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HIV in pregnancy: the risk of mother - to – child transmission and possible interventions.

Obuekwe Ifeyinwa Flossy, Ph.D.

Department Of Pharmaceutical Microbiology, Faculty Of Pharmacy, University Of Benin, Benin City. Nigeria. Tel: 234 – 52 – 602009 Fax: 234 – 52 – 602009
Email: fobuekwe@uniben.edu; ifobuekwe@hotmail.com

Key words

HIV, infection, mother-to-child-transmission, risk, and intervention.

Abstract

HIV infection in pregnancy has become the most common complication of pregnancy in some developing countries. This has major implications for the management of pregnancy and birth. More than 70% of infections are a result of heterosexual transmission and over 90% of infections in children result from mother-to-child- transmission (MTCT). Most of the transmission is thought to occur in late pregnancy and during birth.

Over one million children are living with HIV infection from their mothers. There have been 8.2 million children who have lost their mothers or both parents to AIDS to date in the epidemic, at least 95% of whom have been Africans. Transmission of HIV-1 can occur in-utero at the time of labor and delivery, or postnatally through breastfeeding. Transmission is increased in the presence of high levels of maternal viraemia. Increased strain diversity in the mother may theoretically influence the rate or transmission. Unprotected sexual intercourse during pregnancy has been linked to an increased risk of MTCT.

Women are often blamed incorrectly as the source of HIV infection and carry the dual burden of infection and of caring for infected family members. Gender inequalities, poverty, less access to education and lack of employment opportunities force many women into commercial sex work in order to survive, and this group of women are at very high risk of HIV infection.

Despite this, cultural practices and pressures often prevent women from taking necessary precautions to guard against infection. Use of male condoms is very low in many developing countries. The desire and the societal pressures to reproduce make it difficult for women to practice protected sex. Young women are at highest risk of infection in developing countries, many of them at the beginning of their Reproductive lives. Even after a diagnosis of HIV infection, most women will not change their reproductive choices.

Higher rates of ectopic pregnancies have been reported in HIV-positive women than in uninfected women, which may be related to the effects of other concurrent sexually transmitted infections. Genital tract infections such as Trichomonas vaginalis, Neissria gonorrhoea and Candida albicans infections have been reported to be more common in women with HIV. Syphilis is more common also in HIV-positive women in some African studies. Urinary tract infections (UTI) and bacterial pneumonia are more common during pregnancy in HIV- seropositive women. In addition to these infections and parasitic infestations, any of the HIV-related opportunistic infections can be found during pregnancy.

This study examines possible interventions to prevent MTCT of HIV in pregnancy and suggests the following: adequate alternatives to breastfeeding should be provided for HIV-positive women wherever possible; early cessation of breastfeeding should be encouraged; All HIV-positive pregnant women should be screened for syphilis even in low-prevalent areas; voluntary counseling and testing for couples should be encouraged; use of antiretroviral drugs in pregnancy for the prevention of MTCT of HIV should be encouraged and provided as widely as possible. The escalating prevalence of HIV infection in women is a serous public health issue that demands special attention because the disease appears to affect women in unique ways.

Introduction

The HIV pandemic has greatly affected women of child - bearing age in developing countries and thus, their offspring, through mother- to-child -transmission (MTCT) of the virus. Scientific advances, most of them established by randomized clinical trials, have recently led to the development of practical strategies arriving to reduce the public health burden of MTCT of HIV. Women of child - bearing age constitute half of the 30 million adults living with HIV/AIDS world - wide. Mother- to -child -transmission of HIV during pregnancy, delivery, and breast - feeding is the major route of infection among young children, accounting for an estimated 1600 of the 16,000 new infections that occur every day world wide, most in developing countries.

While mother –to- child HIV transmission in the developed world is rapidly disappearing, the story is different in areas where resources are limited. There is a disproportional increase in seroprevalence among adolescent girls. For example 30% of 17 – year old females and 8.6% of 19 – year old males are HIV infected in Kisumu, Kenya. Due to HIV, 200 of every 1000 children die before their fifth birthday. HIV transmission rates of 18.8% of infants aged 3 months who were fed formulae and received no breast milk, 14.6% in infants exclusively breast fed, and 24.1% in infants that had mixed feeds (breast milk and other liquids/solids) have been reported. The risk of HIV transmission through breastfeeding was estimated in Kenyan women. The risk of acquiring HIV infection by ingesting a liter of milk is similar to the risk associated with a single episode of unprotected sex. Infants younger than four months had a 1.9 fold higher chance of being infected through breastfeeding than infants older than 4 months.

It is extremely difficult to base recommendations on feeding practices for women in resource- poor settings, particularly with regard to women who cannot afford replacement feeding. In communities where HIV infected mothers have very limited options other than breast feeding, pasteurization of human milk by passive heat transfer may be an option.

This study reviewed some literature on HIV in pregnancy, the risk of mother-to-child-transmission (MTCT) and possible interventions.

Limitations of effective interventions.

Even in areas where replacement feeding is an option, counseling practices are poor. Health workers had been inadequately trained regarding knowledge about feeding options available to HIV infected mothers were not given a choice regarding breast feeding; and were not given enough information regarding the safe preparation of formulae feeds and feed quantity and frequency were not discussed.

HIV infected women are inadequately counseled and are often not in a position to make and implement an informed choice. Ambiguous messages regarding breast feeding are given to these mothers because the health services promote the universal message that breast milk is best irrespective of the mother’s HIV status. The negative attitudes of families and fathers towards formulae feeding as well as the cost of formulae are major contributions to this limitation.

Emergence of viral resistance.

There has been a lot of concern to the emergence of viral resistance as a consequence of the use of antiretroviral therapy in the prevention of MTCT. NVP mutations in Ugandan women, and infants have been studied. The K103N mutation was present in 23% of all antiretroviral – native women who received a single dose of NVP and was detected in 44% of infants after delivery, showing that NVP given to infants may select for resistance virus. The occurrence of these mutants should not be an obstacle to delay the implementation of short course regimens to prevent MTCT in developing countries.

Single- therapy nevirapine usage is not the current recommended prophylactic regimen to use in pregnancy HIV infected woman or in any HIV individual except in special circumstances. In the setting of sub Saharan Africa, the benefit of a 50% reduction in transmission greatly outweighs the risk of resistance. The infrastructure required to provide zidovudine, nevirapine and other antiretroviral drugs for pregnant women and the drugs themselves are not yet routinely available in most developing countries. As a result appropriate public health strategies will be required to implement these prophylactic strategies on a wide scale.

Possible intervenions for mother-to-child-transmission of hiv.

Pediatric HIV/AIDS is threatening to reverse substantial gains in child survival achieved earlier as a result of successful immunization and other programs. Practical and cost effective intervention to reduce perinatal transmission of HIV and associated infant and child morbidity and mortality are urgently needed.

Significant strides have been made in recent years towards the reduction of perinatal HIV infection: A number of possible intervention strategies have been proposed or are under investigation (Table 1)

Table 1. Possible strategies known or under investigation for the prevention of mother-to-child transmission of HIVa

Termination Of Pregnancy

Behavioural Interventions

  • Reduction in the frequency of unprotected sexual intercourse during pregnancy
  • Reduction in the number of sexual partners during pregnancy
  • Lifestyle changes, including avoidance of drug use and smoking in pregnancy

Therapeutic Interventions

  • Antiretroviral therapy: Zidovudine alone or combination, long – or short – regimen Vitamin A and other micronutrients
  • Immunotherapy
  • Treatment of STI

Obsteric Interventions

  • Avoidance of invasive tests
  • Birth canal cleansing
  • Caesarean section delivery

Modification Of Infant Feeding Practice

  • Avoidance of breast feeding
  • Early cessation of breastfeeding
  • Heat treatment of expressed breast milk

Adapted from WHO/CHS12.

Research in recent years has led to major advances in both prevention and treatment of HIV – 1 in the United States and Europe. With the wide spread implementation of zidovudine (ZDV) for prevention of perinatal HIV transmission there have been dramatic reductions in new pediatric AIDS cases in the United States since 199413. The only interventions proven to be effective in reducing mother-to-child-transmission of HIV at present are the use of zidovudine (either as a long-course through pregnancy, labor and for six weeks to the infant or as short regimen), cesarean section and the avoidance of breastfeeding14, 15, 16. However, the success of the intervention depends upon the access of HIV-positive women to therapy. In areas where utilization of antenatal care is low, and thus access to counseling, testing and drug provision is reduced, the efficacy will be lower.

The ideal intervention for the reduction of mother – to – child transmission would be one that is widely applicable in resource poor setting17. The use of ZDV in this regimen is not directly applicable to most women in the developing world where the majority of mother-to-child transmission occurs. This is because of the high cost of the intervention (cost per mother –child pair in the USA is over US$1,000); drug reactions; the logistic of monitoring of blood parameters; intravenous infusion during delivery and treatment to the newborn for six weeks. This intervention, in addition needs to be introduced early on in pregnancy, when most women in resource – poor settings only attend antenatal care late in pregnancy. In these settings, lack of access to testing and counseling limits the use of antiretroviral in pregnancy. Disease status may differ more from women in developed countries than those in developing countries with higher rate of anemia, which may be exacerbated by antiretroviral treatment. Some resistant strains of virus have been reported to prevent transmission after ZDV treatment18, 19.

The prevention of new infections in women of reproductive age remains an important component20. This includes the reduction of women’s vulnerability to HIV – 1 infection though the improvement of women’s status in society, the promotion of safer sex, including the use of barrier methods, the provision of information about HIV/AIDS and its prevention and the adequate treatment of sexually transmitted infections21, 22. Women known to be HIV positive should have access to appropriate contraception and information to help them determine their future fertility. Also, access to termination of pregnancy for HIV positive women can also reduce the burden of pediatric AIDS cases but should be viewed as an option for individual women, rather than a public health intervention for the prevention of transmission. It seems that most women living with HIV will decide to continue with pregnancy, even after here termination is offered23, 24.

The management of HIV infection and AIDS is changing rapidly. New drugs become available are rapidly adopted into clinical practice with little rigorous evaluation of their effectiveness. The use of non- nucleoside reverse transcriptase inhibitors (NNRTI) for the prevention of perinatal transmission is another possible approach. Nevirapine is a NNRTI with potent antiretroviral activity and a favorable safety profile, but in which there is a rapid development of drug resistance limiting the duration of its effect. The drug achieves high circulating levels, which are long-lasting raising the possibility of a one-dose treatment in labor. The use of combination therapy is becoming more common, with greater reductions in viral load. Recent recommendations for drug therapy for HIV advise the use of at least two agents, with the possible addition of a protease inhibitor25, 26.

There is interest in the role of micronutrients status in the etiology of HIV transmission and disease progression because improving nutritional status may be a cost – effective prophylactic and treatment modality for HIV –seropositive persons, particularly in developing countries where specific anti-retroviral and prophylactic drugs are virtually unavailable. Nutrition deficiencies are associated with impaired function and could therefore lead to increased incidence (and severity) of infections. By impairing systemic immunity of the mother, micronutrient deficiency could result in increased risks of opportunistic infections, faster HIV disease progression, and possibly increased risk of vertical transmission of the virus. Micronutrient deficiency in the fetus or child may also play an important role in systemic immune response to infections, including HIV infection27.

Following the finding that mothers with low serum levels of vitamin A were more likely to transmit HIV to their children28, supplementation of vitamin A has been suggested as a preventive treatment. The potential advantages of micronutrient supplementation would be the low price possible other nutritional and health benefits for the mother and the fact that the intervention could be implemented simply without the need for HIV testing. Vitamin A deficiency has also been associated with increased viral loads in breast milk, and any reduction following supplementation would also be of benefit in breastfeeding women. Other micronutrients such as Zinc and Selenium have also been suggested as possible preventive agents. Zinc deficiency has adverse effects at multiple points in the immune system and is associated with in creased susceptibility to a variety of pathogens28. Zinc supplementation resulted in significant reductions in the severity of diarrhea, a cute respiratory infections, and malaria among children in several trials29.

Another important micronutrient is selenium, which is an essential component of the antioxidant enzyme glutathione peroxidase. Data from epidemiological studies suggest that selenium has a protective effect against certain cancers, particularly in population where intake is low30. Selenium deficiency has been shown in animal studies to inhibit nonspecific immune function, humoral immunity, cellular immunity including cytotoxicity of T – lymphocytes and natural killer cells and resistance to infection. Selenium supplementation, in contrast, enhances these immune functions, as well as resistance to infections31. The relationships between zinc and selenium status and HIV disease progression have also been examined. Low serum selenium levels were associated with significantly higher risks of mortality and the occurrence of AIDS – defining opportunistic infections, even after adjustment for baseline CD4+ counts and other variables32

In another prospective study, normalization of zinc was associated with higher CD4 + counts among men33, low plasma zinc concentration was also a significant predictor of AIDS mortality in a study from Miami32.

Caesarean section delivery before the onset of labor and rupture of membrane (elective caesarean section, ECS) is associated with a decreased likelihood of vertical transmission of human immunodeficiency syndrome virus type 1 (HIV)34, 35.

Caesarean section has become a common mode of delivery for HIV positive women, despite the lack of conclusive evidence at the time. In the United Kingdom, 44% of HIV positive mothers were delivered by Caesarean section36. Vertical transmission of HIV occurs in large part during the intrapartum period37, through many of several mechanisms21, 107. Thus, it had been postulated that cesarean section performed prior to the onset of labor and rupture of membranes could decrease the risk of vertical transmission. HIV – infected women receiving more potent antiretroviral therapy would be expected to have significantly decreased viral loads, and lower maternal viral loads are associated with a lower risk of vertical transmission38.

Among women without HIV infection, caesarean section delivery has been associated with increased maternal morbidity compared to non-surgical deliveries39, 40. However, such associations are subject to confounding by indication, in that often the fetal or maternal indications for caesarean section themselves are associated with a lower risk of maternal complications than is emergency caesarean section 41. Because of the immunosuppression associated with HIV infection, extrapolation of data regarding the risk of postpartum morbidity among women without HIV infection to HIV – infected women must be approached with caution. Only extremely limited information has been available on the relation between mode of delivery and subsequent maternal morbidity HIV – infected women.

Analyses evaluating the cost-effectiveness and cost – benefit of ECS compared to vaginal delivery to prevent vertical transmission of HIV in the US have been performed and declining results have been described43. ECS resulted in fever HIV cases and decreased costs compared to vaginal delivery among women receiving no antiretroviral therapy during pregnancy. Among women receiving zidovudine prophylaxis or combination antiretroviral therapy, ECS resulted in fever cases, and despite increased costs, was highly cost effective. The result of this study indicates that ECS is a cost – effective intervention to prevent vertical transmission among HIV – infected women receiving various antiretroviral therapy regimens.

Vaginal cleansing during labor.

Most HIV infections in children occur during the time of delivery, and free and cell bound virus has been found in cervical and vaginal secretions. The ocetically, thin mode of transmission could be aborted by cleansing the vagina with an antiseptic or virucidal agent such as chlorhexidine. The use of antiseptic or antiviral agents to cleanse the birth canal during labor and delivery has been hypothesized as a possible approach to reducing intrapartum transmission of HIV – 1.

The intervention using chlorhexidine to cleanse the vagina has potential for low – income countries, because it is cheap enough to be provided to all women without prior voluntary counseling and testing (VCT). The use of chlorhexidine lavage to reduce the transmission of group B streptococci was demonstrated in some Scandinavian studies44. The conecptis attractive for HIV infection as it would be an inexperience, readily achievable in most health care settings, would not require identification of HIV – infected women prior to the intervention and could have other health benefit.

Benzalkonium chloride has been suggested as an alternative antiseptic agent for vaginal lavage, utilizing the antiseptic from 36 weeks gestation in an attempt to maximize the possible benefit. The intervention of vaginal cleansing remains a feasible option for resource poor settings.

Modification of Infant feeding Practices

Transmission of HIV in breast milk is well –established45, but public health approaches to its prevention in the developing would remain problematic. Breastfeeding is responsible for a high proportion of mother – to – child transmission in developing countries, where 1 in 7 children born to HIV – positive mother will be infected though breast milk46. Breastfeeding may double the transmission rate47, and may be the major determinant for the difference in transmission rates between developed and developing countries.

How do women who personally face choices about how to feed their infants view these issues? The choice involves an understanding of the risks and benefits of breastfeeding and its alternatives. Assessing the balance of these risks is difficult, even with all the facts. These choices involve beliefs about mothering and nurturing, and not only the beliefs of the woman but, those of her partner and her community more generally48. Many health care workers are always reluctant to give advice that presupposes choices women do not actually have. A person in poor – resource settings, does not choose to have electricity, good roads, hospital services and even clean water, and most African women have neither. It is only mothers who make the ultimate decision about how to feed their babies. What alternatives are acceptable? Acceptability has to do with the context of use, what alternatives exist, what process surround adoption, and how the healthcare delivery system presents these decisions. One way to assess acceptability is to ask also women what they think and what they would do, given a choice. A first step toward understanding what is acceptable is to review what we know about practice. What do we know about how women feed their babies? The pattern of breastfeeding, especially mixing with other foods, appear to influence HIV transmission risk49. Early weaning is another approach to reducing HIV risk. Potential modification of infant feeding practices include complete avoidance of breastfeeding, early cessation, pasteurizations of breast milk and avoiding breastfeeding in the presence of breast abscesses or cracked nipples50.

Formula milk is not very important in most settings with fewer than 5% of women reporting its use in most countries. The main weaning foods are traditional weaning foods. Few babies are found to use bottles. Inadequate provision of clean water and poor hygienic methods would not encourage use of formula milk. In developed countries few HIV – positive women will breastfeed139. In resource-poor settings, alternatives to breastfeeding may not be feasible for financial, logistical and cultural reason51, 52. Formula is expensive, as are other replacement options. The commitment to formula feeding extends beyond the financial horizon of many probably most families live from hand to month, cannot afford three square meals a day. Many families derive, their income solely from the informal sector and do not receive a paycheck. It is very pathetic to think about a mother suppressing lactation only to find herself unable to buy replacement food for her baby after a mouth or two. Women from a study in Zimbabwe say it is very disturbing, ‘pachivanhu’- “We have to breastfeed most of the time, we cannot afford replacement feeding costs. If not breastfed, the baby will die because of lack of food.”

The economic barrier appears to be the most important barrier, especially if mothers agree that their babies should not be breastfed. After all formula feeding has for many years been recommended to HIV – infected mothers in rich countries. Adoption of replacement feeding in the absence of the husband approval is risky in most African settings, but with the husbands support, tradition may be set aside. Mothers should be given the information of the advantages and disadvantages of breastfeeding with regard to HIV infection, and encouraged to make a fully informed decision about infant feeding. They should be supported in their decision46.

The only way to know what choices women will make and how well to cope with these choices, is to offer them and assess them. By learning from those who must make and live with these hand choices public health workers will be in a better position to offer advice.

Voluntary HIV counseling and Testing (VCT)

The critical element in prevention of MICT of HIV is the identification, through confidential counseling and testing, of women infected with HIV. VTC for HIV/AIDS are now widely accepted as an effective HIV prevention and control strategy among heterosexual couples, particularly in sub-Saharan Africa where heterosexual transmission remains the primary source of new infections.

Access to VCT is directly determined by availability of health services, antenatal clinics (ANC) in particular, and it is an expression at country level of the global iniquities in wealth, stills, and resources, as measured by broad and growth rate per annum etc54.

An appraisal of the psychosocial impact of a diagnosis of HIV among pregnant women in Kwazulu Natal suggested that access to VCT was reduced by employment., poverty, illiteracy, migration and erosion of basic human freedoms56. HIV increases the powerlessness of women and worsens the lack of control over their sexuality and fertility, comprising their capacity to access health services and benefit from them.

In cities with a high prevalence of HIV, most infections occur in cohabiting couples in order for these couples to adopt effective HIV risk reduction behavior, the HIV status of both partners must be known 57. It is known that about a third of women globally receive no antenatal care whatsoever58. Furthermore, only 60% of the roughly133 million births throughout the world, are attended by trained health personnel; this proportion ranges between virtually total coverage in the industrialized world to 28% in the least developed countries and 37% in sub-Saharan Africa54. Again the percentage of pregnant women immunized against tetanus is 52% globally; in sub-Saharan Africa, this figure is as low as 39%. These inadequacies in the provision of health services essential for the introduction of VCT reveal the distance developing countries have to cover in order to implement any intervention for reduction of mother-to child transmission of HIV – 1.

Studies have repeatedly shown that most adults want VTC when offered, but the reasons for refusal among the remaining minority are not well-established59. Documented reasons for test refusal from a large scale study in antenatal clinics in Burkina Faso and Cote d’Ivoire were a “to seek agreement of the partner”, “fear of AIDS” and “the need to make a decision later at home”60. The barriers to access to antiretroviral are worth noting. Apart from the major obstacle of inadequate funds, barriers may include lack of laboratories and technology insufficient health services lack of distribution channels, lack of training, administrative delays and also complexity of care and management.

Where ever possible, voluntary counseling and testing (VCT) should be available to any pregnant woman who requests it and offered to all areas of moderate or high prevalence. Even if ANC services and VCT were accessible and available, how acceptable would they be to women in developing countries? Routine testing of pregnant women without consent or without access to counseling is, however an unacceptable practice and the disadvantages may negate any benefits obtained from knowing the HIV Status of the women. These include, a reluctance to utilize maternity services through fear of discrimination, denial of a positive diagnosis and stigmatization. Even outside a research setting within routine services, African women generally accept HIV testing. In Burkina Faso, West Africa this figure was 99%62. Substantial numbers however, do not retain for their results. The reasons for the failure to return include self- perception of being at high risk for HIV, fear of violence in the event of disclosure, financial difficulties and a change of mind63. A number of factors influence acceptability of HIV testing by pregnant women in developing countries. These included perceived benefits, knowledge of MTCT and available treatment, individual altitude, counseling services and universal testing154.

There are however, a number of potential benefits to women of voluntary HIV testing prior to or during pregnancy. Implementation of VCT services can produce a wider range of benefits. ANC services will improve maternal and infant health care benefits and education and training of appropriate health personnel become feasible. However, in developing countries particularly Africa, VCT services appear to fall shot in many specific features. Medical services are often unavailable continuing support (e.g. counselors, NGOs) is absent, availability is restricted outside research sites, there are few trained counselors, workloads are heavy and training is limited. Knowledge of HIV infection can facilitate early counseling and treatment. Diagnosis in a pregnant mother can reduce MTCT through decisions on continuation of the pregnancy and future fertility; prevention of transmission to sexual partners.

There are also possible disadvantages of HIV testing in pregnancy, and this varies from community to community. An increase in the risk of violence against HIV positive women has been reported. The possibility that the women may be stigmatized within her community and by health workers, higher levels of anxiety and psychological sequelae and concurs about the additional work load for maternity services66, 67, 68. Women should be encouraged to bring their sexual partners for counseling and testing wherever possible. A qualified person should take the blood specimen for an HIV test, using “universal precautions” against accidental transmission in all cases. These must include the safe disposal of needles and syringes. The type of tests used will depend upon local seroprevalence, policy and available facilities. In most cases blood in some areas, dry blood spot testing may be an acceptable alternative. The first line test for HIV antibodies is an enzyme- linked immuno-absorbent assay (ELISA) test, or a rapid test algorithm. Depending on local conditions a confirmatory test with a second ELISA or rapid test using a different test kit, or a Western Blot should be performed.

Report of the use of “same day” rapid test results in a rural hospital in a resource poor setting and in an urban STI clinic have suggested that this is an acceptable and appropriate intervention69, 70. Preliminary reports of the use of dual rapid test for same day diagnosis in antenatal clinics suggest that this is an appropriate and acceptable way to provide testing in this setting the major advantage is that early results enable more women to access antenatal strategies for the prevention of MTCT.

Pre- and post- test counseling are essential elements of the management of HIV infection in pregnancy. Pre- test counseling enables women and men to make informed decisions about an HIV test. Post – test counseling is an integral part of the management of the HIV – positive person and provides an important opportunity for risk-reduction messages for those found to be HIV-positive. Information about HIV testing can be incorporated into the health education and promotion activities of antenatal clinics and need not be too time-consuming within maternity services71. Post –test counseling supplies more than merely giving a positive result, and continued care and advice will be necessary as part of the management throughout the pregnancy period72, 73. Wherever possible counseling should be provided in the woman’s native language and within the same cultural background. The involvement of peer counselors – women who are themselves HIV – infected, who are able to counsel and to share their own experience, successes may be very valuable and should be encouraged. The delay between taking the test and giving the result should be as short as possible as the woman may be very concerned about the test and the implications of the result. Women who test positive should be encouraged to bring their male partner(s) for counseling and testing wherever possible. Post-test counseling should also be provided for HIV – negative women with a focus or providing information to enable them to avoid infections.

When counseling HIV – positive pregnant women there are several issues to be addressed, in addition to the general issues related to HIV infection. These include options of termination of pregnancy, diseases about disclosure to the male partner, interactions of HIV and pregnancy, the risk of mother- to –child – transmission and possible interventions to prevent this infant feeding and HIV and other treatment options (Table 2). HIV – infected women should be given appropriate information to make informed decisions about the continuation of their pregnancy and future fertility74. Termination of pregnancy should be offered to HIV positive women, where this is legal.

Health worker should know that offering a termination should never be coercive and that all women irrespective of their HIV status have the right to determine the course of their reproductive life. Majority of women will elect to continue with the pregnancy75, although there are some reports of increased rate of termination.

Knowledge of HIV infection had little effect on reproductive trends and the decision of future of children in a number of studies17, 76. Voluntary HIV testing and counseling is feasible, and acceptable in the community and proven to save lives77.

Table 2. Issues in counseling HIV – positive pregnant women.

The effect of pregnancy on HIV infection and the effect of HIV infection on pregnancy events.

  • The risk of transmission to the fetus during pregnancy delivery and breastfeeding
  • Termination of pregnancy options
  • Treatment options during pregnancy

Interventions available to attempt to prevent mother to- child – transmission

  • Infant feeding options: The advantages and disadvantages of breastfeeding
  • Disclosure of results to male partners and or to other significant family or community members: advantages and risks
  • The need for follow – up of both mother and child future fertility and contraceptive options.

aAdapted from UNIDS/1994

Several different interventions are now available for the prevention of mother to – child-transmission. The low cost of Nevirapine has given rise to discussions regarding the cost effectiveness of universal administration of Nevirapine to laboring women in high prevalence settings7. Concerns regarding the long- term sustainability and potential for drug resistance in a universally administered Nevirapine regimen lend credence to the continued focus on implementation of testing and counseling in antenatal clinics

Regardless of the outcome of cost – effectiveness discussions, voluntary testing and counseling for couples, remains a critical public health tool to reduce vertical and heterosexual transmission of HIV.

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