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[ HIV prevention ]

Risk begins at birth

The probability of HIV being transmitted from mother to child during pregnancy and delivery can be as high as 25 %. If an HIV-positive woman breastfeeds her baby, the risk rises to 40 %. Around 370,000 children a year are infected with HIV – most of them in Sub-Saharan Africa – and usually by their mother. Yet if proper action is taken, the risk of infection can be radically reduced.


[ By Stefanie Theuring ]

HIV is a much greater threat for children than for adults. A quarter of all infected infants die before their first birthday, two thirds fail to reach the age of five. In 2007, AIDS claimed the lives of around 270,000 children under 15, most of them in sub-Saharan Africa. In Botswana and Zimbabwe, more than a third of all fatalities among children under five are due to HIV.

What is particularly tragic is that mother-to-child transmission could be avoided. In industrialised countries, where appropriate funding is available, vertical transmission risk can be reduced to less than two percent by a combination of antiretroviral drugs, selective delivery by Caesarean section and breastmilk substitutes. In many parts of the world, these measures cannot be introduced as standard – particularly where health systems are poor, money is unavailable and babies are born beyond the reach of professional help.

This does not mean that infected mothers-to-be in poor countries can not take medical precautions to minimise the risk of transmission to their child. To reduce the risk of HIV transmission by as much as 50 %, the easiest and cheapest way is, if a pregnant woman takes a single dose of Nevirapine at the onset of labour and the child too is given Nevirapine after delivery. That is the WHO minimum standard.

In the past 10 years, numerous programmes have been developed to reduce mother-to-child transmission in poor regions. In 2001, the German government tasked the technical cooperation organisation GTZ with launching a major Prevention of Mother-to-Child-Transmission of HIV (PMTCT) pilot project in conjunction with national health ministries in Kenya, Tanzania and Uganda. The Institute of Tropical Medicine at the Charité University Hospital in Berlin was engaged to coordinate scientific cooperation. Planning and implementation were performed in close consultation with national and local authorities and in line with national guidelines and recommendations by international bodies such as the WHO.


Integration into national health systems

The PMTCT measures were embedded in existing antenatal care services, so they were integrated from the outset into the national health systems. Responsibility for implementation resides with local health centre staff. Infrastructures and skills were improved to make the PMTCT happen. Today, more than 140 health facilities in the three countries participate in the programmes.

After detailed consultation, consenting mothers-to-be are now tested for HIV at antenatal clinics. If the result is positive, they are offered a single dose of Nevirapine, which they are advised to keep at home and take at the onset of labour. The women also receive advice – on health, infant nutrition and family planning. For the delivery – or at least no later than 72 hours after it – they are told to return to the health centre so that the drug can also be administered to the newborn child. Afterwards, the women continue to receive assistance, advice and support.

But many women questioned why they should take a test or protect their baby from an infection if the diagnosis for themselves is effectively a death sentence. Therefore, participating women and their families are now offered long-term antiretroviral therapy (ART). These measures are integrated into national ART programmes.

Professional staff training is a particularly important aspect, and needs to be regularly refreshed. Awareness raising and PR work are also crucial. Theatre perform­ances by local drama groups, radio and TV broadcasts, posters and other means are made use of.

PMTCT measures were monitored by scholars from the outset. One focus of research today is on male partners. It is hoped that involving them more closely in antenatal care and PMTCT services will help put mothers-to-be in a stronger position, because women traditionally often have little say in matters of health. Revealing an HIV-positive status to a partner may even threaten a marriage. Therefore, many women refuse HIV tests in antenatal care.

However, it has been found that women's willingness to take part increases if they are professionally informed about HIV and PMTCT – and also tested for infection – together with their partners. Men should definitely be involved in PMTCT schemes – especially since many are infected themselves.

Coherent strategy

"AIDS has a woman's face". This much-quoted statement is particularly true in sub-Saharan Africa, where women now account for 60 % of HIV-positives. Young women, in particular, are affected. The figures in Zwaziland are particularly dramatic: 23 % of women aged between 15 and 24 are infected with the virus; the figure for males in the same age group is six percent.

The high infection rate among young women of childbearing age has dire consequences: worldwide, around two million HIV-positive women a year become pregnant, most of them in the countries of Southern Africa. In 2006 more than a quarter of the women attending antenatal care facilities in Lesotho and South Africa were HIV-positive; in Zwaziland and Botswana, the figure was actually over a third. In East Africa, up to 20 % of pregnant women across the region are affected.

In 2002, the WHO published a recommendation on the problem of mother-to-child transmission of HIV in developing countries. It adopts a four-pronged approach:
– primary prevention of HIV infection among women of reproductive age,
– prevention of unintended pregnancies among HIV-infected women,
– prevention of HIV transmission during pregnancy and delivery and measures to avoid infection through breastfeeding, and
– provision of care for HIV-positive mothers and their children and families.
No one questions that the issue of mother-to-child transmission of HIV should be embedded in general HIV/AIDS policy. However, primary prevention in HIV-endemic countries must on no account be neglected. One prime requirement here is to strengthen women's rights. Women need to be able to take their own informed decisions about their sexual and reproductive behaviour. This helps both guard against new infection among adults and prevent unwanted pregnancies among HIV-positive women. (st)
(st)

D+C, 2008/11, Tribune, Page 424-425