Antiretroviral Interventions to Reduce Mother-to-Child Transmission of Human Immunodeficiency Virus: Challenges for Health Systems, Communities and Society

Article excerpt

Voir page 1042 le resume en francais. En la pagina 1043 figura un resumen en espanol.

Introduction

A study in Thailand showed that short-course zidovudine treatment reduced mother-to-child transmission of the human immunodeficiency virus (HIV) by approximately half among women who did not breastfeed (1). This intervention, involving the administration of zidovudine orally for four weeks, including the day of delivery, requires minimal monitoring and has few adverse effects. It may therefore be feasible and affordable under certain conditions in low-income and middle-income countries.

Negotiations are in progress to obtain a substantial reduction in the price of zidovudine for this indication to make its use relatively cost-effective, even in developing countries. The United Nations Children's Fund (UNICEF), WHO, the United Nations Population Fund (UNFPA) and the Joint United Nations Programme on HIV/AIDS (UNAIDS) support the development of programmes for reducing mother-to-child transmission of HIV in developing countries as rapidly as possible. It is hoped that such interventions may also serve as catalysts for improving associated HIV care and prevention services.

In Uganda a single-dose treatment with nevirapine for mothers and infants (200 mg orally during labour and 2 mg/kg to infants within 72 hours after birth) significantly reduced the risk of perinatal transmission in women who breastfed during the first 14 weeks after childbirth (2). In settings where resources are poor this treatment, which is more affordable and practicable than previously documented interventions, offers promise for the future. It provides hope that strategies will be found for preventing the spread of HIV from infected mothers to their children, particularly where women have difficulty in gaining access to antenatal care and have no safe alternatives to breastfeeding.

Resource allocation

Finance and other resources

There is general agreement that interventions providing antiretroviral treatment for the reduction of mother-to-child transmission in developing countries should not divert resources from other HIV care and prevention activities, and that they should be funded with additional money (Chevalier E, personal communication, 1998). Seven million perinatal deaths, 98% of them in developing countries and most of them preventable, occur globally each year. Maternal mortality is very high at 400-1600 per 100 000 live births (3).

In the sub-Saharan countries where antiretroviral interventions against mother-to-child transmission have been proposed it is arguable that there are more pressing unmet health needs. The general health services are inadequate: mortality among children aged under 5 years is often 200 per 1000 (4) and malnutrition affects up to 40% of children (5). The lifetime risk of maternal death is 1 in 9 in Ethiopia, Mozambique, and Rwanda, and 1 in 14 in Cote d'Ivoire, the Republic of the Congo, and Zambia (6) because of inadequate services in the areas of family planning and antenatal, delivery and postpartum care (7). Furthermore, 30-75% of the people have no access to safe water supplies (8, 9).

The aim of these antiretroviral interventions is to reduce the number of children infected with HIV. However, measures to reduce the number of infections in women and men, such as the treatment of sexually transmitted diseases (10), the provision of condoms (11) and HIV education (12) are not being implemented. Primary prevention aimed at reducing the number of infected pregnant women may be more cost-effective (13). It can therefore be argued that it is more ethically acceptable and rational to devote resources to the prevention of HIV infection in future mothers than to give antiretroviral treatment after maternal infection has occurred.

Financial sustainability

Once antiretroviral interventions have been implemented as pilot projects with external funding, together with associated services such as voluntary counselling and testing, the provision of enhanced maternal and child health services, and the provision of subsidized breast-milk substitutes, and when the prevention of mother-to-child transmission has been demonstrated, demand for these services should be created. …