HIV in Pregnancy: A Review (UNAIDS, 1999, 67 p.): SECTION A : HIV IN PREGNANCY: Appropriate interventions to reduce mother-to-child transmission: Vaginal cleansing

HIV in Pregnancy: A Review (UNAIDS, 1999, 67 p.)

(introduction...)

EXECUTIVE SUMMARY

INTRODUCTION

SECTION A : HIV IN PREGNANCY

(introduction...)

Epidemiology of HIV

Susceptibility of women to HIV infection

(introduction...)

Biological factors

Socio-cultural factors

Effect of pregnancy on the natural history of HIV infection

Effect of HIV infection on pregnancy

Mother-to-child transmission

(introduction...)

Factors affecting mother-to-child transmission of HIV-1

Interventions to prevent mother-to-child transmission of HIV

Appropriate interventions to reduce mother-to-child transmission

(introduction...)

Antiretroviral therapy

Immune therapy

Nutritional interventions

Mode of delivery

Vaginal cleansing

Modification of infant feeding practice

Voluntary HIV counselling and testing in pregnancy

(introduction...)

Testing of antenatal women

Counselling before and after HIV testing in pregnancy

Counselling about pregnancy-related issues

SECTION B : MANAGEMENT OF HIV-POSITIVE PREGNANT WOMEN

(introduction...)

Antenatal care

(introduction...)

Obstetrical management

Examination and investigations

Medical treatment during pregnancy

Antiretroviral therapy

Care during labour and delivery

Postpartum care

Care of neonates

SECTION C : INFECTION CONTROL MEASURES

(introduction...)

Universal precautions

Risks of needlestick injuries

(introduction...)

Management of needlestick injuries and other accidental blood exposure

REFERENCES

Vaginal cleansing

The use of antiseptic or antiviral agents to cleanse the birth canal during labour and delivery has been hypothesized as a possible approach to reducing intrapartum transmission of HIV-1. The use of chlorhexidine lavage to reduce the transmission of group B streptococci was demonstrated in Scandinavian studies²⁹⁹. The concept is attractive for HIV prevention, as it would be an inexpensive intervention, readily achievable in most health care settings, would not require identification of HIV-infected women prior to the intervention and could have other health benefits.

A Malawian quasi-randomized study compared four-hourly aqueous chlorhexidine 0.25% solution by vaginal swabbing after vaginal examinations and a chlorhexidine wash for the baby, with a control group receiving no wash. No overall reduction was shown in the rate of HIV transmission in the study group, however, only 60% of infants were followed up. There was a significant reduction in transmission in mothers who had ruptured membranes for more than four hours²²². Most deliveries in this trial occurred within a short time of the vaginal swabbing procedure. Significant reductions in neonatal and puerperal sepsis were also seen following this intervention³⁰⁰ and use of this procedure may be advantageous for these other health benefits, in addition to any possible role in prevention of mother-to-child transmission of HIV³⁰¹.

Benzalkonium Chloride has been suggested as an alternative antiseptic agent for vaginal lavage, utilizing the antiseptic from 36 weeks gestation in an attempt to maximize the possible benefit (Table 3). The intervention of vaginal cleansing remains a feasible option for resource poor settings and further research work should be undertaken on different concentrations or formulations of agents and methods of application to determine whether the efficacy can be improved.