|UNAIDS Technical Update Mother-to-Child Transmission of HIV (3) -Technical Update - Document (UNAIDS, 2000, 17 p.)|
With the advances described earlier in this document, the world is considerably better equipped today than even one year ago to help pregnant HIV-positive women to safeguard the health of their children. Nonetheless, it must be emphasized that the best means of reducing mother-to-child transmission remains primary prevention - making sure that women of childbearing age do not get infected in the first place; and family planning - making sure that parents have children if and when they wish.
Any national strategy to prevent mother-to-child transmission of HIV should therefore be part of broader strategies to prevent the transmission of HIV and STDs, to care for HIV-positive women and their families, and to promote maternal and child health. The ability to make interventions to reduce MTCT widely available, and as soon as possible, depends on political will, affordability of the interventions, and the strength of existing human resources and infrastructures.
The protection of girls and women from HIV infection.
This will minimize the risk that women of childbearing age are carrying the virus in the first place. It involves promoting safe and responsible sexual behaviour in couples, providing them with knowledge about HIV/AIDS and how to prevent infection, and ensuring that they have the necessary personal skills and access to condoms so that they can act on their knowledge. It also means providing good quality, user-friendly prevention and treatment programmes for other sexually transmitted diseases (STDs), the presence of which increases the risk of HIV transmission as much as 6-10 fold. And, crucially, it means taking steps to deal with the cultural, legal and economic factors that make girls and women specially vulnerable to HIV infection by limiting their autonomy and power to protect themselves.
Referrals to family planning programmes
It is every woman's fundamental right to decide for herself, without coercion, whether or not to have children. The responsibility of the government and health services is to provide HIV-positive women and their partners with comprehensive information and education about the risks associated with childbearing as part of routine public information about HIV/AIDS, to ensure they have real choices of action, and to respect and support the decisions they reach. This means providing good quality, user-friendly and easily accessible family planning services so that HIV-positive women can avoid pregnancy if they choose, and similarly acceptable and accessible abortion services, where the procedure is legal, so that they can terminate pregnancy if desired.
Women who choose replacement feeding because of their HIV infection should also receive advice on contraception to replace the birth-spacing effect of breastfeeding.
In many high HIV prevalence countries, bearing healthy children provides social status and access to family resources - access denied to women whose HIV-infected children sicken and die. To that extent, interventions to reduce HIV transmission from mother to child can help a woman consolidate her social position, despite her HIV infection.
Create an optimal setting for service delivery
In countries with well functioning health systems, the additional service delivery costs of interventions to prevent MTCT may already be affordable. Other countries may require more substantial investments to strengthen their health infrastructure to permit incorporation of large-scale interventions. Where applicable, traditional health and community support systems should also be fully utilized. Such investments will have a broad beneficial effect on the health sector more generally and should be encouraged.
The following characterize the optimum settings in which to implement MTCT prevention interventions:
· All women should have knowledge about HIV and access to the information necessary to make appropriate choices about HIV prevention, sexual and reproductive health, and infant feeding in the context of HIV.
· HIV counselling and testing should be available for pregnant women, those contemplating pregnancy, and their partners.
· All pregnant women should have access to antenatal, delivery and post-partum care, and to a skilled attendant at birth.
· There should be follow-up of children at least until 18 months, especially regarding nutrition and childhood illnesses.
· Women should have easy access to affordable contraceptives.
· Medical and other support services should be accessible to HIV-infected mothers and their families
· Human rights, including reproductive rights and the rights to informed choices and confidentiality, should be respected. This means that the social and medical environment must enable women and families to make informed choices and cope with the choices they make.
Voluntary counselling and testing
All women should have access to voluntary HIV testing. This means testing must be done with the informed consent of the woman, using reliable laboratory tests and ensuring confidentiality (see Conselling and voluntary testing for pregnant women in high HIV prevalence countries. UNAIDS key material). The benefits of information, counselling and HIV testing are not limited to situations where expensive treatment interventions are available (see box), and HIV counselling and testing in relation to pregnancy and other reproductive health services may prove a valuable entry point for provision of counselling and voluntary testing to the wider community of healthy and asymptomatic women and their partners.
In places where acceptability of VCT is poor, carefully designed and monitored pilot programmes will enable health and social service providers to better define counselling requirements and design measures such as long-term support for families that include HIV-positive members, family planning referral, spouse counselling, and communication programmes such as campaigns against discrimination. Many innovative approaches are being developed, and countries are evaluating, documenting and sharing their experiences.
The benefits of information, counselling and voluntary HIV testing for different clients in reproductive health settings - A summary
Potential mothers and fathers
Counselling and voluntary HIV testing can help women and men who may be considering forming or expanding their families to:
· weigh up the risks and advantages of a pregnancy
Pregnant women who test HIV-negative
Counselling a woman following a negative test can help a woman
· understand and maintain safe behaviour to avoid future infection
Pregnant women who test HIV-positive
Counselling a woman following a positive test can help a woman
· decide whether to share her HIV status with anyone, and if so with whom
Partners of pregnant women
Counselling and voluntary testing of partners of pregnant women helps couples
· support one another in decisions about care and infant feeding
The wider community
Widespread availability and use of counselling and voluntary testing for HIV in a community can
· reduce fear, ignorance and stigma surrounding HIV
· reduce spillover of artificial feeding to HIV-negative mothers
Infant feeding programmes
An important response to MTCT is to ensure safe, affordable alternatives to traditional breastfeeding. In industrialized countries, HIV-positive mothers are advised not to breastfeed and, if necessary, are provided with free infant formula. In Thailand, where there is relatively wide access to safe water, HIV-positive mothers are starting to be given free infant formula by the government, provided with information on risk factors, and encouraged not to breastfeed. In most Latin American countries, HIV-positive women are encouraged to avoid breastfeeding.
Realistic and sustainable options in many settings may eventually include exclusive breastfeeding and early cessation of breastfeeding. Home-prepared formula made from animal milks, typically from cows, goats, buffaloes or sheep may help to achieve early weaning. Whatever options eventually become available, counselling programmes will be required to help pregnant women make free and informed choices and to support them in whatever decision they take (see box).
The health of the mother
The use of short-course antiretroviral monotherapy during pregnancy increases an HIV-positive womans chances of having a healthy child without harming her own health. However, it is not a treatment for her. HIV-positive mothers are generally asymptomatic, and at this stage of HIV infection it would not benefit them to continue on antiretroviral monotherapy after giving birth. Where long-term antiretroviral treatments are not yet affordable, HIV-infected mothers and other family members should have early access to drugs that can prevent and treat opportunistic infections (particularly tuberculosis), to social and community support, and to support against discrimination and rejection. Indeed, MTCT prevention is intended to be integrated with other HIV/AIDS and MCH programmes and result in better care and other support services for those found to be HIV-positive.
Improving affordability of interventions
The principal factors that affect the affordability of interventions to prevent MTCT are:
· cost of drugs
· cost of safe alternatives to breastfeeding
· cost of HIV tests
· cost of counselling
The recent trial results allow use of shorter, and therefore cheaper antiretroviral regimens. The cheapest regimen option today is nevirapine, which costs approximately 4 US$ to treat a mother-child pair. In addition to the breakthrough made by the recent trials, WHOs addition of zidovudine and nevirapine to the Essential Drug List facilitates bulk purchasing at negotiated prices. Negotiations between UNAIDS and pharmaceutical industry are ongoing.
Any effort to reduce the cost of using commercial alternatives to breast milk for HIV-positive mothers must conform to the International Code of Marketing of Breast-Milk Substitutes and subsequent World Health Assembly resolutions. However, this still provides considerable flexibility for price negotiations, bulk buying and distribution programmes.
The challenge of reducing the cost of HIV tests is being addressed in a number of ways. Since 1990, WHO has helped governments and agencies to obtain high-quality test kits through negotiation of bulk purchase prices from manufacturers. The average price per kit purchased under this programme is around US$1.00. Nearly half of the kits are simple-and-rapid test kits. (For more information see UNAIDS Technical Update HIV Testing Methods.)
In most developing countries, specialist counsellors are in short supply. And there is unlikely to be enough money available to train and hire as many specialist counsellors as would be needed in the context of routine antenatal care. It is recommended rather to diffuse the work of providing information and of counselling as efficiently as possible though the hierarchy of care. Much of the routine provision of basic information about HIV transmission, prevention and testing for example, can be done in groups.
Cost-effectiveness of MTCT prevention
A recent analysis of the economics of MTCT prevention in low-income countries (see Marseilles in the Key Documents) estimated a cost per case averted of US $298 for use of a single dose of NVP to both mother and child in settings where HIV prevalence is 30%. Costs taken into account were the antiretroviral itself, test kits, service delivery costs. Although data on costs of treating HIV+ children are scarce, best available data from South-Africa indicate a cost of approximately 300 US$, similar to the cost per averted case.
Where more resources are put in child care, the costs per case averted will clearly become much lower than the care cost, and the use of antiretrovirals to prevent MTCT will become cost saving. The cost estimates per averted case correspond to US $11 (using NVP) per disability-adjusted life year (DALY), figures that compare favourably with other HIV and non HIV-related interventions in sub-Saharan Africa. (Note that the World Bank suggests that interventions costing around $50 per DALY compare favourably with other uses of health resources in low- and middle-income countries.).
The most powerful means of effecting change generally lies in demonstrating the success of interventions through well monitored pilot programmes. In Botswana for example, the government has decided to scale-up the intervention after an initial pilot period of 8 months: The Botswanan Prevention of Mother-to-Child Transmission (MTCT) of HIV Program was launched in Gaborone and Francistown in April 1999. Voluntary counselling and testing was offered to all pregnant women in government health facilities. Oral AZT was provided to HIV-positive women starting at 34 weeks of pregnancy and during labour and AZT syrup was given to the babies born to HIV-positive mothers. The intervention also included infant feeding counselling and provision of infant formula to women who opt not to breastfeed. In the first 8 months of the program, out of 7,000 ANC clients, over 4,000 have been counselled, of which 46% have been tested, and 41% were found positive. By January 2000, 221 women and 367 infants had received AZT. A programme review, done in January 2000, suggested some ways to overcome the obstacles encountered during the pilot phase such as developing an adequate IEC strategy, mobilising communities and increasing coverage with pre-test counselling through more widespread counselling training of health care workers. The review team concluded that scaling-up was advisable.
HIV and infant feeding: guidelines for policy makers
Given the vital importance of breast milk for child health, and the proven risk of HIV transmission through breastfeeding, it is now crucial that governments and public health authorities develop policies on HIV infection and infant feeding. The following excerpts from the UNAIDS, UNICEF and WHO joint guidelines on HIV and infant feeding provide policy-makers with key elements for formulating such policies. (The full text of these guidelines can be requested from UNAIDS or viewed on the Internet at http://www.unaids.org)
Decision-makers need to consider the following:
... If the government offers free or subsidized breast-milk substitutes to some or all HIV-positive mothers who choose not to breastfeed, these mothers must be assured of breast-milk substitutes for at least 6 months. Additional costs include micronutrient supplements and extra health care costs for non-breastfed children. Against this can be set reduced costs of treating fewer children with AIDS.
... If free or subsidized breast-milk substitutes are to be offered, they need to be distributed efficiently to the mothers who are eligible for them, but controlled to prevent spillover to mothers who are HIV negative or of unknown status.