Prevention of mother-to-child transmission:
UNAIDS recommends three integrated strategies to prevent mother-to-child transmission of HIV:26
1. Preventing HIV infection in young people and women of childbearing age
This can be achieved through community education about HIV, especially addressing men, screening and treatment of STIs, increasing access to VCT, promoting condoms, and providing access to safe blood. New HIV infections during pregnancy or the breastfeeding period are associated with particularly high rates of transmission from a mother to her infant. Advise men that unprotected sex with others while their partner is pregnant or breastfeeding carries a high risk of acquiring HIV infection, which can be transmitted to their partner and so to their infant.
2. Preventing unwanted pregnancy among women/couples with HIV infection
Strengthen men’s and women’s reproductive health services. Encourage planning for pregnancies. Train health workers to counsel HIV-positive women or women with HIV-related signs and symptoms about their risk of MTCT. However, HIV should never be used as a reason to pressure women into having or not having children. New mothers who do not breastfeed or stop breastfeeding early are at greater risk of becoming pregnant. Family planning services are particularly important for HIV-infected women who choose to avoid breastfeeding for the prevention of MTCT.
3. Preventing transmission of HIV from an infected mother to her infant
Ways to reduce the risk of transmission from the mother to the child include:
• Using antiretroviral drugs to reduce HIV viral load during pregnancy and delivery and/or post-partum.
• Providing elective cesarian section before the onset of labor where feasible and safe.
• Avoiding unnecessary invasive procedures (artificial rupture of membranes, episiotomy).
• Avoiding breastfeeding when replacement feeding is acceptable, affordable, sustainable and safe.
Current recommendations of the inter-agency task team on infant feeding and HIV-infected mothers:27
• When replacement feeding is acceptable, feasible, affordable, sustainable and safe, avoidance of all breastfeeding by HIV-infected mothers is recommended.
• If any of these conditions is not met, exclusive breastfeeding is recommended during the first months of life.
• All HIV-infected mothers should receive counseling, which includes provision of general information about the risks and benefits of various infant feeding options, and specific guidance in selecting the option most likely to be suitable for their situation. Whatever a mother decides, she should be supported in her choice.
• To minimize HIV transmission risk, breastfeeding should be discontinued as soon as feasible, taking into account local circumstances, the individual woman’s situation and the risks of replacement feeding (including infections other than HIV and malnutrition).
• HIV-infected women who breastfeed should be assisted to ensure that they breastfeed exclusively and use a good breastfeeding technique to prevent breast conditions, such as mastitis, breast abscess and nipple fissure, which should be treated promptly if they occur.
Srinivas Kuruganti, Freedom Foundation, Bangalore India
However, making these interventions available to women in resource-limited settings in a safe and sustainable manner is complex. In refugee settings, where facilities are generally inadequate, supplies of milk or formula cannot be guaranteed, and women may need to travel with their babies, it will almost always be safer for the baby to be breastfed, even if the mother is known to be infected with HIV. Therefore, in these settings, exclusive breastfeeding (nothing but breast milk, not even water) is likely to be the safest option for the baby. The woman should be supported in her choice of infant feeding method. Early cessation of breastfeeding should only be considered when adequate replacement food can be provided sustainably and safely fed to the infant. If the baby is not breastfed, a cup and spoon should be used rather than a bottle.
In refugee settings where resources are scarce and women may have difficulty accessing cesarean section for complicated deliveries, it is not likely to be feasible or safe to offer elective cesarean section to HIV-positive pregnant women.