:
and Confidential Counselling and Testing (VCCT) Access
to information and to HIV testing and counselling constitutes a
fundamental human right. It is critical for women to be aware of
their HIV status as their actions impact on the health and well
being of their families and can prevent subsequent sexual transmission.
Counselling provides women with information about their condition,
whether positive or negative, so they can make informed choices.
And it educates pregnant women about what they can do to prevent
mother to child transmission. In countries with high HIV infection
rates, UNICEF supports the introduction of voluntary and confidential
counselling and testing as a prerequisite for the implementation
of other interventions to reduce HIV transmission. The most effective
interventions to reduce transmission from mother to child depend
on the mother knowing her HIV status and subsequently receiving
the necessary counselling and information if she tests positive.
Voluntary and confidential counselling and testing services, therefore,
need to be widely available and acceptable to adolescent
girls, pregnant women and their partners. In view of women's
risks of stigma, violence and loss of family and livelihood, confidentiality
is an essential element of counselling, testing and of all other
services for HIV positive women. The goal is that within two years,
70 per cent of all women attending antenatal clinics will have access
to voluntary and confidential counselling and testing. If positive,
pregnant women need access to counselling
concerning their own futures as well as about infant feeding options
to help them weigh the benefits and risks of breastfeeding and alternative
feeding methods. HIV positive women should be supported to make
their own decisions and to carry out their choice of infant feeding
method. The majority of women, however, test HIV negative. For them
and their partners, counselling provides important information about
measures, including safe sexual practices, critical to helping them
remain HIV negative. HIV voluntary confidential counselling and
testing in relation to pregnancy and other reproductive health services
often proves to be a valuable entry point for the provision of VCCT
to the wider community of women, their partners, and young people.
A growing number of studies have indicated that voluntary confidential
counselling and testing can contribute to an increase in an individual's
safe behaviour-and reduce fear, stigma, and discrimination at the
community level. UNICEF strongly believes that access to information,
and to testing and counselling, constitutes a fundamental human
right. Knowing one's serostatus (HIV+ or HIV-) is an individual's
right, if s/he chooses to be tested. Therefore, effective strategies
to ensure access to testing and counselling services must be a priority.
A number of hurdles still need to be overcome to achieve effective
voluntary and confidential counselling and testing. The cost of
these services remains high in most countries. There is also a dearth
of well trained counsellors and an over-reliance on volunteers in
many areas. Fear of stigma and discrimination among women and adolescent
girls regarding a potentially positive HIV status still inhibits
adequate use of VCCT services even where they are available. The
quality of services must also be improved to boost use.
and confidential counselling and testing, particularly
of pregnant women, can reduce the risk of mother to child transmission
(MTCT) as well prevent subsequent sexual transmission of HIV/AIDS.
HIV positive women need counselling in order to be able to make
informed decisions about their own as well as their families'
futures and about infant feeding options. Women testing HIV
negative need to be counselled about preventive measures including
safe sexual behaviour.
to HIV positive pregnant women and ensuring safe delivery procedures
can reduce risk of transmission at delivery. AZT, administered
from 36 weeks gestation through labour until delivery, or a
single dose of nevirapine given during labour and to the baby
within three days of birth, are generally safe and can substantially
reduce the risk of a mother transmitting HIV to her child. Both
are on the WHO list of essential drugs.
regarding infant feeding options can
also reduce the risk of transmitting HIV from mother to child.
Though HIV can be transmitted through breastfeeding, breastfeeding
may nevertheless be the optimal choice a mother can make in
certain situations about how to feed her infant. Counselling
provides women with knowledge about the risks, benefits and
costs of the various feeding alternatives, including breastfeeding,
so that the mother can make her own informed decision about
how best and most safely to feed her newborn child.
Antiretroviral drugs reduce mother to child transmission when started
before, during delivery, but even if taken within 48 hours after
delivery. Antiretrovirals work mainly through two mechanisms:
the viral load in the mother so a lesser quantity of virus is
transmitted to the infant.
the virus from "fixating" itself in the child, also called "post-exposure
through antiretroviral therapy given in the antenatal period and
during delivery persists through the breastfeeding period. Continuing
antiretrovirals in breastfed children is a promising new intervention
likely to be effective in reducing transmission of HIV through
breastmilk. Although some side effects have been observed, antiretrovirals
are generally safe with the benefits of the drugs outweigh the
risk of side effects. These drugs continue to be monitored. UNICEF-assisted
MTCT prevention programmes use the drug AZT (sometimes called
zidovudine or ZDV) and have adopted the protocol initially developed
in Thailand in 1997. This short regimen gave 300 mg AZT orally
twice daily from 36 weeks gestation until the onset of labour
and 300 mg every three hours from the onset of labour until delivery.
This regimen decreased mother to child HIV-1 transmission by 37-38
per cent in breastfeeding populations after 18 months and by 50
per cent in non-breastfeeding populations. Botswana used a modified
regimen of antiretroviral therapy at 34 weeks and administered
AZT syrup to the baby for four weeks.
1999, the results of a major research study in Uganda became available
which showed that another drug, nevirapine, could achieve
an equivalent reduction of transmission with only a single dose
to the mother during labour and a single dose to the baby within
three days of birth. The nevirapine regimen costs about $4.00
for each mother /child pair. The current consensus of the UN agencies
is that nevirapine is one of the suitable regimens for decreasing
the risk of MTCT of HIV/AIDS, especially for women who detect
their HIV positive status or arrive at the health facility too
late in the pregnancy to benefit from the AZT regimen. The new
single dose nevirapine regimen substantially lowers the cost barrier
that has kept many countries from adopting drug strategies to
prevent perinatal transmission. Long term follow-up of both the
mothers and babies remains a high priority to assess any late
drug toxicities as well as long term survival. Research results
may indicate that a combination of nevirapine with AZT or other
drugs may be more effective. Findings will have important implications
for the provision of interventions to prevent MTCT of HIV in developing
countries. Both AZT and nevirapine are on the WHO List of Essential
Drugs for MTCT. The low cost of nevirapine does not, however,
justify mass treatment without individual counselling and testing.
The side effects of nevirapine have not been fully established
yet. Additionally, blanketing populations with this drug can create
resistance to it
Feeding and HIV
are best placed to decide how to feed their infants, but to
make an informed choice, they need counselling to know the
advantages, risks, benefits and costs associated with all
infant feeding options. Trained counsellors can also support
mothers as they make and carry out their own decisions. The
guidelines regarding infant feeding accommodate all
infant feeding options for mothers with HIV. Furthermore,
they support a fully informed choice based on all available
information and advocating that mothers be provided with new
and better information as it becomes available.
is a possibility of transmitting HIV through breastfeeding, replacement
feeding is an option for mothers. If an HIV-infected mother has
access to an adequate supply of breastmilk substitutes, knows
how to use them, has access to fuel and clean water and the time
to prepare breastmilk substitutes safely, refraining from breastfeeding
will reduce the risk of transmitting HIV through breastfeeding.
In countries where families live in poverty, have limited education
and poor access to the resources required to provide safe feeding
alternatives to breastfeeding, including counselling, however,
the risk of death from diarrhoea, respiratory, and other infections
associated with replacement feeding can be as great or greater
than the risk of transmitting HIV through breastfeeding. As a
general principle, the guidelines advocate that in all populations,
irrespective of HIV infection rates, breastfeeding should be protected,
promoted and supported and that HIV positive mothers who choose
to breastfeed should be given full support for their decisions.
Women who do not wish to be tested for HIV and those who have
tested negative should be encouraged to breastfeed. If an HIV
positive mother chooses to breastfeed, she should do so exclusively.
Combining breastfeeding and replacement feeding is inadvisable
because partial breastfeeding supplemented with water, formula
or other drinks appears to elevate health risks, including HIV
transmission, possibly because these supplements can damage the
infant's gut and make it easier for viruses to cross the intestinal
of ongoing research to
determine mechanisms of HIV transmission from an infected mother
to her child is that the risk of transmission will be reduced
if the duration of breastfeeding is limited. The exclusively breastfeeding
mother, therefore, may wish to stop breastfeeding completely at
4 to 6 months to prevent late postnatal MTCT. However, at the
present time, the evidence is not strong enough to make a firm
recommendation on a specific cut-off age when breastfeeding should
completely stop. Recommendations will be kept under review as
knowledge in this area increases.