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Aids and maternity in India

 | 
Patrice Cohen
, 
Suniti Solomon

Part 2. Prevention of HIV/AIDS mother to child transmission

5. Prevention of Mother to Child Transmission of HIV Infection in India: A Medical Perspective

Suniti Solomon

Texte intégral

1At the end of 2002, records showed an estimate of 42 million people with HIV of which almost half of the infections are women (UNAIDS/WHO 2002). Perinatal transmission accounts for over 90 % of infections among infected children (Ranbaxy Science Foundation 2000). It is estimated that 2.4 million HIV -infected women deliver babies each year, resulting in 600,000 new infections worldwide in infants annually i.e. about 1,600 infants acquire HIV infection each day. The Joint United Nations Program on HIV/AIDS (UNAIDS) warns of a tremendous global increase in infant and childhood deaths as a direct result of the AIDS pandemic. HIV prevalence among antenatal women in often used as a surrogate marker for HIV prevalence in the general community.

2HIV prevalence among women attending antenatal clinics is reported to be higher than 1 % in Andhra Pradesh, Karnataka, Maharashtra, Manipur, Nagaland and Tamil Nadu. There are 27 million live births every year in India. With an average prevalence rate of 2 % HIV infection among ANC women - about 4,80,000 of them would be HIV positive. If we were to consider mother-to-child transmission (MTCT), rate of 42 % as reported in some African studies, India would be burdened with 2,01,600 HIV infected children every year (Brown H.W, Vallabhaneni S., Solomon S, et al., 2001).

3As the world enters the third decade of the AIDS epidemic, the evidence of its impact is undeniable. Antenatal care facilities need to include processes of effective HIV counselling and confidential testing to establish the HIV status of pregnant women and to provide an intervention to those women who are identified as infected or at risk (Lambert, J.S, S.A.Nogueira and E.H. Anderson, 2001). However, access to prenatal care services varies considerably and it has been estimated that 32 % of women globally receive no prenatal care. Women also ignore their health condition; most often due to competing priorities that demand resources. This presents a considerable barrier to reduce perinatal HIV transmission. If mothers do not receive adequate and early antenatal care, a timely opportunity to have healthy babies born free of HIV and other debilitating conditions is lost. Even when access to care is not an issue, there are other barriers that can get in the way of adequate care, such as the lack of sensitivity to the needs of women.

4A large number of pregnant women seek antenatal care in government hospitals in their last trimester. One of the indicators employed by the government for evaluating their MCH services (for 1998-99) shows a 23 % gap between the expected and achieved early antenatal registrations. Poverty and illiteracy seem be the main reasons for delayed registrations.

Pregnancy and HIV

5Most often, women discover their HIV positive status during their pregnancy, just after the delivery of their baby or when their baby becomes ill (D’Ubaldo C, Pezzotti P, Rezza G, et al. 1998). For many women, becoming pregnant initiates their first contact with a health care clinic or worker.

  • 1 See Clinical Course of HIV Infection for Women, p. 26-28 or Annex II.

6In general, pregnancy does not affect the progression of HIV disease in women who are infected but whose immune system have not yet been compromised by HIV and are still healthy. If a woman develops opportunistic infections characteristic of HIV during her pregnancy, treatment should be determined on a case-by-case basis as some medications may be harmful to the foetus1. For example, recommendations for treating tuberculosis in pregnant women have been modified due to the potential teratogenic effects of specific medications (streptomycin and pyrazinamide). Annex IV presents a review of the basic recommendations for the care of a pregnant woman and her infant.

7Currently, there is no evidence that HIV harms the development of the baby. However, the risk of miscarriage (spontaneous abortion) is higher in HIV infected women (Miotti PG, Dallabetta G, Ndovi E, & al., 1998). In general, if a woman has HIV/AIDS, she is more likely to have complications such as:

  • Spontaneous abortions (Miscarriage) - loss of the baby during pregnancy
  • Fever and infections.
  • Premature labour
  • Baby with low birth weight
  • Severe infections after birth -women who have HIV are more likely to have infections after delivery that does not respond to the usual treatment with antibiotics.

8In the absence of ARV therapy during pregnancy, the risk of woman having an HIV- infected child ranges between 25 to 35 percent. Children who contract HIV may be infected in the womb, during delivery or through breastfeeding. If born infected, nearly 80 % of children will die before the age of 5 years as a result of HIV - aggravated malnutrition, diarrhoea and respiratory infections.

Counselling and Testing

  • 2 See Clinical Course of HIV Infection for Women, Section: Counselling and Testing (pp. 21-25).

9The counsellor or health care worker needs to conduct a risk assessment chart for the women during the antenatal interview, prior to collecting blood for an HIV test. Counselling and testing should be done in an ethical manner; covering both pre-test and post-test counselling2.

Reproductive Counselling

10A woman who is pregnant and infected with HIV needs to be offered reproductive health options:

  • Continuing the pregnancy
  • Continuing the pregnancy and taking antiretroviral drugs (zidovudine)
  • Interrupting the pregnancy

11If a woman learns that she is infected with HIV during pregnancy, the first responsibility of the counsellor and HCWs should be to offer her emotional support.

12Nondirective and non-judgmental reproductive counselling should be provided so that a woman can make informed choices regarding the continuation of her pregnancy and adopt safe and responsible behaviour for the safety of herself, her child and others. There are several issues that the HCW can discuss with the HIV positive antenatal woman:

  • How HIV will affect her pregnancy?
  • The risks of transmitting HIV to the baby
  • Measures available to reduce or prevent these risks
  • The prognosis for infants who become infected
  • The benefits and risks of antiretroviral therapy
  • Infant feeding counselling (breastfeeding versus replacement feeding)

13The woman has the right to make her own decision. If a woman has a supportive, understanding and open-minded partner/spouse, she may consider discussing her reproductive options with that person.

14It is important to encourage women to accept help from others while at the same time recognise their unique role within their families. Many times, women neglect their own health concerns, placing their children’s or partner’s health first. It is common for women to serve as the primary caregiver in a family and balance their care-giving responsibilities with employment and/or taking care of children.

15Women with HIV are likely to fear the loss of their roles as mother and caregiver and may experience extreme guilt if any of their children are also infected. They may also have strong feelings of anger at the individual who infected them.

16Social support systems need to be easily available to women within their own communities. The counsellor should have a list of support systems readily available within the community. Support services should include peer support groups (that allow women to exchange information and personal experiences), education, counselling (individual, couples, grief and bereavement), home care, child care, spiritual support and hotlines to assist women living with HIV / AIDS and their families in managing the psychosocial aspects of the situation and the disease progression. Family caregivers will also need support and opportunities for rest periods (respite care, adult day programs) from a care-giving situation to avoid “burn out”.

17One of the primary concerns for many infected women is the present and future support and care of their children, as often their partner is also infected, is sick or has passed away. Assistance with arranging surrogate childcare should be offered as part of supportive counselling services.

Preventing the Passage of HIV from Mother to Baby: Risk Factors

18There are several risk factors that have been found to be associated with an increased risk of HIV transmission from the mother to the infant. These include:

Maternal Factors

  • Poor maternal nutritional status
  • Recent infection with HIV. A woman who has been infected with HIV within the last 2 to 3 months is more likely to transmit the virus to her infant
  • Advanced stage of HIV infection or AIDS
  • Low CD4 + cell counts (low level of white blood cells)
  • High viral load
  • Presence of p24-antigenemia (a component of HIV detected in blood)
  • Infection with certain sexually transmitted infections (herpes, syphilis, chancroid)
  • Lack of access to antiretroviral drugs

Obstetrical Factors

  • Premature delivery of the baby (less than 37 weeks)
  • Premature rupture of membranes. The risk dramatically increases when the membranes have been ruptured for more than 4 hours.
  • Inflammation of placental membranes
  • Use of instruments during labour and/or delivery

Postpartum Factors

  • Breastfeeding
  • Duration of breastfeeding
  • Unhealthy breast conditions. Cracked or bleeding nipples increase the risk of transmission

Preventive Strategies

19There are several preventive strategies that reduce, or may reduce, the risk of a mother passing her HIV infection to her unborn infant. These include antiretroviral medication, proper nutrition, replacement feeding for infants, intra-partum management, elective caesarean section and vaginal lavage.

Antiretroviral Therapy

20The chances that an HIV infected woman will transmit HIV infection to her infant are greatly reduced by using antiretroviral (ARV) drug therapy. The first indication that ARV treatment can help prevent the transmission of HIV came with the results of the ACTG 076 study published in 1994. In this study, zidovudine (or AZT) treatment during pregnancy reduced the risk of mother to child transmission of HIV by as much as two- thirds (from 25 percent to 8 percent).

21Zidovudine is taken orally by the mother after 14 weeks of pregnancy and is continued throughout the pregnancy and during birth by intravenous therapy. Zidovudine syrup is given to the newborn every 6 hours beginning 8 to 12 hours after birth and continued for the first 6 weeks of her or his life.

22Recent studies in Thailand and Cote d’Ivoire have indicated that a short course of AZT therapy, given late in pregnancy and during delivery, reduces the rate of HIV transmission from infected mothers to infants by one half (51 percent) and is safe for use in developing regions (Brown H.W, Vallabhaneni S., Solomon S, & al., 2001). Compared to the previous schedule, this regimen involves a much shorter course of therapy during pregnancy, an oral dose rather than an intravenous dose during delivery and no infant dose. In addition, this short course AZT treatment is 10 times less expensive and thus more affordable for developing regions than the 076 protocols.

23The regimen involves the mother taking 300-mg zidovudine orally twice daily from 36 weeks gestation (generally, the last 4 weeks of pregnancy) until the onset of labour and 300- mg zidovudine every three hours from the onset of labour until delivery. It is important to note that in these studies all women were advised not to breastfeed, were provided with infant formula and had high adherence to ARV therapy.

24The PETRA trial has shown that an even briefer treatment given at labour and followed by a week of combined drug therapy (AZT and 3TC) for both mothers and infants reduces the rate of HIV transmission by 37 percent. Women took the double-drug pills twice a day, once in the morning and again in the evening, and the infant took the drugs in a syrup form for one week.

25This form of drug therapy is estimated to cost 1/5 of the price of the previous short course treatment. However, the study only followed the children for six weeks after birth and did not address the issue of breastfeeding. Nevertheless, it provides evidence that treating women at the time of labour, which in many developing regions is the first time expectant women seek medical assistance, can be effective in preventing mother to child transmission of HIV.

26The most recent study conducted in Uganda (HIVNET 012) involved the use of nevirapine to prevent the transmission of HIV from mother to infant. Nevirapine lowered the risk of HIV transmission by nearly 50 percent in a breastfeeding population at 14 to 16 weeks of life. The risk at later ages, in infants that continue to breastfeed, will be determined through follow-up until they are 18 months of age.

27In this study, women received 200 mg of nevirapine orally at the onset of labour and 2 mg/kg was administered to babies within 72 hours of birth. Nevirapine has the advantage compared to other forms of drug therapy of being less costly (approximately $ 4.00 per mother-child pair) as well as being administered in a single dose. However, at the present time, this therapy is not widely recommended although it is being used in some developing countries.

28In all cases, recommendations for ARV therapy should be discussed with the pregnant woman with the context of possible risks and benefits to her and the baby before starting any drug treatment. To date, no studies have shown an increased risk of birth or growth problems in children exposed to AZT.

Nutrition

29The importance of good nutrition should be stressed to the mother throughout her pregnancy. Lack of adequate nutrition has been shown to increase the rate of transmission of HIV from a mother to her baby. Infants become infected because their mothers either do not have enough food to eat (low caloric intake) or are not eating the right types of foods (poor micronutrient status).

30Good nutrition helps the body fight infections, enhances pregnancy outcomes (proper birth-weight babies, decreased infant mortality), enables HIV-fighting drugs to work properly and, in some cases, may ease drug related side effects. Pregnant women should also be educated about the importance of following food and water safety precautions to avoid contamination and subsequent infections (see Annex V).

31Several studies have shown that women who are deficient in vitamin A during pregnancy may be more likely to have HIV infected babies, infants with increased mortality and children with growth failure (in height and weight). Eating foods rich in vitamin A (e.g. green leafy vegetables, carrots, yellow vegetables, red and chilli peppers, mangos, papayas, cantaloupes, eggs, chicken and other animal liver, kidney and dairy products) and taking supplements may help to reduce the transmission of HIV from mother to infant. As an excess of vitamin A intake can be toxic, supplementation with beta-carotene (the precursor to vitamin A) is recommended.

32A recent study has also shown that taking a multivitamin during pregnancy reduces adverse birth outcomes. HIV -1 infected pregnant women who took multivitamins between 12 and 27 weeks of gestation had improved pregnancy outcomes and increased CD4+ cell counts compared to women who did not take any vitamins or took only vitamin A supplements. However, this study did not examine the impact of taking multivitamins on the transmission of HIV from mothers to their infants.

Breastfeeding

33For women who are not infected with HIV or who do not know their status (i.e. have not yet been tested for HIV), breastfeeding is the best infant feeding choice. Breastfeeding provides many benefits for the mother and the baby.

34It protects infants against respiratory and intestinal infections, allergies and diarrhoea due to anti-infective properties in breast milk, and

  • Provides important nutrients and antibodies
  • Reduces the risk of postpartum haemorrhage
  • Enhances the physical and emotional health of mother and infant
  • Promotes birth/family spacing
  • Promotes correct teeth, jaw and speech development

35However, pregnant women who have been diagnosed with HIV infection should be advised not to breastfeed their infants in order to reduce the risk of HIV transmission to their infants (Lambert, J.S, S.A.Nogueira and E.H. Anderson, 2001). They should receive counselling about the possible benefits and risks of breastfeeding and be offered feeding alternatives (commercial infant formula, dried milk powder and evaporated milk, modified animal milks, heat treated-breast-milk). Both women and their partners need to be counselled on appropriate hygiene and mixing techniques and taught how to use cups to feed their infants.

36To ensure sufficient nutritional benefits, breast-milk substitutes need to be made available continuously to the mother for at least 6 months. The provision of feeding substitutes should be linked to follow-up visits by HCWs to monitor infant health and growth (ideally at 2 to 4 week intervals). Follow-up services should be provided to infants until, at least, 18 months of age.

37The following are WHO recommendations for HCWs on HIV and infant feeding:

  • Women who do not know their HIV status should be advised to seek counselling and testing to determine their HIV status. Women cannot make informed choices about infant feeding if they do not know their HIV status
  • Women who know they do not have HIV infection should be advised to breastfeed
  • Women who know that they have HIV infection need to be provided with counselling on alternative feeding methods. This counselling must include the possible benefits and risks of breastfeeding and breast-milk substitutes as well as assessment of the mother’s ability to access feeding substitutes. Possible barriers include: lack of availability, high cost, contaminated water supply and poor sanitation.

38In all cases, pregnant women need adequate information and education to determine the most appropriate feeding strategy for their infants. All women must be supported in their choice of infant feeding method whether they choose to breastfeed or not.

Intrapartum Management

  • 3 See Clinical Course of HIV Infection for Women, Annex VI.

39HCWs need to ensure careful maintenance of universal body fluid precautions3. Gloves should be used at all times and all open wounds, sores and cuts on hands and arms should be covered.

40The use of scalp electrodes or foetal scalp sampling during labour and delivery should be avoided unless absolutely necessary. The prolonged rupture of membranes should be avoided. If the membranes are ruptured, intravenous zidovudine (AZT) therapy should be started and delivery of the infant facilitated.

Elective Cesarean Section

41In general, caesarean sections (C-sections) should be reserved for obstetrical indications. However, recent studies have shown that performing elective C-sections before the onset of labour may have a potential role in reducing the risk of passing HIV infection from the mother to the newborn.

42A large study has shown that pregnant women infected with HIV can reduce the risk of transmitting the virus to their infants if they delivery by elective C-section before they have gone into labour and before their membranes have ruptured. It is important to note that HIV - infected women who were breast feeding their infants were not included in this study.

43The study found that the likelihood of mother to infant transmission of HIV was decreased by approximately 50 percent among children whose mothers delivered by elective C- section. This finding was consistent when the following factors were taken into account: infant birth weight, stage of mother’s HIV-related disease and receipt of antiretroviral drugs by the mother and child.

44Of the mothers who did not receive zidovudine (AZT) or other antiretrovirals during pregnancy and during labour and whose children did not receive such drugs during the first few weeks of life, 10.4 percent of the mothers who delivered by elective C-section transmitted the virus to their infants, as compared to 19 percent of the women who delivered by other modes of delivery.

45Of the mothers who did receive ARVs during pregnancy and during labour and whose children received drugs during the first few weeks of life, 2.0 percent of those who delivered by elective C-section transmitted the virus to their infants, as compared to 7.3 percent who delivered by other means.

46However, the potential benefit of caesarean delivery in reducing HIV transmission must be weighed against the possibility of increased post-operative infections, other complications among HIV-infected women and cost. In all cases, women need to receive counselling about the possible benefits and risks associated with an elective C-section to ensure they make an informed decision regarding this choice of delivery as a preventive option.

Vaginal Lavage

47There are several studies being conducted on the potential of vaginal lavage to prevent the perinatal transmission of HIV. Studies have shown that cleaning the birth canal with chlorhexidine at delivery results in favourable birth outcomes for women whether they are infected with HIV / AIDS or not.

48Although the intervention does not significantly reduce perinatal HIV transmission, it has been shown to reduce perinatal transmission when a woman’s membranes are ruptured for longer than 4 hours (38.8 percent to 24.4 percent).

49A woman’s birth canal is cleaned manually with a cotton pad soaked in 0.25 percent chlorhexidine on admission in labour and every four hours until delivery. Vaginal washing with chlorhexidine is associated with the following health benefits:

  • Fewer admissions of infants to the hospital due to neonatal problems
  • A lower rate of postpartum infections in women regardless of their HIV status
  • A shorter postpartum hospital stay for women.

50A multifaceted approach to offering pregnant women who are HIV positive to better access to voluntary counselling and testing and health care services, and further formula food to their infants is an integral part in assisting the pregnant women in preventing perinatal transmission of HIV.

Bibliographie

References

Abeni, DD., Porta, D., Perucci, CA., 1998. “Deliveries, abortion and HIV-1 infection in Rome”, 1989-1994. The Lazio AIDS Collaborative Group.. Eur J Epidemiol. 1998 Jul; 14 (5): 521-2.

Brown, H.W., Vallabhaneni, S., Solomon, S., Mothi, SN., McGarvey, ST., Jackson, TJ., Putcha, M., Brenner, SE., Mate, KS., Cu-Uvin, S., 2001. “Attitudes towards Prenatal HIV-testing and treatment among pregnant women in Southern India”-, International Journal of STD and AIDS – June 2001 Vol. 12, Issue 6, pg. 390-394.

D’Ubaldo, C., Pezzotti, P., Rezza, G., Branca, M., Ippolit, 1998. “Association between HIV-1 infection and miscarriage: a retrospective study”. DIANAIDS Collaborative Study Group: Diagnositic Iniziale Anomalie Neoplastiche AIDS. AIDS 1998 Jun 18; 12 (9): 1087-93.

Miotti, PG., Dallabetta, G., Ndovi, E., Liomba, G., Saah Chiphangwi, J., 1998. “HIV –1 and pregnant women: associated factors, prevalence, estimate of incidence and role in fetal wastage in central Africa”, AIDS 1990 Aug; 4 (8): 773-6.

Lambert, J.S., S.A. Nogueira and E.H. Anderson, 2001. Manual for the clinical care of HIV-infected pregnant women, Glaxo Wellcome Educational Grant.

Ranbaxy Science Foundation (ed.), 2000. HIV/AIDS in India. Proceedings of Round Table Conference Series. # 6, April 2000, New Delhi, India.

UNAIDS/WHO, 2002. AIDS Epidemic Update. (Dec.) - Joint United Nations Programme on HIV/AIDS (UNAIDS). World Health Organization (WHO).

Notes

1 See Clinical Course of HIV Infection for Women, p. 26-28 or Annex II.

2 See Clinical Course of HIV Infection for Women, Section: Counselling and Testing (pp. 21-25).

3 See Clinical Course of HIV Infection for Women, Annex VI.

© Institut Français de Pondichéry, 2004

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