Preventing Mother-to-child Transmission of HIV in Resource-limited Settings

Hendramoorthy Maheswaran; Ruth M. Bland

Disclosures

Future Virology. 2009;4(2):165-175. 

In This Article

Abstract and Introduction

Abstract

Mother-to-child transmission (MTCT) before, during and after delivery may result in the acquisition of HIV for 30-35% of infants of HIV-infected mothers. Peripartum HIV transmission can be reduced to under 5% in resource-limited settings using a feasible prophylactic antiretroviral regimen. Reducing postnatal transmission through breastfeeding, whilst maintaining child survival, is an urgent priority, given that breastfeeding causes one-third to one-half of all infant HIV infections. Recent evidence highlights the impact of breastfeeding duration and pattern, and hazards associated with the avoidance of breastfeeding in different settings. New international guidelines on HIV and infant feeding have been published. Despite knowledge of how to reduce MTCT of HIV in resource-poor settings, an unacceptably low proportion of women access prevention of MTCT services (PMTCT); follow-up of women and children is poor. To improve survival of mothers and children, health services need to be strengthened, with the integration of PMTCT into existing maternal and child health services.

Introduction

The HIV epidemic has had a devastating effect on children and young people under 15 years of age, with an estimated 2 million (1.9-2.3 million) people infected with HIV, and 370,000 (330,000-410,000) new HIV infections in 2007[201]. In sub-Saharan Africa, approximately 12 million children under 18 years old have been orphaned through HIV. A total of 90% of HIV-infected children live in sub-Saharan Africa, having acquired HIV through mother-to-child transmission (MTCT) during pregnancy, delivery or through breastfeeding; although transmission during early pregnancy is rare[1,2]. Children who are HIV-exposed, but not themselves infected, are at an increased risk of morbidity and mortality[3,4,5], particularly if they have lost their mother[6,7]. Prevention of MTCT (PMTCT) of HIV and improving the survival and quality of life of mothers is urgent if child mortality is to be reduced, and the Millenium Development Goals and other global calls to action are to be achieved (Table 1).

In developed countries, MTCT rates below 2% have been achieved using combination antiretroviral therapy (ART), elective caesarean section and avoidance of all breastfeeding[8,9,10,202]. Similar results have been reported from Africa, mainly in the context of research studies or well-resourced programs[11,12,13]. However, only an estimated 18% of pregnant women in low and middle-income countries had HIV counseling and testing in 2007, and only 5% of HIV-infected women accessed PMTCT interventions in the 30 African countries with the highest HIV prevalence[14]; a huge shortfall from the UN target of 80% by 2010[201].

In this article, we review research findings and significant changes in policies since 2000 in relation to PMTCT in resource-limited settings, and discuss challenges and barriers to scaling up effective interventions. We carried out a literature search using the PubMed database for studies relating to the subject published after 2000. Keywords used in the search included: 'PMTCT', 'pregnancy', 'mother-to-child transmission', 'ART', 'HAART' and 'pregnancy'. Reference lists of related articles were searched for relevant studies, as were the abstracts of recent conferences and the files of the authors. We focused our search on resource-poor settings, and the two authors were responsible for deciding on the manuscripts to be cited in this article. We present our findings under six headings: approaches to counseling and testing; ART regimen for reducing perinatal transmission; HAART for pregnant women who require therapy for their own health; safety of antiretrovirals (ARVs) during pregnancy; infant feeding and HIV; and follow-up of women and children after delivery.

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