Antiretroviral drugs and the prevention of mother-to-child transmission of HIV infection in resource-constrained settings

This paper analyses the different alternatives that are available for the prevention of mother-to-child transmission (MTCT) of HIV in resource-constrained settings, and makes recommendations about the best course of action in a number of situations.

The paper argues that there are effective interventions to significantly reduce the risk of MTCT, namely:

• birth by caesarean
• use of antiretrovirals (ARV)
• avoidance of breastfeeding.

However, these interventions are of difficult application in resource-constrained settings.

By the end of December 2002, 88% of countries had national MTCT prevention policies in place. However, many countries with severe HIV/AIDS epidemics have experienced difficulty in increasing access to MTCT prevention services. Therefore, the paper argues that a comprehensive and integrated approach to prevent HIV infection in women, infants and young children is urgently required.

Findings and conclusions include:

• interventions focusing on HIV-infected pregnant women need to be complemented by interventions that address primary prevention of HIV infection, particularly in women of child-bearing age and their partners, and prevention of unintended pregnancies among HIV-infected women
• specific recommendations depend on when in pregnancy the HIV-infected woman is first identified and on the need for ARV treatment to delay disease progression
• all efforts should be provided to ensure that all pregnant women who need ARV treatment following the WHO guidelines can have access to it
• for pregnant women who do not yet need, or have access to, ARV treatment for their own disease, the use of ARV prophylaxis for prevention of HIV transmission to their infants is recommended
• the choice of ARV drug regimens should be based on evidence of safety and efficacy in reducing the transmission of HIV from mothers to infants
• the choice of ARV drug regimen should be made locally, taking into account issues of feasibility, efficacy and cost
• the efficacy of potent ARV treatment in preventing postnatal transmission of HIV during breastfeeding is not yet known
• an alternative approach to prevention of transmission through breastfeeding may be prophylaxis given to the breastfed uninfected infant, and this is being explored in a number of trials.

[adapted from author]