Prevention of Mother-to-Child Transmission (PMTCT) PDF Print E-mail
It is a common misunderstanding that pregnant women who are HIV-positive will automatically pass the disease to their babies. This is not true. Only one out of every three children born to HIV-positive mothers will become infected with HIV disease. In other words two out of every three babies will be born healthy. With an appropriate PMTCT programme this risk can be reduced by half, so that five out of six babies born to HIV-positive mothers will be healthy.
 
PMTCT is one of the most crucial issues in the current struggle against HIV infection. The Department of Health estimated that approximately 100 000 babies became infected in 2002 through mother-to-child transmission. If every HIV-positive mother had been offered the PMTCT programme around 50 000 babies could have been saved from HIV infection.
 
It is therefore important for all women with HIV disease who become pregnant to enrol in the PMTCT programme and reduce the risk of transmitting the disease to their unborn children. If a woman does not know her status when she falls pregnant she should consider having an HIV test. If she tests negative she can continue to make sure she stays negative by practising safe sex at all times. If she tests positive she can enrol in the programme and find out how to protect her child from getting the disease. It is important that she continues to practise safe sex at all times too. This will protect her partner if he is HIV-negative. If he is also HIV-positive it will protect her from being exposed to additional viruses.

The following topics are covered in this section:

How HIV disease is passed from mother to baby
There are three ways in which mother-to-child transmission of HIV disease can occur:
  • In the womb. Disease transmission seldom occurs this way as the baby is protected in a bag containing amniotic fluid and the mother’s blood and baby’s blood never come into direct contact.
  • During labour and delivery. The majority of babies (60-85%) are infected during or immediately after delivery. The risk of infection increases as soon as the waters break and when the afterbirth comes away from the womb
  • After birth, through breastfeeding. Breastfeeding accounts for approximately 15% of mother-to-child transmission cases. This percentage is reduced if the mother breastfeeds exclusively and if she breastfeeds for a shorter period. The risk of transmission remains constant throughout the period of breastfeeding period; it is not higher at the beginning. If a mother has been very recently infected, or if she has advanced HIV disease, the risk of passing the disease on through breast milk increases to around 30%. This because the mother has a much higher viral load (number of viruses in her body) during the very early and late stages of HIV infection. This means there will be more viruses present in the breast milk
What is the PMTCT Programme?
When a mother attends the clinic, Midwife Obstetric Unit (MOU) or hospital for her first antenatal visit, she will be given counselling and asked if she wants to take an HIV test. The test is voluntary and the results are kept confidential, which means that only the counsellor and the health professionals looking after the mother will know the results. If the mother is HIV-positive she will be invited to join the government’s free PMTCT programme.

The programme includes both treatment and educational elements.

 1) Drug treatment regime:
  • Once labour begins mothers take a single dose of the antiretroviral drug, Nevirapine. Most clinics give this tablet to the mother who is instructed to take it as soon as her labour starts. If she takes it too early (before labour has properly begun) she will be given another tablet in the labour ward.
  • Nevirapine is also given in syrup form to the baby within 6-72 hours of birth. 
  • Treatment with Nevirapine only reduces the chance of the baby contracting the disease during delivery, which accounts for most infections (60-80%). It does not stop the baby getting infected while still in the womb or through breast milk.
  • The treatment only benefits the baby. It does not help the mother or cure her of HIV disease.
  • The treatment regime in the Western Cape is different to other provinces. Mothers are prescribed AZT twice daily from 34 weeks. They are also given a dose every three hours during labour plus a single dose of Nevirapine. The babies receive a single dose of Nevirapine within 6-72 hours of birth plus a seven-day course of AZT.
  • The government is presently considering a national treatment protocol that will include a regime of dual therapy (AZT and Nevirapine, as already prescribed in the Western Cape) to be given to the mother from 34 weeks. It is now recognised that giving a single dose of Nevirapine is a substandard intervention and this new policy should be implemented immediately. Again this intervention treatment will only help to further reduce the transmission rate during delivery; it will not benefit the mother.
2) Infant feeding programme:
Counselling and advice on infant feeding for HIV-positive mothers is provided as part of the PMTCT programme.
  • Mothers are given a choice to either exclusively breastfeed for 4-6 months or exclusively formula feed. Mixed feeding (a mixture of breast and formula milk) is associated with higher transmission rates and is strongly discouraged.
  • Exclusive breastfeeding means that the baby must only receive breast milk. The baby must not be given any tea, juice, infant formula or even water during this period. Breast milk is the best food for the baby and helps the baby develop a strong immune system. This helps to protect the baby from developing HIV disease. However if other foods are introduced at the same time it weakens the digestive system making it easier for the HIV virus to get into the baby’s blood.
  • Exclusive formula feeding means only giving the baby formula feed, prepared strictly according to the instructions. The water must be clean and freshly boiled and the bottles and teats must be properly sterilised, otherwise the baby can get very sick and even die. Mothers choosing to formula feed will get free milk powder for six months. They will get two tins of milk powder on discharge and will then get eight tins per month, which they will need to collect from the local baby clinic.
  • Health advisors need to take into account local conditions. If clean water is not readily available or if the clinic has problems supplying regular infant formula, women should be encouraged to rather choose the exclusive breastfeeding option. 
  • In some communities there is a stigma attached to formula feeding because some people think that it identifies the mothers who are HIV-positive. Many mothers are therefore reluctant to choose this option. It is important that the mothers who choose to formula feed are properly supported by the clinic staff, their families and the community in order for this option to be successful.
  • In some cases a ‘wet’ nurse who is HIV-negative can be found to feed the baby. This is not always practical but it offers an ideal solution as the baby receives all the benefits of breast milk without any risk.  
3) The baby’s health and development: 
  • The mother is instructed to attend the post-natal clinic regularly to have the baby weighed, to get different immunisations, and to be given milk powder if she is formula feeding.
  • Antibiotic medicine is given to all babies to prevent pneumonia developing.
  • Babies are tested for HIV disease at 14 weeks. If the baby’s test is negative then the antibiotic medication is stopped. If the baby tests positive then the antibiotic medication is continued. A baby that is HIV-positive will need special care throughout its life.
4) The mother’s health and development: 
  • Mothers are encouraged to attend the clinic regularly for check-ups and to get all opportunistic infections treated early.
  • They are advised to continue using condoms every time they have sex. This will protect their partners if they are still HIV-negative, and reduce additional exposure to the virus if both partners are HIV-positive. 
  • Mothers will be given counselling about contraception. If they haven’t already informed their partners of their status, they will be encouraged to do so. The partners will be advised to get tested.
  • Mothers are encouraged to join an appropriate support group providing psychosocial support as well as information on eating healthily and ways to look after herself and her baby.
Antiretroviral Treatment (ART) for Pregnant Mothers
Women with the highest viral load (number of viruses in their blood) have a greater chance of transmitting the disease to their children. Viral loads are generally higher in people who have been recently infected (before the body’s immune system starts to fight back) and in advanced stages of the disease (when the immune system is damaged and AIDS develops).
 
If a pregnant woman develops AIDS (a CD4 count below 200, or one of the illnesses associated with AIDS) she may be able to receive ART for herself. This will usually only start after the first three months of pregnancy unless her CD4 count is very low, and will then continue for the rest of her life.  
If a woman who is already receiving ART falls pregnant she must see her doctor immediately to make sure the drugs she is taking are safe for her baby. Some of the antiretroviral drugs can harm the unborn baby.
 
An HIV-positive woman who falls pregnant has, like all women, the right to choose whether to have the baby or not. She may decide to terminate the pregnancy.
 
National Implementation of the PMTCT Programme 
Numerous studies have shown that the PMTCT programme saves lives, unnecessary suffering and disease, as well as being very cost effective. This programme should be available at every antenatal and maternity unit throughout the country. However statistics from 2003 showed that PMTCT programmes had not been widely implemented, with Mpumalanga offering no programme whatsoever. For example the percentages of maternity units providing PMTCT treatment in 2003 varied widely with some provinces like Limpopo (38%), Western Cape (32%), North West (26%) and Northern Cape (25%) doing better than KwaZulu-Natal (18%), Free State (17%), Gauteng (17%), Eastern Cape (12%) and Mpumalanga (0%).
There is no information available on the current coverage of the PMTCT programme throughout the different provinces, but most provinces report an increase in the number of facilities offering the PMTCT programme since 2003. Some provinces seem to have improved dramatically judging by the 2004 District Health Information Service (DHIS) information about the uptake rate of HIV testing by pregnant women, as well as the uptake of Nevirapine treatment by both mothers and their babies. These statistics must, however, be interpreted with caution as they have not been verified and in some provinces are too unreliable to be used with confidence, especially regarding the Nevirapine uptake. For the PMTCT programme to reach every HIV-positive pregnant mother there needs to be a 100% uptake of HIV testing throughout the country. Both the Western Cape and KwaZulu-Natal are approaching the 100% target but the other provinces are lagging well behind. Clearly much more needs to be done to ensure that babies don’t continue to be needlessly infected.
 
DHIS Statistics for 2004 on uptake of HIV testing
 

Province

% mothers testing positive for HIV disease

Western Cape

76-100

KwaZulu-Natal

72-90

Gauteng

15-62

Free State

15-60

North West

15-60

Limpopo

20-40

Mpumalanga

<20

Northern Cape

Unreliable data

Eastern Cape

Unreliable data

 
The results of the PMTCT testing programme confirm the prevalence rate of HIV infection established by the National HIV and Syphilis Antenatal Survey for 2004, with KwaZulu-Natal showing the highest rates of infection at 40.7% and the Western Cape showing the lowest in the country at 15.4%.
 
[A comprehensive analysis of the implementation of the PMTCT programme within the different provinces is available in the District Health Barometer report (pages 28-41), published by the Health Systems Trust (www.hst.org.za)]
 
Effectiveness of National PMTCT Programmes
Research at sites providing PMTCT programmes has shown that those in the poorest areas have higher transmission rates than those in better-resourced areas. While the treatment part of the PMTCT programme appears to work equally well, there are differences in the support and care of the women and their babies once they are discharged.
 
Most children infected after birth contract HIV as a result of receiving mixed feeding. Exclusive breastfeeding or exclusive formula feeding are both much safer options than mixed feeding. Many of the rural areas report interruptions in the provision of formula feed, which then leads to mixed feeding. In addition women in these areas are less likely to tell their families that they are HIV-positive, and therefore don’t get the support and encouragement they need to strictly follow a safe feeding option.
To reduce the HIV infection due to breastfeeding, mothers need more education about the safer feeding options for their babies. The ones who choose to formula feed also need a consistent supply of formula milk. More attention therefore needs to be paid to the postnatal component of the programme.