(introduction...)

The following issues need consideration:

2.1 Counselling and voluntary testing

For women to take advantage of measures to reduce MTCT, they will need to know and accept their HIV status. Voluntary counselling and testing services therefore need to be widely available and acceptable. Ideally, everyone should have access to such services since there are clear advantages to knowing one’s serological status.

People who know they are HIV-infected are likely to be motivated to look after their health, perhaps with behaviour and lifestyle changes, and to seek early medical attention for problems. They can make informed decisions about sexual practices, childbearing, and infant feeding, and take steps to protect partners who may still be uninfected. Those whose test results are negative can be counselled about how to protect themselves and their children from infection.

Furthermore, voluntary counselling and testing has an important role to play in challenging denial of the epidemic: it helps societies which are currently only aware of people who are ill with AIDS to recognize that there are many more people living with HIV and who show no outward signs. However, it must be emphasized that, unless people have real choices for action once they have their test results, there is no good reason to take a test.

However, providing voluntary counselling and testing for the whole population will not necessarily be justified in low HIV prevalence areas where resources are scarce. And even where justified on the basis of prevalence, it will not be a realistic option in some places because the health infrastructure is not sufficiently strong to support the service. For, besides the cost and practical requirements of providing counselling and testing itself, there must be an efficient referral system to a range of other basic services that people need once they have received their test results. These include family planning, prevention and treatment of sexually transmitted diseases (STDs), mother-and-child health services, and health care for infected people including prevention and treatment of opportunistic infections, counselling, and psychological support.

Taking local conditions into account, therefore, policy-makers need to decide what kind of counselling and testing services are most appropriate and feasible, and what action, if any, is required to strengthen the health system that supports them. In particular, decisions need to be made about whether to make counselling and testing available to the whole population (comprehensive VCT); or to target the service at women or couples making use of reproductive health services in areas where the HIV prevalence is especially high (targeted antenatal VCT); or to offer counselling and testing to all women attending antenatal services as part of a programme to reduce MTCT of HIV (routine antenatal VCT).

2.2 Stigma and discrimination

Measures to reduce MTCT of HIV, especially the administration of antiretroviral drugs and avoidance of breastfeeding, make it virtually impossible for HIV-positive women to keep their infection a secret from their families and people in the wider community. It is therefore essential to the safety and acceptability of MTCT interventions that effective steps be taken to combat rejection of people with HIV/AIDS. Where women fear discrimination, violence, and perhaps even murder if they are identified as HIV-infected, they will be reluctant or completely unable to take advantage of opportunities offered to protect their infants from infection. Special attention should be paid, in particular, to developing positive and non-judgemental attitudes towards HIV/AIDS in health staff so that they can serve their clients with empathy. In places where stigmatization of HIV-infected people is a serious problem, it would be advisable to introduce the antiretroviral strategy for reducing MTCT in a pilot programme initially, so that the risks can be carefully monitored and ways of dealing with stigma and discrimination tested.

It is still common for women to be blamed for spreading STDs, including HIV, despite the fact that very often they are infected by the husband or partner to whom they are entirely faithful. To challenge this pervasive prejudice, as well as to encourage joint responsibility for childbearing and related decisions, it is a good idea to offer counselling and testing to pregnant women’s partners also, where this is feasible and desired.

2.3 Health care systems

A programme of voluntary counselling and testing, antiretroviral drugs and replacement feeding can only be set up where there is an efficiently functioning health system with certain key services.

Mother-and-child health services, including widely available and acceptable antenatal, delivery and postnatal services, are essential.

And counselling services, family planning services and medical care for HIV-positive women and their children should also be part of the basic health care provision. These services need to be carefully prepared for the integration of the new programme. In particular, steps are required to ensure:

a) easy access and privacy for clients attending services. This will require assessment of the physical environment of clinics, and perhaps rearrangement of activities;

b) continuity of care and a good flow of information between the various units involved in the management of HIV-positive clients;

c) technical supervision of services to enhance quality;

d) opportunities for clients to express their needs and their views.

Where the basic services are already in place and operating efficiently, the cost of providing counselling and testing, antiretroviral drugs and replacement feeding is likely to be well distributed across the health system and relatively easy to absorb. However, in places where the health infrastructure needs considerable strengthening and perhaps even building from scratch to support the new programme, the additional cost will assume greater significance. Since expansion and improvement of the health system benefit the whole of society, it is important that the MTCT programme is not expected to bear an undue and perhaps crippling proportion of the costs and responsibility. If the provision of antiretroviral drugs and replacement feeding is to be sustainable over the long term, the financial burden must be fairly distributed across the health services. Policy-makers should take account, also, of the fact that improvements in access and quality of services have a tendency to increase public expectations of health and therefore the demands on the health services.

2.4 Replacement feeding

The issue of replacement feeding is a complex one.¹ Promotion of breastfeeding as the best possible nutrition for infants has been the cornerstone of child health and survival strategies for the past two decades, and has played a major part in lowering infant mortality in many parts of the world. It remains the best option for the great majority of infants, and in providing for replacement feeding as part of the strategy to reduce MTCT of HIV, policy-makers need to take into account the risks of undermining breastfeeding generally, and of relaxing vital controls on the promotion of infant formula by the industry. They also need a sound assessment of how safe it is to recommend replacement feeding in their local setting. For example, is infant formula readily available; is the supply of formula assured over the long term; do people have access to clean water and fuel for boiling it; and are they sufficiently educated and informed to make up replacement feeds correctly? If used incorrectly - mixed with dirty, unboiled water, for example, or over-diluted - breastmilk substitutes can cause infection, malnutrition and death. Where the risks associated with replacement feeding are not clear, research will be necessary to establish the facts, and strategies should be tested in pilot projects. The fact that the fertility lowering effects of breastfeeding will be inactivated makes the availability of family planning services as part of postpartum care a necessity.

¹ For a comprehensive discussion of the issue, see: HIV and infant feeding: guidelines for decision-makers UNAIDS/98.3