Care and support for people living with HIV/AIDS

Opening new doors with counselling and testingOnce a pregnant woman knows she has HIV and agrees to an antiretroviral regimen,she should take a full course of drugs, be counselled about options for feeding herinfant and future reproductive options, and be supported in her choice of infant feedingand family planning method.Starting and completing a full course of treatment, even a one-month course ofAZT, has proved difficult in the pilot projects carried out so far. Those in Côted’Ivoire and Cape Town reported starting rates of 37–85%, and in the latter only18% of those who started AZT completed a full one-month course. The mainexplanation was that the duration of pregnancy was often underestimated andwomen started their drugs too late in pregnancy. These rates are likely to improvewith the introduction of much shorter courses of antiretrovirals, such as the nevirapineregimen.Infant feeding presents further dilemmas. Controversy surrounds the competingrisks to the infant of HIV infection and replacement feeding in areas with pooraccess to sanitation, infant formula milk powder and education. Another dilemma,in countries where breastfeeding goes on in public, is that women and others in thissetting may come to associate replacement feeding with being HIV-infected.Probably because of different perceptions about the risks of stigma and the healthrisks to the child, the proportion of women who chose replacement feeding rangedfrom 50% in Abidjan, Côte d’Ivoire, to 60% in Botswana and 92% in Cape Town,South Africa.To decrease mother-to-child transmission more successfully, further information isneeded about HIV transmission and other health risks associated with varioustypes of infant feeding. A report from South Africa in 1999 argued for exclusivebreastfeeding; infants given “mixed feeding” appeared to have a higher risk of HIVtransmission than those given either breast milk alone or exclusive replacementfeeding. A randomized controlled trial in Kenya, which followed the children of HIVinfectedwomen until the age of two years, reported a lower mortality rate amongthose who had received replacement feeding, a difference due mainly to the higherHIV infection rates among the breastfed infants.The results of these relatively small and somewhat conflicting studies cannot beregarded as final. Seven pilot projects that have been started in sub-Saharan Africaand Central America, with the support of UNICEF and the other members of theUnited Nations Interagency Task Team working on this issue (UNFPA, WHO and theUNAIDS Secretariat), should help to optimize infant-feeding approaches. At thesame time, it is important to find ways of decreasing the risk of HIV transmissionthrough breast milk, as it is likely that a substantial proportion of HIV-infectedwomen will continue to wish to feed their infants in this way. Fortunately, at leastone clinical study is being planned to assess the efficacy of antiretroviral prophylaxisadministered to infants during the breastfeeding period.The pilot projects will also need to learn how to provide care and support, not justfor the HIV-infected mother and her infant but for the other members of her family.83