How mother-to-child HIV transmission can be prevented

“According to World Health Organisation, women living with HIV are advised to exclusively breastfeed (rather than mixed feeding), provided that they are on ART. This is because, while formula feeding offers the safest option for postnatal HIV prevention, in resource poor settings, it is not always easy for families to afford formula or access things such as clean water which is needed when mixing the babies’ milk.” Mother- to -child transmission (MTCT) is the spread of HIV from an HIV-positive mother to her baby during pregnancy, delivery, or when breastfeeding. Mother-to-child transmission of HIV is also known as perinatal transmission of HIV. According to Dr Iba Mayele, an obstetrician gynecologist at Gynecology Clinic Galien Kimironko, Gasabo District, pregnant women with HIV should take medicine to prevent mother-to- child transmission of HIV and to protect their own health as most HIV medicine is safe to use during pregnancy. He says factors which increase the risk of transmission include smoking, substance abuse, vitamin A deficiency, malnutrition and a high viral load. “Mother-to-child HIV transmission occurs in-utero, peripartum, and post-natally via breastfeeding. The risk of HIV transmission to the infant can be significantly reduced with antiretroviral medication,” says Dr Kenneth Ruzindana, a gynecologist from Kibagabaga Hospital. Risk of the baby acquiring HIV During delivery or while breastfeeding, Mayele says if the mother does not receive treatment, 25 per cent of babies born to women with HIV will be infected by the virus but with treatment, that percentage can reduce to less than 2 per cent. “If no preventative steps are taken, the risk of HIV transmission during child-birth is estimated to be 10 to 20 per cent. However, the chance of transmission is even greater if the baby is exposed to HIV infected blood or fluid,” he notes. Ruzindana says about 15 per cent of new-borns to HIV-positive women will become infected if they breastfeed for 24 hours or longer because the risk of transmission depends on whether the mother breastfeeds exclusively. Prevention Mayele urges heathcare providers to avoid performing amniotomis (intentionally rupturing the amniotic sac to induce labour) as well as episiotomy since it increases the risk of transmission by 2 per cent for every hour after the membrane has been ruptured. Episiotomy, also known as perineotomy, is a surgical incision of the perineum and the posterior vaginal wall generally done by a midwife or obstetrician during second stage of labor to quickly enlarge the opening for the baby to pass through. According to Ruzindana, throughout pregnancy, the baby is given nevirapine and for at least six weeks post-delivery. Mayele explains that Cesarean section performed before labour or the rupture of membrane may significantly reduce the risk of perinatal transmission of HIV. Mayele says intervention is making sure that the mother is on ARVs. “Many pregnant women who are HIV-positive will already be taking antiretroviral therapy (ART) but for treatment, naive women, earlier initiation of ART is associated with increased likelihood of viral suppression by the time of delivery and decreased risk of transmission,” he explains. Dr John Muganda, an obstetrician gynecologist at Harmony Clinic Kigali, says the primary prevention of mother-to-child-transmission is to counsel people against contracting HIV/AIDs. There is also clinical or biological assessment, where he encourages HIV-positive women to visit hospitals in order for doctors to help them plan for the pregnancy. “Thus, we recommend initiation of ART as soon as HIV is diagnosed in a pregnant woman or as soon as pregnancy is diagnosed in untreated women with an established HIV diagnosis,” Ruzindana says. He further says the risk of HIV transmission from mother to infant has declined to historically low levels with the use of antiretroviral medication. Ruzindana adds that the combined use of maternal antepartum, maternal intrapartum, and infant antiretroviral prophylaxis maximises infant pre-exposure and post-exposure prophylaxis to decrease the risk of HIV acquisition. “Replacement feeding is recommended for infants born to HIV-infected mother in resource-rich settings. However, in developing countries like Rwanda, replacement feeding is associated with greater infant morbidity and mortality from diarrheal diseases, pneumonia, and other infectious diseases. “Therefore the Ministry of Health has adopted exclusive breastfeeding, in combination with antiretroviral interventions, for the first six months of life as it leads to nutritional and immunologic benefits for the infant,” Ruzindana says. He advises mothers to subsequently breastfeed along with antiretroviral treatment (with support to encourage adherence during breastfeeding) and appropriate complementary feeding which should continue up to 24 months or longer. Dr Theodomir Sebazungu, a doctor at University Teaching Hospital of Kigali, says mothers with HIV should be adherent on treatment before, during and after delivery in order to reduce the viral load. “The less the number of viruses, the less the mother is likely to infect the baby. Ideally, the viral load should be undetectable, but after delivery the mother should continue taking her medication as well as giving prophylactic medication (Nevirapine) to the baby for the six weeks recommended. She should also visit a health centre every two weeks for weighing the baby since doses are weight dependent,” he says. According to World Health Organisation, women living with HIV are advised to exclusively breastfeed (rather than mixed feeding), provided that they are on ART. This is because, while formula feeding offers the safest option for postnatal HIV prevention, in resource poor settings, it is not always easy for families to afford formula or access things such as clean water which is needed when mixing the babies’ milk. Muganda enlightens that the WHO stage of assessment is necessary since the doctors assess the HIV-positive woman to see whether her immune system is low and help fix all the problems, as well as give necessary advice before pregnancy. “Gynecologists also test the CD4 cells first; if it is high (above 350) then it is good, but if it is below 350, then the viral load in the blood is high, thus an increased risk of transmission of the virus to the baby,” he says. He however says that, if the woman is assessed when she is already pregnant and found that she is infected, she should start the treatment immediately and if they respond well to the treatment, the CD4 cells will increase and thus higher chances of the fetus not to be infected. Muganda advises husbands of infected women to also be treated and if he is tolerating the treatment. The couple should have protected sex as well, he adds. He calls upon couples to do thorough continuous check-ups together because a woman can get infected in the course of the pregnancy or when she is breastfeeding which is dangerous to the baby. The rate of mother-to-child transmission is less than 2 per cent in Rwanda.