1.2 Prevention strategies

Until recently, countries had only two main strategies for limiting the numbers of HIV-infected infants:

· primary prevention of MTCT - taking steps to protect women of childbearing age from becoming infected with HIV in the first place;

· the provision of family planning services, and pregnancy termination where this is legal, to enable women to avoid unwanted births.

These remain the most important strategies for reducing HIV among young children and essential activities in all national AIDS campaigns.

Today, however, there is a third option for HIV-positive women who want to give birth which consists of a course of antiretroviral drugs for the mother (and sometimes the child), and replacement feeding for the infant. A recent trial in Thailand using a short course of zidovudine has shown that this strategy is able to reduce the risk of MTCT to below 10% when breastfeeding is strictly avoided. Alternative regimens using short courses of other antiretroviral drugs, sometimes in combination, will soon be available. Furthermore, trials are being conducted to find out what happens if mothers do subsequently breastfeed their babies instead of giving replacement feeds. This is a critical issue since the majority of HIV-positive women who risk transmitting the virus to their infants come from cultures where breastfeeding is the norm, and where replacement feeding presents great difficulties for many women.

Introducing a strategy of antiretroviral drug use and replacement feeding is, however, a complex process. To take advantage of the intervention, mothers need to know that they are HIV-positive, and they must therefore have access to voluntary counselling and testing. Costs and benefits need to be carefully assessed. Policy-makers need to decide what kind of programme is feasible and most appropriate for their countries, and whether or not to test models of the strategy in pilot projects before introducing it more widely. Such a programme requires a commitment to ensuring there is an efficiently functioning primary health care system with certain key services as a basis for introducing the strategy. Where these conditions do not already exist, decisions need to be made about how to strengthen the health infrastructure, what time-frame would be realistic, and what else is needed to create the conditions for safe and successful introduction of antiretroviral drugs and replacement feeding.

The purpose of this paper is to review the key issues for consideration in policy-making, and to propose ways in which the strategy might be tailored to suit local conditions. The paper is intended for all those with a part to play and a special interest in national policy making with respect to HIV prevention and care.