HIV prevention is not enough: child survival in the context of prevention of mother to child HIV transmission

Abstract

Clinical and epidemiologic research has identified increasingly effective interventions to reduce mother to child HIV transmission in resource-limited settings These scientific breakthroughs have been implemented in some programmes, although much remains to be done to improve coverage and quality of these programmes. But prevention of HIV transmission is not enough. It is necessary also to consider ways to improve maternal health and protect child survival.A win-win approach is to ensure that all pregnant and lactating women with CD4 counts of <350 cells/mm3 have access to antiretroviral therapy. On its own, this approach will substantially improve maternal health and markedly reduce mother to child HIV transmission during pregnancy and delivery and through breastfeeding. This approach can be combined with additional interventions for women with higher CD4 counts, either extended prophylaxis to infants or extended regimens of antiretroviral drugs to women, to reduce transmission even further.Attempts to encourage women to abstain from all breastfeeding or to shorten the optimal duration of breastfeeding have led to increases in mortality among both uninfected and infected children. A better approach is to support breastfeeding while strengthening programmes to provide antiretroviral therapy for pregnant and lactating women who need it and offering antiretroviral drug interventions through the duration of breastfeeding. This will lead to reduced HIV transmission and will protect the health of women without compromising the health and well-being of infants and young children.

Figure 1

Transmission rates and proportions of infections. Panel A - Transmission rates and proportions of infections due to transmission through different routes among breastfed infants born to HIV-infected mothers if no interventions are provided. Panel B - Transmission rates and proportions of infections among breastfed infants born to HIV-infected mothers when short course antiretroviral interventions are provided.

Figure 2

Why treating only women with low CD4 counts reduces postnatal HIV transmission. Panel A - Postnatal HIV transmission rates in the population are an average of low rates among women with high CD4 counts and high rates among women with low CD4 counts. Panel B - When antiretroviral therapy is given to women with low CD4 counts, the postnatal HIV transmission rate in this group, and in the overall population, declines to low levels.

Figure 3

Balancing adverse outcomes in breastfed and non-breastfed infants. Panel A - When effective antiretroviral drugs are not provided, abstinence from breastfeeding or early weaning may result in no benefit for HIV-free survival, i.e., number of extra uninfected deaths caused = number of HIV infections prevented. Panel B - When effective antiretroviral drugs are provided, abstinence from breastfeeding or early weaning results in worse outcomes, i.e., number of extra uninfected deaths (in black outline) caused > number of HIV infections (in red outline) prevented.

Figure 4

HIV-free survival by breastfeeding practice. HIV-free survival of children born to HIV-infected women with CD4 counts >350 is better if breastfeeding continues than if breastfeeding stops early [47].