• Importance of PMTCT
  
• How HIV disease is passed from mother to baby
• What is the PMTCT programme?
• Antiretroviral treatment for pregnant mothers
• National implementation of the PMTCT programme
• Effectiveness of national PMTCT programmes

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 substantially so that less than 5% of babies become infected via their mothers. PMTCT is one of the most crucial issues in the current struggle against HIV infection. Thousands of babies are becoming infected unnecessarily, causing much suffering and further stretching limited health facilities.

 

An unacceptably high number of babies, around 70 000, are born with HIV every year, reflecting poor prevention of mother-to-child transmission. HIV and AIDS is one of the main contributors to South Africa’s infant mortality rate which barely declined between 1990 (49 deaths per 1000 infants) and 2007 (46 per 1000), when all regions of the world saw far greater decreases. The lack of improvement in child mortality in South Africa can largely be attributed to the HIV epidemic, and specifically the transmission of HIV from mother to child.

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?

In January 2008 the government announced a new national protocol for the PMTCT programme to replace the 2003 programme. The new protocol contains the following guidelines*:

1) HIV treatment and testing:

• 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

• 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 first tested for HIV disease at 6 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 and antiretroviral treatment (ART) will be started according to the new guidelines (February 2010) released by the Department of Health which state that all HIV-positive babies under a year must receive ART

• 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 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).

Recent new guidelines (February 2010) state that if an HIV-positive pregnant woman's CD4 count drops below 350 (previously the cut off point was 200) she will qualify for antiretroviral treatment (ART) 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. When 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

The results of the PMTCT testing programme have confirmed 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%.

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.

In conclusion, the PMTCT programme will only be successful if there is a near 100% take up by pregnant mothers. National campaigns need to promote testing; planned parenthood; reproductive choices; counselling; treatment for pregnant women; dual therapy and appropriate feeding strategies for infants. Strategies to increase the take-up of testing and treatment of children and their fathers also need to be widely promoted and effected.