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HIV and AIDS
Table 2: Possible Interventions to Prevent Breast Milk Transmission of HIV
Risk Factor for Transmission Related Intervention
Duration of exposure to breast milk of an HIV-1-infected woman Complete avoidance of breastfeeding*
Higher maternal viral load Maternal antiretrovirals (while breastfeeding) to decrease viral load
Chemical or heat treatment of breast milk to decrease viral load
Factors facilitating transfer of HIV-1 from the breastfeeding mother to the child Prevention and treatment of maternal breast abnormalities and infant candidiasis
Exclusive breastfeeding (avoidance of mixed breastfeeding)*
Child’s susceptibility to HIV infection while breastfeeding Active immunisation
Passive immunisation
Antiretroviral prophylaxis to the infant while breastfeeding*
*Efficacy demonstrated.
nevirapine at birth with one week of zidovudine, and then were be considered. Potential safety problems related to ARVs for
randomised to no subsequent prophylaxis, nevirapine until the age of 14 prevention of MTCT include
44
foetal toxicity (e.g. congenital
weeks or nevirapine with zidovudine until the age of 14 weeks. Among anomalies, low birth weight, pre-term birth); short-term adverse
infants uninfected at birth, both of the extended prophylaxis regimens effects on the mother and/or on the infant (e.g. anaemia or other
conveyed a significantly lower risk of HIV infection (and a greater laboratory abnormalities); and long-term adverse consequences for
likelihood of HIV-free survival) among infants at nine months of age the child (e.g. cancer).
compared with the control arm.
22
Relatively limited information has been published regarding the use of
ARVs for prevention of MTCT of HIV and the development of resistance.
Further research is needed regarding The USPHS guidelines
28
recommend resistance testing for all pregnant
not only the pathogenesis of and risk
women not currently using ARVs (before starting treatment or
prophylaxis) and for all pregnant women receiving ARV therapy who have
factors for mother-to-child transmission
persistently detectable plasma viral loads or sub-optimal viral suppression.
of HIV, but also to develop new or to
In settings where adequate staffing and infrastructure exist for utilisation
adapt existing interventions for the
of Caesarean section before labour and before ruptured membranes as
realities of different settings.
an intervention to prevent MTCT of HIV, various issues have been raised.
First, its effectiveness among women with low viral loads or women who
are receiving combination ARV regimens has been questioned. However,
Future Challenges published data indicate that Caesarean section before labour and before
Despite major successes in the prevention of MTCT of HIV, such ruptured membranes is effective in preventing MTCT even among those
transmission continues to occur, and there remain a number of significant pregnant women who have viral loads of less than 1,000 copies/ml
45–49
challenges if the goal of complete eradication of MTCT is to be realised. or who are receiving combination ARV regimens. Second, cost-
First, primary prevention is essential (i.e. prevention of acquisition of HIV effectiveness analyses suggest this intervention remains cost-effective
infection by adolescent girls and women). Next, increasing the proportion even at very low rates of MTCT.
50
Third, the potential benefit of
of women accessing pre-natal care contributes to prevention of MTCT. As Caesarean section before labour and ruptured membranes for prevention
part of pre-natal care, pregnant women can access HIV diagnostic testing of MTCT must be weighed against possible deleterious effects of surgical
and, if found to be HIV-infected, can initiate one or more interventions to delivery for the mother, for the infant and for the obstetrician.
51–54
prevent transmission (in addition to accessing appropriate care and Caesarean delivery may be associated with an increased risk of post-
treatment for her own HIV infection). The greatest effectiveness of current partum morbidity among HIV-infected women compared with
preventative interventions is predicated upon a pregnant woman knowing uninfected women, but assessment of currently available data suggest
her HIV infection status before becoming pregnant, or else as early as post-partum morbidity rates among HIV-infected women are not
possible during pregnancy. The CDC has recommended ‘opt-out’ HIV sufficiently frequent or severe to outweigh the potential benefit of
testing for all individuals aged 13–64 years receiving care in healthcare Caesarean section for the prevention of MTCT.
28
Analyses of morbidity of
settings (including pregnant women).
43
HIV testing is treated as part of infants of HIV-infected women associated with the mother’s mode of
routine care, and it is performed unless the patient objects (opts out). delivery are under way. Although we know the risk must be extremely
General consent for medical care is considered to encompass consent for small, there are essentially no data regarding the relative risk of
HIV testing, and no specific consent for HIV testing would be requested or accidental acquisition of HIV infection by obstetricians or other
required in order for the testing to be performed. It is specifically healthcare workers according to mode of delivery.
54
recommended that women who arrive in labour with unknown or
undocumented HIV infection status be screened with a rapid HIV test, and Finally, further research is needed regarding not only the pathogenesis of
ARV prophylaxis be initiated based on a positive result on the rapid HIV test and risk factors for MTCT of HIV, but also to develop new or to adapt
(without awaiting confirmation).
43
Re-screening for HIV infection during existing interventions for the realities of different settings, especially
pregnancy is emphasised in these guidelines.
43
resource-poor settings. In resource-poor settings, where the burden of
HIV disease is much greater than in resource-rich settings, complete
In addition, adverse events and other issues related to utilisation of avoidance of breastfeeding is often not possible or acceptable, and
existing efficacious interventions for prevention of MTCT of HIV must Caaesarean delivery for the prevention of MTCT of HIV is generally not
36 EUROPEAN INFECTIOUS DISEASE
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