Antiretrovirals for reducing the risk of mother-to-child transmission of HIV infection
RHL practical aspects by McIntyre J
The World Health Organization has promoted a four-pronged approach to reducing mother-to-child transmission: prevention of new infections in parents-to-be, prevention of unwanted pregnancies in HIV-infected women, prevention of transmission from an HIV-infected mother to her infant and access to appropriate treatment and care. This review confirms the efficacy of strategies to prevent transmission to the infant; but the challenge remains in their implementation.
The review confirms the efficacy of short course regimens of antiretrovirals in various regimens and of intrapartum and postpartum Nevirapine. In well-resourced settings, combination antiretroviral therapy (ART) is used through pregnancy to prevent MTCT, achieving very low transmission rates. Women who qualify to start ART should do so while pregnant, and, where combination ART is not available, an efficacious short course regimen should be provided to women who do not yet need ART.
The choice of antiretrovirals within health services is best determined by consideration of the local circumstances. Recommendations for care should also consider information available on the risk of transmission through breast milk and other risk factors for transmission.
FIRST CONTACT (PRIMARY CARE) LEVEL
All pregnant women should have access to voluntary counselling and testing for HIV, which is best done using rapid tests with same day results. HIV-positive women should be assessed clinically and a CD4 test performed if possible, to determine whether referral for initiation of ART is needed. If not, mothers should be given information about the use of antiretroviral treatment during pregnancy for the prevention of mother-to-child transmission and should have the option to take this treatment. Women should be given information about the risk of transmission from HIV in breast milk, as well as on the advantages and disadvantages of breastfeeding. They should be given the opportunity to decide on infant feeding choices before the time of delivery and they should be supported in their choice. Access should be provided to postpartum reproductive health services, including appropriate contraception if desired.
REFERRAL HOSPITAL (SECONDARY CARE) LEVEL
All women should have access to voluntary counseling and testing for HIV. Antiretroviral treatment or PMTCT prophylaxis should be offered to all HIV-positive pregnant women. Prolonged rupture of membranes should be avoided where possible. Elective caesarean section appears to reduce the risk of transmission, and may be applicable in some settings. The decision on mode of delivery will have to take into consideration the available resources, use of antiretrovirals and availability of follow up care. Women should be counselled on infant feeding and family planning as above.
AT HOME OR IN THE COMMUNITY
Counselling and testing should be available to sexual partners of pregnant women, and follow up testing should be available on request for those women and their partners who have tested negative during a pregnancy. HIV-positive women should be referred to community based support groups. Interventions to prevent new HIV infections in women and men should continue.
This document should be cited as: McIntyre J. Antiretrovirals for reducing the risk of mother-to-child transmission of HIV infection: RHL practical aspects (last revised: 22 August 2007). The WHO Reproductive Health Library; Geneva: World Health Organization.