(introduction...)

The ideal intervention for the reduction of mother-to-child transmission would be one that is widely applicable in resource poor settings²⁵². Vaginal disinfection and vitamin A administration would not require identification of HIV positive women, but would be applicable to all pregnant women. The minimum requirements for the implementation of other interventions in health services include²⁵³:

· access to and use of appropriate antenatal, intrapartum and postpartum care with adequately trained health workers

· adequate pre and post test counselling services

· ability to afford the cost of reliable HIV testing

· appropriate laboratory facilities to monitor blood parameters during long regimen

· delivery units with access to disinfectants, gloves and clean needles

· acceptance and uptake of the intervention by HIV-infected women

· a regimen that is logistically possible to implement in terms of dosing times and routes, drug storage and distribution

· a regimen which is affordable for the health service.

The widespread implementation of strategies to prevent mother-to-child transmission of HIV presents a number of challenges to the existing antenatal and obstetric services. The need for such strategies is greatest in the most resource constrained settings. The provision of interventions to prevent mother-to-child transmission of HIV should not further overburden existing services. In many areas, antenatal care services are not sufficiently available, accessible or utilized and they may not be of adequate quality to take on these interventions. These services will need to be strengthened in the years ahead in order to deliver mother-to-child transmission prevention strategies effectively.

In addition if interventions are introduced into clinical practice to decrease the risk of mother-to-child transmission their effectiveness outside of the context of a randomized controlled trial should be monitored. Careful follow-up of the mothers and infants of such programmes will be essential to determine the generalisability of clinical trial results to the practical setting.

The management of HIV infection and AIDS is changing rapidly. New drugs become available and are rapidly adopted into clinical practice with little rigorous evaluation of their effectiveness. In pregnancy the situation is little different. Within one month in 1999, four substantial randomized trials of interventions aimed at decreasing the risk of mother-to-child transmission of HIV infection were published. Many more trials are on-going and can be expected to report in the next two years. The following section, therefore, represents the evidence that was available at the end of May 1999. As new randomized trials are published they will be incorporated into an ongoing systematic review and meta-analysis of interventions aimed at decreasing the risk of mother-to-child transmission of HIV infection published in the Cochrane Library²⁵⁴.