7. A decision tree

Clearly, national and local circumstances will have a major influence on decisions regarding the adoption of voluntary counselling and testing, antiretroviral drugs and replacement feeding. The following “decision tree” is proposed as a means of assisting those involved in national and local policy-making to decide on:

a) the appropriate levels of provision, and
b) the best model of operation of the strategy.

The influencing factors:

· seroprevalence of HIV in the country or community will determine the costs of inaction and the relative cost-effectiveness of different screening strategies

· attitudes towards HIV in the country or community will determine the risk of discrimination against women found to have HIV, the likelihood of infrinsgement of their rights, and the expected accept-ability of the intervention

· the risks associated with replacement feeding will determine whether or not the intervention can be introduced on a large scale immediately or whether pilot projects will be needed initially so that lessons can be learnt about how to make replacement feeding safer

· the state of the existing health system and Mother-and-Child Health services (including family planning) will determine the expenditure of effort and resources required to strengthen them sufficiently to support the new programme

· the maturity of the epidemic and level of social support that has developed to cope with it will determine how big a burden will be imposed upon the MTCT programmes by increased demand for health care and counselling

· the wider benefits to society will have to be taken into account when balancing costs and benefits of the intervention

· available financing for MTCT interventions and associated services will be a major consideration in decision-making.

These factors will vary a great deal from one place to another. The following table proposes a decision-making process to assist policy-makers who wish to consider adopting an antiretroviral drug and replacement feeding strategy that is suited to their situation, and that reflects the local HIV prevalence, available resources, health system performance and expected risks associated with replacement feeding.

Table 1: Combination of services appropriate to different circumstances

(Key: VCT = voluntary counselling and testing; ARV = antiretroviral drugs; RF = replacement feeding.)

Definitions

1. Local health system meets requirements

Access to adequate Mother-and-Child Health services including antenatal, delivery, postnatal and family planning services and continuing medical and psychosocial support for mother and child

2. Short ARV

Regimens as used in Thailand and Cd’Ivoire studies

300 mg ZDV twice-daily from 36 weeks
300 mg ZDV 3-hourly during labour

(Note: alternatives to the Thai regimen will soon be available for short ARV)

3. Long ARV

Other regimens including ACTG 076 and regimens using a combination of antiretroviral drugs and antiretrovirals for the neonate as well as the mother.

4. Known HIV-positive

Women who present for antenatal care having already been tested for HIV outside the maternal health services, and found to be infected.

5. Targeted antenatal VCT

Voluntary counselling and testing offered to pregnant women and their partners in communities (geographical or social networks) where HIV prevalence is particularly high.

6. Routine antenatal VCT

Voluntary counselling and testing offered to all women attending antenatal services and their partners as a matter of course

7. Pilot introduction of VCT and ARV/RF

Introduction of the full strategy in a selected number of sites, and careful monitoring and evaluation of the processes and their impact, with particular attention to replacement feeding

8. Prepare the health system

Where the health system does not meet the requirements for the successful introduction of the strategy, careful preparation is needed for voluntary counselling and testing, mother-and-child health services, and medical and support services for seropositive women and their children.

List of documents on MTCT available through UNAIDS Information Centre or through UNAIDS web site (www.unaids.org):

General Information:

UNAIDS Technical Update on HIV Transmission from Mother to Child (October 1998)

Prevention of HIV Transmission from Mother to Child: Planning for Programme Implementation. Report from a Meeting, Geneva, 23- 24 March 1998

Prevention of HIV Transmission from Mother to Child: Strategic options (May 1999) AIDS 5 years since ICPD: Emerging issues and challenges for women, young people and infants. (1998)

HIV Counselling and Testing:

Counselling and voluntary HIV testing for pregnant women in high HIV prevalence countries: Guidance for service providers (May 1999)

The importance of simple/rapid assays in HIV testing. WHO/UNAIDS recommendations (Weekly Epidemiological Record 1998, 73, 321-328)

Antiretroviral treatments:

WHO/UNAIDS recommendations on the safe and effective use of short-course ZDV for prevention of mother-to-child transmission of HIV. (Weekly Epidemiological Record 1998, 73,313-320)

The use of antiretroviral drugs to reduce mother to child transmission of HIV (module 6). Nine guidance modules on antiretroviral treatments. (UNAIDS/98.7)

HIV and Infant feeding:

HIV and infant feeding: A review of HIV transmission through breastfeeding (UNAIDS/98.5)

HIV and infant feeding: Guidelines for decision-makers (UNAIDS/98.3)

HIV and infant feeding: A guide for health care managers and supervisors (UNAIDS/98.4)

WHO/UNAIDS/UNICEF Technical Consultation on HIV and Infant Feeding Implementation guidelines. Report from a meeting, Geneva 20-22 April 1998.

HIV and infant feeding: A UNAIDS/ UNICEF/WHO policy statement (May 1997)

Planning, Implementation and Monitoring & Evaluation:

Vertical Transmission of HIV - A Rapid Assessment Guide (1998) Local Monitoring and Evaluation of the Integrated Prevention of Mother to Child HIV Transmission in Low-income Countries (1999).

MTCT prevention in Asia:

Thaineua V. et al. From research to practice: Use of short-course zidovudine to prevent mother-to-child HIV transmission in the context of routine health care in Northern Thailand (South East Asian Journal of Tropical Medecine and Public Health, 1998).

MTCT prevention in Latin America:

Prevention of vertical transmission of HIV. Report from a workshop, Buenos Aires 29-31 July 1998.

MTCT prevention in Africa:

The Zimbabwe Mother-to-Child HIV Transmission Prevention Project: Situation Analysis.

Notes:

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