Increasing the scope and intensity of interventions to prevent HIV infection in infants: best interests of women and children | ICRH

Authors and affiliation: 

M F Chersich (ICRH-Kenya) and S M F Luchters (ICRH-Kenya)M Temmerman (ICRH-Ghent)

Ranking: 

A1

Published: 

The Southern African Journal of HIV Medicine

Publication Date: 

01/03/2007

Background: There is a mismatch between the HIV prevention needs of children and the quality and scope of prevention of mother-to child transmission (PMTCT) services. Although near-elimination of paediatric HIV has taken place in many settings, PMTCT programmes in Africa have little impact so far. Given that it is in the child’s best interests to detect exposure to HIV shortly after birth and to institute preventive interventions, routine HIV testing may be justified for all infants born to women of unknown HIV status. HIV testing for women at child health and immunisation clinics would enable more women to benefit from knowing their status and to receive infant feeding counselling and support. Discussion: Initiating antiretroviral therapy (ART) for pregnant women helps ensure that benefits of PMTCT programmes accrue to both women and infants. Though given high priority by PMTCT guidelines, ART for pregnant women with indications for treatment has been inadequately operationalised. Guidance is needed on practical aspects of developing well-functioning linkages between antenatal and ART services. So far, efforts to prevent HIV infection in children have focused on providing short-course ARV regimens for MTCT prophylaxis, most commonly single-dose NVP (sd-NVP). In several African countries, studies have recently investigated the role of triple- ARV regimens used solely for MTCT prophylaxis. These regimens are given to women without indications for ART, and are stopped after childbirth (or after weaning). Such interventions bridge the gap in outcomes between infants born to women in Africa (including the South African private sector) and those in the USA, Europe, Brazil and other settings. In addition to using more effective ARV prophylaxis, to improve impact of PMTCT programmes, several interventions around childbirth and during breastfeeding warrant consideration. Essentially, a case could be made that the best interests of the infant and the infant’s right to preventive health care (article 24 of CRC) supersede the woman’s need for autonomy. Further ethical and legal consideration of this scenario is necessary. It is surprising that paediatricians have not been more vociferous advocates for routine testing of newborns, well within the best interests of those they serve. Similarly, children with AIDS could argue that by failing to test them for HIV exposure, the health providers who cared for them around childbirth neglected to protect them from HIV infection and did not act in their best interests, as legally obliged. Conclusions: In sum, while HIV infection in infants has effectively been eliminated in many settings, in Africa the potential for intervention at each service delivery-point is, so far, underutilised and of low quality. There is an inequitable mismatch between the HIV prevention needs of children and the services provided, necessitating a critical review of prevailing strategies. Despite the level of funding and attention available for HIV interventions, by measures such as coverage, outcomes and equity, PMTCT programmes have performed worse than syphilis control or ART programmes. PMTCT has fallen off the HIV bandwagon and needs to climb back on. For that to occur, stronger bolder national and international leadership is needed, reenergising the current approach with innovative strategies based firmly on public health principles.