What Works for Women and Girls

manifested before being switched to new drugs, which reduces future treatment optionsand increases the risk of transmission.”Gap noted generally in Africa (Ford et al., 2009b: 1809).4. Interventions are needed to address gender inequality related to uptake and adherence ofART and ARV prophylaxis. [See Chapter 7. Treatment]9D. Safe Motherhood and Preventionof Vertical Transmission: DeliveryThere is little evaluated evidence available regarding delivery options for HIV-positive women,though research has shown that by substantially lowering viral load, HAART can diminish theadvantage of a cesarean section in reducing perinatal transmission (Sagay et al., 2008; Sharmaand Spearman, 2008). Cesarean sections are not always available or safe in many developingcountry settings. In situations where a safe cesarean section can be provided however, furtherresearch is needed to determine whether HIV-positive women suffer more adverse events dueto the procedure. Further research is also needed on whether elective cesarean sections providePMTCT benefits for HIV-positive pregnant women who have viral loads lower than 1,000copies/mL (Anderson and Cu-Uvin, 2009). While cesareansections may not be the best option for the delivery for“I had to clean myself alone.They did not clean the baby.”—HIV-positive woman,postpartum, Dominican Republic(Human Rights Watch, 2004j: 30)HIV-positive women in resource poor settings, they remainnecessary surgical procedures in some cases to reduce thematernal mortality associated with difficult deliveries.In vaginal deliveries, routine episiotomies have beenshown to be particularly risky for HIV-positive women. Astudy in South Africa of 241 HIV-positive women comparedto 427 HIV-negative women who gave birth and were evaluatedat four intervals (within 72 hours post delivery, and atone, two, and six weeks) for clinical signs of postpartum infection, found that episiotomy wasassociated with a two-fold increased risk of postpartum infections among the HIV-positivewomen. Among HIV-positive women with low CD4 counts, the risk of postpartum infectionassociated with episiotomy was even higher. Because the majority of postpartum infectionswere detected at the one-week review, it is important to have a skilled attendant examine thewoman postpartum within the week following delivery (Sebitloane et al., 2009).The mode of delivery does not seem to affect HIV disease progression. A study from1990 to 2004 in the United States found no difference in HIV-related disease progressionafter delivery for HIV-1-positive women delivering through elective cesarean section (beforemembrane rupture), non-elective cesarean section (after membrane rupture), or vaginally. Ofthe 1,491 births where mode of delivery was documented, 1,087 were vaginal, 183 were elective246 CHAPTER 9 SAFE MOTHERHOOD AND PREVENTION OF VERTICAL TRANSMISSION