Opening new doors <strong>with</strong> counselling <strong>and</strong> testingOnce a pregnant woman knows she has <strong>HIV</strong> <strong>and</strong> agrees to an antiretroviral regimen,she should take a full course of drugs, be counselled about options <strong>for</strong> feeding herinfant <strong>and</strong> future reproductive options, <strong>and</strong> be <strong>support</strong>ed in her choice of infant feeding<strong>and</strong> family planning method.Starting <strong>and</strong> 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 <strong>and</strong> Cape Town reported starting rates of 37–85%, <strong>and</strong> 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 <strong>and</strong>women started their drugs too late in pregnancy. These rates are likely to improve<strong>with</strong> 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 <strong>HIV</strong> infection <strong>and</strong> replacement feeding in areas <strong>with</strong> pooraccess to sanitation, infant <strong>for</strong>mula milk powder <strong>and</strong> education. Another dilemma,in countries where breastfeeding goes on in public, is that women <strong>and</strong> others in thissetting may come to associate replacement feeding <strong>with</strong> being <strong>HIV</strong>-infected.Probably because of different perceptions about the risks of stigma <strong>and</strong> the healthrisks to the child, the proportion of women who chose replacement feeding rangedfrom 50% in Abidjan, Côte d’Ivoire, to 60% in Botswana <strong>and</strong> 92% in Cape Town,South Africa.To decrease mother-to-child transmission more successfully, further in<strong>for</strong>mation isneeded about <strong>HIV</strong> transmission <strong>and</strong> other health risks associated <strong>with</strong> varioustypes of infant feeding. A report from South Africa in 1999 argued <strong>for</strong> exclusivebreastfeeding; infants given “mixed feeding” appeared to have a higher risk of <strong>HIV</strong>transmission than those given either breast milk alone or exclusive replacementfeeding. A r<strong>and</strong>omized controlled trial in Kenya, which followed the children of <strong>HIV</strong>infectedwomen until the age of two years, reported a lower mortality rate amongthose who had received replacement feeding, a difference due mainly to the higher<strong>HIV</strong> infection rates among the breastfed infants.The results of these relatively small <strong>and</strong> somewhat conflicting studies cannot beregarded as final. Seven pilot projects that have been started in sub-Saharan Africa<strong>and</strong> Central America, <strong>with</strong> the <strong>support</strong> of UNICEF <strong>and</strong> the other members of theUnited Nations Interagency Task Team working on this issue (UNFPA, WHO <strong>and</strong> theUN<strong>AIDS</strong> Secretariat), should help to optimize infant-feeding approaches. At thesame time, it is important to find ways of decreasing the risk of <strong>HIV</strong> transmissionthrough breast milk, as it is likely that a substantial proportion of <strong>HIV</strong>-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 <strong>and</strong> <strong>support</strong>, not just<strong>for</strong> the <strong>HIV</strong>-infected mother <strong>and</strong> her infant but <strong>for</strong> the other members of her family.83
Report on the global <strong>HIV</strong>/<strong>AIDS</strong> epidemic – June 2000This is largely uncharted territory in developing countries, where it will be necessaryto create good referral links from mother <strong>and</strong> child health centres to other facilities<strong>and</strong> services in the health system <strong>and</strong> plan ahead <strong>for</strong> the increased case-load.The biggest challenge of all will be to exp<strong>and</strong> coverage beyond the pilot projects toreach all <strong>HIV</strong>-infected pregnant women <strong>and</strong> their families. As part of planning ahead<strong>for</strong> this expansion, health systems will have to rise to the considerable challenge ofimproving infrastructure, training, motivating <strong>and</strong> retaining the necessary healthstaff, <strong>and</strong> improving distribution systems so that <strong>HIV</strong> test kits, drugs <strong>and</strong> infant <strong>for</strong>mulaare consistently available to those who need them.84
Change language