Safe Motherhood and Prevention of Vertical Transmission

What Works

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Two vital components of AIDS programming for women living with HIV are ensuring safe motherhood through access to health care during pregnancy and childbirth and ensuring access to services to prevent vertical HIV transmission. In 2008, an estimated 1.4 million pregnant women living with HIV in low- and middle-income countries gave birth. Sub-Saharan Africa accounted for 91% of all pregnant women living with HIV (UNAIDS, 2009d).  Globally, of the 136 million women who gave birth each year between 2005-2010, an estimated 60 million women delivered at home each year without access to skilled attendants (Berer, 2004) and may not have access to prevention of mother-to-child transmission (PMTCT) services. “….Significant increases in PMTCT coverage among those at risk can only be achieved by substantially increasing uptake of general ANC and delivery services….PMTCT programmes need to be strengthened by investing more generally in maternal health services…” (Kasenga et al., 2009: 1).  For example, less than 70% of women in the Middle East and North Africa region have at least one antenatal checkup, hindering PMTCT efforts (Remien et al., 2009). In Cambodia, 78% of births occur at home or outside medical facilities in which PMTCT services are available (ITPC, 2009). Programs to prevent vertical transmission, often referred to as prevention of mother-to-child transmission (PMTCT) programs, have historically focused on infant outcomes, rather than both the mother and infant.[1] Improving health systems and providing evidence-based interventions to ensure safe motherhood is critical for all women, and especially so for women living with HIV.

Vertical Transmission Can Occur At Multiple Points

Vertical HIV transmission can occur in utero, during delivery and during breastfeeding.  These are all points for reducing the probability of transmission while also serving as critical points for addressing women’s health needs. Recent estimates of maternal mortality for 181 countries from 1980 to 2008 found that of the 342,900 estimated maternal deaths worldwide in 2008, 61,400 were attributed to HIV (Hogan et al., 2010).

While it is impossible for an HIV-negative woman to give birth to an HIV-positive infant, it is possible for a woman to seroconvert during her pregnancy; starting her pregnancy as HIV-negative and becoming HIV-positive through sexual transmission from a sexual partner, unscreened blood transfusions, injecting drug use or rape during the course of pregnancy. In some societies, men are encouraged to have multiple partners while their wife/partner is pregnant or breastfeeding which can lead to women seroconverting (Ghanotakis, 2010). Studies also show that significant proportions of women who are pregnant suffer from violence (Dunkle et al., 2004; Guo et al., 2004 cited in Tang et al., 2008; Cripe et al., 2008; Ellsberg, 2006). [See also Chapter 11B. Strengthening the Enabling Environment: Addressing Violence Against Women] Perinatal transmission is usually considered the time between 20 weeks of gestation and 28 days following birth. However, breastfeeding, when transmission can continue to occur, may be a period of months and even two or three years following birth.  A woman can acquire HIV before or after the birth of her child and vertical transmission of HIV is still possible as long as breastfeeding continues. If a woman is HIV-positive and breastfeeds, because safe drinking water and replacement feeding are not available to her, or to avoid HIV stigma, her infant born HIV-negative can become HIV-positive.

The Four Pillars of PMTCT

Prevention of vertical transmission has been categorized into four pillars, each of which contributes to preventing HIV acquisition and transmission (Glion Call to Action, 2004; UNAIDS, 2006; UNICEF, 2008).

Pillar 1: Preventing Primary HIV Infection in Women

Primary prevention of HIV among adults remains critical to any efforts to reduce vertical transmission. Women who remain HIV-negative cannot transmit HIV to their infants. Further, “children whose mothers have died, regardless of the mother’s HIV status, are less likely to survive to their fifth birthday than are children of HIV-infected women who are still alive” (Zaba et al., 2005 cited in Heymann et al., 2007a). The programming in Chapter 3. Prevention for Women, Chapter 4. Prevention for Key Affected Populations, Chapter 5. Prevention for Young People and Chapter 11. Strengthening the Enabling Environment address this first prong of preventing primary HIV infection in women.

Pillar 2: Preventing Unintended Pregnancy Among Women Living with HIV

Preventing unintended pregnancies can have a significant impact on reducing perinatal transmission of HIV and is a fundamental right for women. Once fully informed of her options, a woman can decide about her reproductive choices and make an informed decision about her fertility. The benefits of family planning include preventing unintended pregnancies; reducing maternal and infant deaths; and greater educational and economic opportunities for women (Halperin et al., 2009a). A 2006 modeling study found that for the same cost as treatment with antiretroviral drugs to prevent perinatal transmission, contraceptive use can avert nearly 30 percent more unintended HIV-positive births (Reynolds et al., 2006a).  It is estimated that 22 percent of unintended HIV-positive births are already being prevented through current levels of contraceptive use in sub-Saharan Africa (Reynolds et al., 2006a).  “One of the neglected areas in PMTCT globally has been the issue of fertility desires and fertility planning for HIV-positive women and their partners” (McIntyre and Lallemont, 2008b: 137).  Interventions related to this pillar are included in this chapter as well as in Chapter 8. Meeting the Sexual and Reproductive Health Needs of Women Living With HIV. 

Pillar 3: Preventing Vertical Transmission of HIV During Pregnancy, Delivery and Postpartum

Well-functioning maternal health programs are essential for all women, but particularly for pregnant women living with HIV. Access to preconception care, HIV testing and counseling that guarantees confidentiality, HIV treatment options, and evidence-based options in delivery and for postpartum care are critical to meeting the needs of women living with HIV and preventing perinatal transmission. Interventions related to this pillar are included in this chapter.

Pillar 4: Family Treatment – Providing Care, Treatment and Support to HIV-Positive Women, Their Children and Families

Family treatment (also referred to as PMTCT-Plus) refers to programming that aims to reduce vertical transmission as well as to provide services before, during and after pregnancy for women living with HIV and to other family or household members. Globally, maternal-child health facilities have traditionally excluded men even though fatherhood is important in almost all societies and women often want the support of their male partners during pregnancy, labor, delivery and the postpartum period. Good maternal health can also be highly dependent on access to HIV prevention, treatment and care for men, as focusing on men in addition to women protects the health of women and, by extension, their children. 

Involving men in PMTCT programs—with the permission of women—is an important component in increasing women’s uptake of HIV testing, prevention, treatment and care (Ghanotakis, 2010). Yet in 2007, only 5% of the male partners of women attending antenatal care were tested for HIV (UNAIDS, 2009e). Involving men in PMTCT programs can also help address the gender issues that impact women’s acquisition of HIV, as well as access to prevention, testing, treatment and care. [See also Chapter 11. Strengthening the Enabling Environment] Recent work has focused on men and fatherhood (Barker et al., 2010). Programs such as Women Fighting AIDS in Kenya is successfully working to increase male involvement in PMTCT services (Ovaro and Kaduwa, 2008). A number of programs, such as EngenderHealth’s Men as Partners or Catholic Medical Mission Board’s Men Taking Action in Zambia are working to increase the positive involvement of men in maternal health care in general, but few evaluated studies were found for PMTCT programs. PMTCT programs may learn from involving men in safe motherhood programs. Interventions related to this pillar are included in Chapter 7. Treatment, Chapter 10. Preventing, Detecting and Treating Critical Co-Infections, and Chapter 12. Care and Support.

Most PMTCT Programs Focus On Pillar 3

Despite the importance of pillars one and two in preventing vertical transmission, “for most programs in the field, PMTCT is in fact focused on the program’s third and fourth components” (Msellati, 2009:808). While this chapter touches on pillar two, additional information on preventing unintended pregnancies is in Chapter 8. Meeting the Sexual and Reproductive Health Needs of Women Living With HIV. The majority of this chapter focuses on pillar three – safe motherhood and prevention of vertical transmission. The other pillars are covered, however, in additional chapters as noted above.

What Works in Safe Motherhood and Preventing Vertical Transmission

A number of proven strategies work to reduce the risk of HIV transmission from mother to child.  Confidential HIV testing with counseling during antenatal care that includes women, and with their permission, their partners, is a critical foundation for reducing vertical transmission of HIV. HIV testing and counseling allows women to know their serostatus and make appropriate decisions to prevent vertical transmission. Maternal use of ARV therapy for her own health saves the lives of both mother and child and reduces orphan death in the long term. ARV prophylaxis during pregnancy drastically reduces perinatal transmission. Initiating ARV therapy or prophylaxis in a timely fashion and adherence are also important. [See Chapter 7. Treatment] A 2008 review on child survival and PMTCT reported that child survival depends largely upon the mother’s health and survival. HAART for pregnant women dramatically reduces perinatal transmission; reduces the risk of resistance to antiretroviral drugs related to monotherapy or duo therapy; and the risk of virological failure of HAART for HIV-positive children (Russo et al., 2009). In November 2009, WHO released new rapid advice recommending ARV use for treatment or prophylaxis for pregnant women: http://www.who.int/hiv/pub/mtct/rapid_advice_mtct.pdf. 

Improvement of maternal health services globally will be necessary to reach all women and infants who need services, ensuring safe motherhood and prevention of vertical transmission. Provision of contraception to women who wish to avoid pregnancy is the first step in preventing vertical transmission. In order to best advise a woman living with HIV about her options for safe motherhood and prevention of HIV transmission to her future child, it is optimal to reach her prior to pregnancy.  However, most women become aware of their positive serostatus once they are pregnant, via HIV testing during antenatal care. Strengthening access to early antenatal care, services for labor and delivery and postpartum is essential to providing adequate PMTCT services. During antenatal care, HIV testing, treatment options, syphilis screening malaria prophylaxis and other essential antenatal care must be fundamental services for pregnant women living with HIV. Access to basic emergency obstetric care and emergency obstetric care is also essential for pregnant women living with HIV. All the interventions noted in “What Works, Safe Motherhood” (Gay et al., 2003) take on additional importance for HIV-positive women [www.policyproject.com/pubs/generalreport/SM_WhatWorksps2.pdf]. For recent evidence and information on maternal health, see also WHO, 2010a; WHO, 2009g; WHO, 2006c and the website of the Maternal Health Taskforce: www.maternalhealthtaskforce.org.

Not All Of The Science Related to PMTCT Is Resolved

In many respects, programming for PMTCT is quite advanced and yet for some aspects of PMTCT, current research provides incomplete and complex guidance, adding to the ongoing challenge of programming to meet the needs of women and to reduce vertical transmission.  Many unknowns remain about HIV in pregnancy and how best to provide appropriate and good care to women and their infants. Topics such as perinatal ARV therapy and breastfeeding continue to raise questions. Some of the scientific evidence points to contradictory conclusions and further guidance from the WHO is anticipated. “…After more than two decades of intensive research into HIV, the precise mechanism or even route of the vertical transmission of the virus remains unknown” (de Vries and Peek, 2008: 679). But pregnancy is a time where many women have multiple contacts with health providers, “creating an opportunity to assess and address women’s sexual risk and HIV and STI status” (Kershaw et al., 2006: 310).  However, one fact remains clear: it is vital that HIV-positive women are given counseling and support with the most accurate and comprehensive information available so that they can make informed decisions about their health and the health of their children.

This Chapter is Organized According to How Women Access Services

The evidence for what works in preventing perinatal transmission in this chapter is organized according to the way women access health services, particularly maternal health services:  prevention of unintended pregnancies, preconception planning; antenatal care (testing and counseling, treatment); delivery; and postpartum. 

 

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[1] In fact, PMTCT, itself, is “a name that implies that mothers are the source of the virus, rather than the latest in a long chain of transmission” (Lewis and Donovan, 2009: iv). This document primarily uses the term vertical transmission.

Strategies

• Prevention for Women
• Prevention for Key Affected Populations
• Prevention for Young People
• HIV Testing and Counseling for Women
• Treatment
• Meeting the Sexual and Reproductive Health Needs of Women Living With HIV
• Safe Motherhood and Prevention of Vertical Transmission
  • Preventing Unintended Pregnancies
  • Pre-Conception
  • Antenatal Care - Testing and Counseling
  • Antenatal Care - Treatment
  • Delivery
  • Postpartum
• Preventing, Detecting and Treating Critical Co-Infections
• Strengthening the Enabling Environment
• Care and Support
• Structuring Health Services to Meet Women’s Needs