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We have to do all we can to improve maternal health and prevent the mother-to-child transmission (MTCT) of HIV. South Africa has the highest HIV and Aids burden in the world, with about 5.7 million people infected with HIV in 2009. More than 257,000 of those infected are children; around 70,000 are born with HIV every year. Those under the age of 13 are generally infected during pregnancy, childbirth, or breastfeeding.
MTCT requires a three-fold strategy.
Treatment for the HIV positive mother
Women who have reached the advanced stages of HIV disease need a combination of antiretroviral medications to stay as healthy as possible. These medications, which must be taken every day for the rest of the woman’s life, are also highly effective at preventing mother-to-child transmission (PMTCT) of HIV.
The 2010 World Health Organisation (WHO) recommendations are that pregnant women, who are HIV-positive, are to receive treatment when their CD4 count dips below 350 cells/mm. This is a welcome change from the 200-cell threshold required previously, and includes a course of either triple antiretroviral medications (ARVs) for the mother and/or nevirapine for the baby, depending on their clinical requirements. In another policy change, all other pregnant women who test HIV-positive should begin receiving treatment at 14 weeks rather than in the last term of pregnancy. Postnatal treatment for mothers has also been revised; mothers should now receive Tenofovir (TDF) and Emtracitabine (FTC) to avoid developing resistance to the ARVs.
It is advisable for women who require treatment, to start either immediately or after the first trimester. Their babies will usually be given a course of treatment for the first few days or weeks of life, to lower the risk even further.
If these medications are unavailable, then under the 2006 WHO recommendations, the mother should begin taking AZT after 28 weeks of pregnancy or as soon as possible thereafter. During labour, she should take AZT and 3TC plus a single dose of nevirapine. Her baby should receive a single dose of nevirapine immediately after birth, followed by a seven-day course of AZT. The mother should continue taking AZT and 3TC for seven days after delivery as an added precaution against developing resistance to the medication.
Drug resistant HIV
It has been shown that about a third of the women who take single dose nevirapine develop drug resistant HIV, which can make subsequent treatment involving nevirapine and efavirenz (a related medication) less effective. While drug resistant HIV tends to decrease over time, there is a chance that it may persist for many months in some parts of the body, even if it is undetected in the blood, weakening the effectiveness of the treatment in the longer-term.
Feeding the baby
While breastfeeding is best for most babies, it can unfortunately also transmit HIV. On no account should a mother who is not taking any ARVs feed her baby, as there is a 40% chance that a baby who is breastfeed for two or more years will become infected.
Replacement feeding (also known as formula) means giving a baby commercial infant formula (prepared from powder and boiling water) or home-modified animal milk (boiled with added water, sugar and micronutrients) instead of breast milk.
Replacement feeding is the only infant feeding method that does not expose an infant to HIV. Where clean water and facilities are available; it is usually promoted as the only option.
According to the World Health Organization (WHO), there is a 2% chance of the baby becoming HIV positive when ARVs are taken responsibly and consistently throughout the pregnancy, the baby is given nothing but breast milk for the first six months of life, appropriate complementary foods are introduced thereafter, and the mother continues breastfeeding for the first 12 months of her baby’s life.
However, if the medication is not taken correctly 100% of the time, there is a risk that the baby either will become infected with HIV or will become resistant to the medication. Breast milk provides all of the fluids and nutrients that a young baby needs, so exclusive breastfeeding means that even water can and should be avoided.
Problems with breastfeeding
Unfortunately, encouraging mothers to practise exclusive breastfeeding is far from easy. In sub-Saharan Africa, it is normal for a baby to be given water, teas, porridge or other foods as well as breast milk, even during the first few weeks of life.
A problem arises when the mother is back home with the extended family who are unaware of the HIV status of the mother. There can be issues of stigma and pressures from the family. A South African health worker reported that "the family will offer to buy her formula when she has chosen to breastfeed, they will tell her that breast milk is not enough for the baby, she must also mix it with formula feeding, and she can't deny that because she hasn't told them why she chose to exclusively breastfeed her baby so she will just mix feed."
Then again, a mother may decide to breastfeed exclusively, but then start giving her infant additional fluids because she does not believe she has enough breast milk.
Many HIV positive women may also not be able to obtain an extended course of ARVs right through their pregnancy and six-month breastfeeding period.
Weaning the baby
The longer an HIV positive mother breastfeeds, the more likely she is to infect her baby, however this risk has to be weighed against the benefits of breastfeeding. Owing to the high risk of diarrhoea among infants and the benefit of ARVs, WHO strongly advises that the baby is weaned gradually; rapid weaning can cause an increase in HIV transmission and even cause the baby's death. By controlling the duration of weaning and continuing to take the ARVs for one week after breastfeeding has stopped altogether, transmission and infant mortality and morbidity are reduced.
An HIV-positive mother may undergo a caesarean section to protect her baby from direct contact with her blood and other bodily fluids but the risk of HIV transmission should be weighed against the possible harm due to the intervention.
Take time to discuss ways of reducing the risk of HIV transmission to your baby with your caregiver as soon as you know that you are pregnant.