Academic journal article Bulletin of the World Health Organization

Reducing Perinatal HIV Transmission in Developing Countries through Antenatal and Delivery Care, and Breastfeeding: Supporting Infant Survival by Supporting Women's Survival

Academic journal article Bulletin of the World Health Organization

Reducing Perinatal HIV Transmission in Developing Countries through Antenatal and Delivery Care, and Breastfeeding: Supporting Infant Survival by Supporting Women's Survival

Article excerpt

Introduction

In southern African countries, where the pandemic of human immunodeficiency virus (HIV) is moving faster than prevention efforts, paediatric wards of hospitals are becoming overcrowded with infants and children dying of acquired immunodeficiency syndrome (AIDS) (1), and the average rate of HIV infection in women attending antenatal clinics can be 30% or more (2). In 1997, UNAIDS/WHO estimated that 590 000 children worldwide were newly infected with HIV in utero or during birth or breastfeeding, and that over 2 million HIV-positive women would give birth during 1998 (3).

In 1998, a joint UNAIDS/UNICEF/WHO working group announced a series of pilot studies of an intervention to reduce perinatal transmission of HIV (4). These were to involve 30 000 HIV-positive pregnant women at 30 sites in 11 countries (eight in sub-Saharan Africa, two in Asia and one in Latin America), and were based on the new guidelines on HIV and infant feeding (5).

Available information, however, raises questions about the extent of the public health benefit that can be achieved through this intervention in the poorer developing countries, in view of the limited capacity of antenatal and delivery services and the practical and ethical dilemmas involved in women using breastfeeding replacements without adequate counselling and support (6, 7). This paper argues that these dilemmas would be better resolved through integrated pregnancy, delivery, and HIV/AIDS care that protects both women's and infants' health and lives, even though it would cost more.

The UNAIDS/UNICEF/WHO intervention and increased infant survival

The UNAIDS/UNICEF/WHO intervention is based on a package of six components (4).

* Early access to adequate antenatal care.

* Voluntary and confidential counselling and HIV testing for women and their partners.

* A short course of perinatal antiretroviral treatment (AZT) given to HIV-positive women in the last weeks of pregnancy and during delivery (and possibly also to their newborn infants).

* Improved care during labour and delivery.

* Counselling for HIV-positive pregnant women on alternative methods of infant feeding.

* Support for HIV-positive mothers who choose not to breastfeed, to enable them to use breastfeeding replacements safely without violating the International Code of Marketing of Breast-milk Substitutes and related World Health Assembly resolutions.

Efforts to protect infants at risk of perinatally transmitted HIV have been universally welcomed, and many infants will be protected from HIV infection if this package is implemented fully. However, unless additional resources and skilled health personnel are found, most developing countries are likely to focus on only two of the six components, restricted to women with a positive HIV test, i.e. short-course perinatal AZT treatment and provision of baby milk powder to replace breastfeeding. Implementing these two components, all other things being equal, is far better than doing nothing. The two together would also be more effective than short-course perinatal AZT treatment on its own (8), since the benefit gained during delivery would be reduced by the risk of infection through breastfeeding. The guidelines acknowledge that it may be necessary to limit the intervention to AZT treatment alone when the use of a breastfeeding replacement is not feasible, but this reduces the potential public health benefit even further. Since a variety of factors must be taken into account, trial-based evidence will be needed to show the extent to which actual implementation of this intervention results in an overall reduction in infant mortality and morbidity (6).

Ensuring that breastfeeding replacements can and will be used safely

Deaths from AIDS have increased infant mortality in all the developing countries where HIV in women of childbearing age is found. …

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