What Works for Women and Girls

(Remien et al., 2009). In Cambodia, 78% of births occur at home or outside medical facilitiesin which PMTCT services are available (ITPC, 2009). Programs to prevent vertical transmission,often referred to as prevention of mother-to-child transmission (PMTCT) programs, havehistorically focused on infant outcomes, rather than both the mother and infant. 1 Improvinghealth systems and providing evidence-based interventions to ensure safe motherhood is criticalfor all women, and especially so for women living with HIV.Vertical Transmission Can Occur at Multiple PointsVertical HIV transmission can occur in utero, during delivery and during breastfeeding. Theseare all points for reducing the probability of transmission while also serving as critical pointsfor addressing women’s health needs. Recent estimates of maternal mortality for 181 countriesfrom 1980 to 2008 found that of the 342,900 estimated maternal deaths worldwide in 2008,61,400 were attributed to HIV (Hogan et al., 2010).While it is impossible for an HIV-negative woman to give birth to an HIV-positive infant,it is possible for a woman to seroconvert during her pregnancy; starting her pregnancy asHIV-negative and becoming HIV-positive through sexual transmission from a sexual partner,unscreened blood transfusions, injecting drug use or rape during the course of pregnancy. Insome societies, men are encouraged to have multiple partners while their wife/partner is pregnantor breastfeeding which can lead to women seroconverting (Ghanotakis, 2010). Studies alsoshow that significant proportions of women who are pregnant suffer from violence (Dunkle etal., 2004; Guo et al., 2004 cited in Tang et al., 2008; Cripe et al., 2008; Ellsberg, 2006). [Seealso Chapter 11B. Strengthening the Enabling Environment: Addressing Violence Against Women]Perinatal transmission is usually considered the time between 20 weeks of gestation and 28days following birth. However, breastfeeding, when transmission can continue to occur, maybe a period of months and even two or three years following birth. A woman can acquire HIVbefore or after the birth of her child and vertical transmission of HIV is still possible as longas breastfeeding continues. If a woman is HIV-positive and breastfeeds, because safe drinkingwater and replacement feeding are not available to her, or to avoid HIV stigma, her infant bornHIV-negative can become HIV-positive.The Four Pillars of PMTCTPrevention of vertical transmission has been categorized into four pillars, each of which contributesto preventing HIV acquisition and transmission (Glion Call to Action, 2004; UNAIDS,2006; UNICEF, 2008).1 In fact, PMTCT, itself, is “a name that implies that mothers are the source of the virus, rather than the latest ina long chain of transmission” (Lewis and Donovan, 2009: iv). This document primarily uses the term verticaltransmission.206 CHAPTER 9 SAFE MOTHERHOOD AND PREVENTION OF VERTICAL TRANSMISSION