5. Questions of ethics

A guiding principle behind the introduction of any measure to reduce MTCT is that it is the pregnant woman’s absolute right to choose, on the basis of full information, whether or not to take advantage of the intervention. Coercion is not justified under any circumstances, even if it seems to be in the best interests of the woman or her child, and her choice should always be accepted and respected.

Introducing antiretroviral drug programmes for the prevention of mother-to-child transmission in countries where antiretrovirals are not available for the treatment of HIV-positive people more generally has raised sometimes heated debate about the ethical implications.

The question is asked: If a mother’s access to antiretroviral drugs is limited to the period of pregnancy and labour, does this amount to treating the mother for the sake of her baby alone?

In fact, the question is based on an erroneous perception, for an antiretroviral drug used for the purpose of preventing MTCT of HIV is not really a treatment, but a “vaccine” for the infant. A useful analogy is the rubella vaccine given to pregnant women to protect their offspring from the ill-effects of maternal infection. Rubella vaccination does not meet with ethical objections, despite the fact that it, too, could be seen as treating the mother for the sake of the baby.

The fact that antiretrovirals can serve two separate purposes - as vaccine for infants against MTCT of HIV, and as treatment for HIV-infected individuals - is, of course, very significant. But the issue of antiretroviral treatment for infected people must be considered separately from the issue of antiretroviral drugs used for the prevention of MTCT. It requires debate and policy decisions outside the scope of MTCT policy-making. However, it is a point of principle when adopting a strategy of antiretroviral drug use and replacement feeding that HIV-positive pregnant women must be assured of the best possible care available in their countries. In some places, antiretroviral drugs will be available for therapy, too; in others, such treatment will simply not be feasible.

It is important also to note that a short course of antiretrovirals during pregnancy, while increasing the chance that she will give birth to an uninfected baby, does no harm to the health of an HIV-positive woman. The only possible risk is anaemia. But anyone taking antiretrovirals for HIV should be screened for this condition in advance, and treated for it if necessary. Concern is sometimes expressed that the strategy might encourage the development of drug-resistant strains of HIV. However, the risk of resistance developing is minimal with such a short period of drug use.

Another concern is the idea that introducing this strategy for the prevention of MTCT might exacerbate the problem of orphaned children, increasing the burden of care on families and society. It is widely assumed that children born to HIV-infected mothers do not survive long enough to become orphans. But this is a misconception. In the absence of preventive measures for pregnant HIV-infected women, around 65% of the children born to them will escape infection but face orphanhood; of those who are infected (35%), many will likewise survive longer than their mother. With the prevention strategy, the percentage of uninfected children facing orphanhood will rise to almost 90% but in parallel there will be a significant decrease - two- to three-fold - in the number of infected orphans. Thus, with or without the intervention, the great majority of the babies born to HIV-infected mothers will be exposed to the risk of being orphaned. The intervention does not therefore affect in any significant way the need for societies to make provision for their orphaned children. However, from the point of view of planning for care and allocating resources, it is important to recognise that, with measures to reduce MTCT, many fewer orphaned children will be HIV-infected and in need of medical care and support, many of them long-term. It is also worth noting that improving perinatal care and diagnosing HIV infection to permit early access to care may prolong the life of mothers. HIV-positive women may also live longer if they do not have to cope with sick children. Thus, their children will have the care of their mothers and be spared the misery and vulnerability of orphanhood for longer.