The value of highly active antiretroviral therapy in the prevention of mother-to-child transmission of HIV.

Over 90% of the children infected with HIV globally were as a result of mother-to-child transmission. With a high prevalence of HIV among women of reproductive age and a high fertility rate in Nigeria, the prevention of mother-to-child transmission of HIV is an important strategy to curb the menace of HIV. This paper examines the value of highly active antiretroviral treatment in the prevention of mother-to-child transmission of HIV. Pregnant women attending the antenatal clinic of the University of Maiduguri Teaching Hospital were offered voluntary counselling and testing for HIV. Seropositive women who fulfilled the criteria for administration of antiretroviral drugs were offered a triple combination of nevirapine, stavudine and lamivudine in pregnancy. Women who did not fulfil the criteria were offered single dose nevirapine in labour. The newborn of all HIV-positive women were offered nevirapine suspension within 72 h of delivery. Overall transmission rate for women who had combination treatment was 9.1% which was lowered to zero level among those that had elective caesarean section and infant formula in addition to the drugs. Those who had single dose nevirapine in labour had a transmission rate of 33.3%. It is recommended that the single dose nevirapine be abandoned in favour of combination treatment.     

Prevention of mother-to-child transmission of HIV: antiretroviral strategies

The World Health Organization's Strategic Approaches to the Prevention of HIV Infection in Infants includes 4 components: primary prevention of HIV-1 infection; prevention of unintended pregnancies among HIV-1-infected women; prevention of transmission of HIV-1 infection from mothers to children; and provision of ongoing support, care, and treatment to HIV-1-infected women and their families. This review focuses on antiretrovirals for secondary prevention of HIV-1 infection-prevention of HIV-1 transmission from an HIV-1-infected woman to her child. Antiretroviral strategies to prevent the mother-to-child transmission of HIV-1 in nonbreastfeeding populations comprise antiretroviral treatment of HIV-1-infected pregnant women needing antiretrovirals for their own health, antiretroviral prophylaxis for HIV-1-infected pregnant women not yet meeting criteria for treatment, and antiretroviral prophylaxis for infants of HIV-1-infected mothers. The review primarily addresses antiretroviral strategies for nonbreastfeeding, HIV-1-infected women and their infants in resource-rich settings, such as the United States. Antiretroviral strategies to prevent antepartum, intrapartum, and early postnatal transmission in resource-poor settings are also addressed, albeit more briefly.     

Strategies for prevention of mother-to-child transmission of HIV.

Over 90 per cent of paediatric HIV infections are maternally acquired, most of these in sub-Saharan Africa. Mortality trends underscore the humanitarian and ethical obligation for urgent global action to protect children from HIV. With the adoption of anti-retroviral therapy in pregnancy, mother-to-child transmission rates have declined to 4-6 per cent in the USA and other industrialised countries. In low-resource settings, where most of the children are continuously being exposed to HIV, the cost of anti-retroviral therapy is prohibitive. Very few developing countries apart from Botswana, Thailand and Brazil have national policies for integration of preventive anti-retroviral therapy in antenatal clinics. This paper reviews anti-retroviral and non-anti-retroviral interventions for prevention of mother-to-child transmission of HIV. To support the health of mothers as well, it supports the implementation of a comprehensive package of care in pregnancy and post-partum, such as access to antenatal and delivery services; anti-retroviral preventive therapy; malaria treatment; family planning; multivitamin, iron and folate supplementation; counselling on feeding options; post-natal care for the child and post-partum care for the mother, and calls for a strategy for advocacy, programme communication and community mobilisation.     

HIV drug resistance and mother-to-child transmission of HIV

This article covers HIV drug resistance among pregnant women and the implications of transmission of resistant HIV to the infant. Resistance to antiretroviral drugs may be acquired or can emerge while HIV-infected pregnant women are on antiretroviral therapy, either before or during pregnancy. Resistance to antiretroviral drugs among HIV-infected infants may be acquired from the mother in utero or during the intrapartum period. Resistance may also emerge from exposure to antiretroviral drugs given to the infant for prophylaxis against HIV transmission. In settings where breastfeeding is practiced, ongoing transmission of HIV from breastfeeding may lead to transmission of resistant HIV from the mother. If the mother is taking antiretroviral drugs while breastfeeding, resistance to antiretroviral drugs may emerge in an HIV-infected infant from ingestion of antiretroviral drugs via breast milk. The magnitude and implications of antiretroviral resistance among HIV-infected pregnant women and HIV-infected infants are summarized.     

孕激素预防流产

妊娠早中期应用孕激素并不能预防先兆流产。但有一项小样本研究发现,使用孕激素可降低曾有过反复流产妇女的流产风险。     

Community gate keepers' awareness and perception of prevention of mother-to-child transmission of HIV services in Ibadan, Nigeria

Each year, around half a million children aged under 15 become infected with HIV and more than 90% are the result of mother-to-child transmission. Services to prevent mother-to-child HIV transmission (PMTCT) are therefore important entry points for HIV/AIDS prevention, treatment and care services for women, their children and families. The study aimed at identifying level of awareness and knowledge of PMTCT services that can be utilized in improving access. The methodology consisted of 20 individual in-depth interviews spread over Adabeji, Adeoyo/Agbadagbudu, Jakiru/Onipasan and Eleta communities, in Ibadan among household heads, religious and community based leaders. Key factors identified were low knowledge of mother to child transmission, lack of knowledge of the PMTCT services, inadequate community sensitization, inadequate healthcare facilities. The success of PMTCT programmes demands a shift towards a more community-based approach which calls for strong advocacy, enlightenment and community mobilization for improved awareness and utilization of PMTCT services.     

Timing and determinants of mother-to-child transmission of HIV in Nigeria

Objective

To characterize the timing and determinants of mother-to-child transmission (MTCT) of HIV among mothers receiving single-dose nevirapine to prevent MTCT in Nigeria.

Methods

Three hundred and seventy-one HIV-infected mothers and their infants were followed from birth, at 1 week, and at 1, 3, 6, and 12 months. Risks of in utero (IU), intrapartum (IP/EPP), and postnatal (PP) transmission were quantified using conditional Cox regressions.

Results

Maternal viral load was the only risk factor for IU transmission after controlling for known risk factors. Low birth weight, premature birth, mixed feeding, and maternal viral load were associated with IP/EPP transmission. Increased PP transmission was associated with low birth weight and mixed feeding. At 6 months, mixed-fed infants were more likely to acquire infection than formula-fed infants (hazard ratio = 5.74; 95% CI, 1.26-26.2).

Conclusion

Risk factors for IU transmission differed from those of IP and PP transmission. Reducing mixed feeding and low birth weight delivery among HIV-infected mothers can further decrease IP and PP transmission.     

Preventing mother-to-child transmission of HIV: successes and challenges

Mother-to-child transmission of HIV continues to be a major cause of infant morbidity and mortality in resource-poor settings. Intrapartum and postpartum nevirapine-based regimens have been introduced in many settings. New research has shown that better efficacy can be achieved with the addition of single-dose nevirapine to short course zidovudine regimens, and that selection of nevirapine-resistant virus can be reduced with a short postpartum combination antiretroviral cover. Women who need antiretroviral therapy for their own health should receive it in pregnancy, and access for pregnant women needs to be expanded urgently. The reduction of transmission through breastfeeding remains a challenge.     

Prevention of mother-to-child transmission of HIV at Maiduguri, Nigeria.

The human immunodeficiency virus (HIV) can be transmitted vertically through the placenta in utero, during labour and delivery and through breast milk. In Nigeria, about 5.8% of women attending antenatal clinics were HIV infected as of December 2002. It was projected that by the end of the year 2002, there were about 849,000 orphans resulting from AIDS and about 755,000 established paediatric AIDS in this country. Interventions to prevent mother-to-child transmission of HIV include voluntary counselling and testing (VCT), administration of antiretroviral drugs (ARV), modification of obstetric practices and infant feeding options in HIV infection. Over the period July 2002-June 2003, 262 pregnant women received VCT at the antenatal clinic of the University of Maiduguri Teaching Hospital, and 207 (79%) agreed to be tested. Thirty-one (11.8%) were HIV positive. The majority of the HIV positive mothers received nevirapine in labour while 35% had combination ARV drugs in pregnancy. All the infants received nevirapine suspension within 72 hours of delivery. Expensive and slow testing facilities, insufficient and inconsistent counsellors, lack of ARV drugs for both mother and baby as well as unaffordable caesarean delivery were some of the constraints being faced at this centre. It is recommended that the governments at various levels should show more commitment to the programme of preventing mother-to-child transmission of HIV.     

Primiparous mothers' knowledge about mother-to-child transmission of HIV in Lusaka, Zambia

Objective

to learn what primiparous mothers in Lusaka, Zambia know about human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS), mother-to-child transmission (MTCT) of HIV, and breast feeding.

Design

qualitative interviews analysed by thematic manifest content analysis.

Setting

postnatal wards at Lusaka University Teaching Hospital.

Participants

14 primiparous mothers were interviewed.

Findings

1 year after implementation of the prevention of MTCT programme in Zambia, the majority of the women interviewed lacked basic knowledge about MTCT. They did not know that HIV is present in breast milk and that it is a source of transmission. Few mothers had been informed about breast feeding, correct attachment and ways of avoiding breast infection. The mothers seemed to be uncertain about what HIV actually is, and they preferred to talk about MTCT and safe breast feeding rather than HIV/AIDS in general, which was the main reason for their participation in the study. According to the mothers, the most effective way of preventing transmission of HIV to the unborn baby was a single dose of nevirapine. Many believed that treatment is equal to cure and gives the baby full protection. The overall feeling of mothers was that they had not received information and support from the antenatal clinics and postnatal wards. The more traditional women preferred not to discuss these issues with their friends, their husbands or their families, which may make it more difficult to spread information and encourage couples to make decisions about their and their baby's future.

Conclusion

these findings suggest that primiparous mothers and their families need more education about MTCT of HIV. The mothers also need basic education about breast feeding and how to avoid breast injuries. The main reason for mothers’ poor knowledge may be that health workers do not have the necessary information. There seems to be a need for training in breast-feeding and baby-feeding counselling in the context of HIV in order to promote exclusive and safe breast feeding. As such, further research about health workers’ knowledge and methods of teaching is required.     

The prevention of mother-to-child HIV transmission programme in Lilongwe,Malawi: why do so many women drop out

Mother-to-child transmission of HIV constitutes a substantial burden of new HIV infections in sub-Saharan Africa, and losses to follow-up continue to undermine prevention of mother-to-child transmission of HIV (PMTCT) programmes. This qualitative study sought to clarify why some women who were enrolled in a PMTCT programme in Lilongwe, Malawi, did not fully participate in follow-up visits in the first six months after testing HIV-positive. Twenty-eight women, 14 who participated fully in the programme and 14 who dropped out, were purposively selected for in-depth interview at two clinics. Focus group discussions with 15 previously interviewed and 13 newly recruited women were also conducted. Discussions with 12 of the women's husbands were also carried out. Although the proportion of women being tested has reportedly increased, losses to follow-up have shifted and are occurring at every step after testing. Major emerging themes associated with dropping out of the PMTCT programme within six months after delivery were to avoid involuntary HIV disclosure and negative community reactions, unequal gender relations, difficulties accessing care and treatment, and lack of support from husbands. The whole approach to the delivery of the PMTCT programme and home visits must be reconsidered, to improve confidentiality and minimise stigmatization. Women need to be empowered economically and supported to access HIV treatment and care with their partners, to benefit their whole family.     

Prevention of mother-to-child transmission of HIV in resource-rich and -poor settings

Without prevention, a third of HIV-exposed infants acquire HIV in breastfeeding populations before, during, or after delivery through mother-to-child transmission (MTCT). Whereas MTCT is now a sentinel event in resource-rich countries with antiretroviral prophylaxis, caesarean section, and avoidance of breastfeeding, this is not yet the case in resource-poor settings because breastfeeding is crucial to infant survival. Recent advances in postpartum maternal and infant prophylaxis enables safer breastfeeding, and increasing numbers of women accessing treatment and prevention of MTCT services in sub-Saharan Africa is leading to optimism that MTCT could be eliminated here also, as reflected in the UNAIDS target of 2015.     

穴位按压防治HIV母婴阻断新生儿喂养不耐受的疗效观察

目的观察穴位按压防治人类免疫缺陷病毒(HIV)母婴阻断新生儿喂养不耐受的临床效果。方法 2013年7月至2015年7月在广州市第八人民医院出生的HIV母婴阻断新生儿102例,随机分为观察组52例与对照组各50例。两组均出生后4h内即开始足月儿配方奶喂养,并于第一次吃奶同时开始给予奈韦拉平口服混悬液抗病毒阻断治疗,每次1.5mL,每日1次。根据新生儿的喂养耐受情况个体化调整奶量,期间常规监测血糖,如血糖偏低或经口喂养摄入能量不足者可联合静脉营养支持至经口喂养可满足其生长所需能量为止。观察组在对照组的基础上联合穴位按压。新生儿出生后24h且生命体征平稳,即可开始进行穴位按压,取穴:足三里、中脘、天枢、脾俞及胃俞,依次按压以上穴位(足三里及天枢为双侧同时按压),每个穴位按压时间先从每次1min开始,新生儿适应后,可逐渐延长至每次2min,每日2次。两组患儿在研究期间均不使用促胃肠动力药。观察喂养不耐受发生情况、每日奶量增加速度、完全经口喂养日龄及恢复出生体质量日龄。结果观察组奶量增加速度快于对照组,完全经口喂养日龄及恢复出生体质量日龄均早于对照组,差异均有统计学意义(P0.05)。观察组呕吐、腹胀、胃潴留及奶量增加困难发生率均低于对照组,差异均有统计学意义(P0.05)。结论穴位按压可有效防治HIV母婴阻断新生儿喂养不耐受的发生。     

Determinants of male involvement in the prevention of mother-to-child transmission of HIV programme in Eastern Uganda: a cross-sectional survey

Background  

Mother-to-child transmission of HIV (MTCT) accounts for over 95% of all paediatric HIV infections worldwide. Several studies have shown that male participation in the antenatal care of their spouses together with couple counselling and testing for HIV, increases use of the interventions for HIV prevention. The prevention programme of MTCT (PMTCT) was launched in Uganda in 2000 and Mbale in 2002. Less than 10% of the pregnant women accepted antenatal HIV testing at Mbale Regional Referral Hospital in 2003; couple counselling and testing for HIV was low. Therefore, we conducted the study to determine the level of male involvement and identify its determinants in the PMTCT programme.     

Cochrane评价:抗逆转录酶疗法降低艾滋病病毒母婴传播的危险度

1 背景。在母乳喂养人群中应该考虑到较长期使用尼维拉平(尤其结合早期断奶)的潜在价值，因为它能进一步降低母婴传播的危险度。现正在进行的对抗逆转录病毒联合疗法的评估具有重大意义，那些有能力开展此项治疗的国家可以立即从中受益。在那些资源贫乏的国家，仍应将可替代抗逆转录病毒联合疗法的有效、可负担、安全和可接受的其它降低母婴传播疗法的研究列入研究议程(UNAIDS／WHO)。     

Poor sensitivity of field rapid HIV testing: implications for mother-to-child transmission programme

We validated rapid HIV tests among pregnant women in a clinical setting. Field testing was performed using First Response 1,2,3 or Standard Diagnostic and Pareekshak tests. Results were confirmed by third generation HIV ELISA. Discordant or negative, specimens were confirmed by RNA PCR and a fourth generation ELISA test. Sensitivity and specificity were 94.5% (CI: 85.8–98.2) and 100% for First Response; 87.5% (CI: 46.7–99.3) and 100% (CI: 87.7–100%) for Standard Diagnostic and 90.2% (CI: 81.2–95.4) and 100% (CI: 98–100%) for Pareekshak. These sensitivities were lower than laboratory validation which approached 100%. The low-field sensitivity results have implications for Prevention of Mother-to-Child Transmission services.     

Missed opportunities for prevention of mother-to-child transmission of HIV-1 in the NISDI Perinatal and LILAC cohorts

ObjectiveTo evaluate cases of mother-to-child transmission of HIV-1 at multiple sites in Latin America and the Caribbean in terms of missed opportunities for prevention.MethodsPregnant women infected with HIV-1 were eligible for inclusion if they were enrolled in either the NISDI Perinatal or LILAC protocols by October 20, 2009, and had delivered a live infant with known HIV-1 infection status after March 1, 2006.ResultsOf 711 eligible mothers, 10 delivered infants infected with HIV-1. The transmission rate was 1.4% (95% CI, 0.7–2.6). Timing of transmission was in utero or intrapartum (n = 5), intrapartum (n = 2), intrapartum or early postnatal (n = 1), and unknown (n = 2). Possible missed opportunities for prevention included poor control of maternal viral load during pregnancy; late initiation of antiretrovirals during pregnancy; lack of cesarean delivery before labor and before rupture of membranes; late diagnosis of HIV-1 infection; lack of intrapartum antiretrovirals; and incomplete avoidance of breastfeeding.ConclusionEarly knowledge of HIV-1 infection status (ideally before or in early pregnancy) would aid timely initiation of antiretroviral treatment and strategies designed to prevent mother-to-child transmission. Use of antiretrovirals must be appropriately monitored in terms of adherence and drug resistance. If feasible, breastfeeding should be completely avoided. Presented in part at the XIX International AIDS Conference (Washington, DC; July 22-27, 2012); abstract WEPE163.