World AIDS Day 2012

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This year, World AIDS Day (01 December) continues last year’s theme of "Getting to zero” - zero new HIV infections, zero discrimination, zero AIDS related deaths. It is a formidable goal, but one that may indeed be possible to achieve.

About 330,000 children became infected with HIV in 2011, more than 900 children each day.[1] Virtually all of these infections occurred in low- and middle-income countries, especially in sub-Saharan Africa and in countries such as India, where the HIV epidemic’s impact has been profound. When a pregnant woman has HIV, she may transmit this infection to her unborn child. Even if her child does not have HIV at birth, the baby is at risk of infection through the mother’s breastmilk. The amount of HIV in the mother’s bloodstream (viral load) is a key variable in the child’s risk of becoming infected.

While 330,000 is a huge and unacceptable number, it is still about 25% fewer child infections than occurred in 2009 and 43% fewer than occurred in 2003. The world has entered a critical period in which there is the very real possibility of eliminating all new mother-to-child HIV transmission within the next few years, as well as keeping HIV-infected mothers alive.[2] In addition to rapid improvement in access to services that prevent mother-to-child transmission of HIV (PMTCT), the World Health Organization (WHO)’s 2010 PMTCT guidelines (largely informed by reviews prepared by the Cochrane HIV/AIDS Group), introduced more effective options for preventing transmission from mothers to babies. Following the publication of these guidelines, a new option emerged, which is to provide lifelong antiretroviral therapy (ART) to all HIV-infected pregnant women, regardless of whether they are clinically eligible, or how well they seem. ART has recently been shown to interrupt HIV transmission by as much as 96%.[3] Many countries have already adopted this approach to treating HIV-infected pregnant women.

The WHO is in the process of developing new consolidated guidelines for ART, which will include all WHO guidance relevant to the use of antiretroviral medicines for HIV prevention and treatment. The consolidated guidelines will incorporate technical, programmatic and operational guidance for PMTCT; HIV and tuberculosis; ART for adolescents and adults; paediatric ART; and health services integration and delivery. The Cochrane HIV/AIDS Group has worked closely with WHO throughout 2012 in preparing numerous systematic reviews and GRADE evidence profiles to inform these guidelines. The new guidelines are expected to be released in mid-2013.

Eliminating new cases of HIV in children will take a great deal of committed funding and political leadership, as well as human resources for health, improved programme synergies, and coordinated approaches to HIV prevention and treatment. However, there is reason to be hopeful.

Introduction written by Ms Tara Horvath (co-Managing Editor, Cochrane HIV/AIDS Group).

The Cochrane HIV/AIDS group has selected a number of recent Cochrane Reviews investigating measures to prevent mother-to-child transmission of HIV infection, with the goal of zero new HIV infections in newborns and young children.

Interventions to prevent mother-child transmission of HIV infection

Antiretroviral therapy (ART) for treating HIV infection in ART-eligible pregnant women
Mother-to-child transmission (MTCT) is the primary means by which children worldwide acquire HIV infection. MTCT occurs during three major timepoints during pregnancy and the postpartum period: in utero, intrapartum, and during breastfeeding. Strategies to reduce MTCT focus on these periods of exposure and include maternal and infant use of ART, caesarean section before onset of labour or rupture of membranes, and complete avoidance of breastfeeding. Where these combined interventions are available, the risk of MTCT is as low as 1-2%. Thus, ART used among mothers who require treatment of HIV for their own health also plays a significant role in decreasing MTCT. This review assesses the current literature regarding the treatment of HIV infection in pregnant women who are clinically or immunologically eligible for ART. It evaluates the optimal time to start therapy in relation to the woman’s laboratory parameters and/or gestational age. It also includes an analysis of which specific antiretroviral medications to start in women who are not yet on ART and which agents to continue in women who are already on ART.

Antiretrovirals for reducing the risk of mother-to-child transmission of HIV infection
Antiretroviral drugs reduce viral replication and can reduce mother-to-child transmission of HIV either by lowering plasma viral load in pregnant women or through post-exposure prophylaxis in their newborns. In rich countries, highly active antiretroviral therapy (HAART) which usually comprises three drugs, has reduced the mother-to-child transmission rates to around 1-2%, but HAART is not always available in low- and middle-income countries. In these countries, various simpler and less costly antiretroviral regimens have been offered to pregnant women or to their newborn babies, or to both. This review examines whether, and to what extent, antiretroviral regimens aimed at decreasing the risk of mother-to-child transmission of HIV infection achieve a clinically useful decrease in transmission risk, and what effect these interventions have on maternal and infant mortality and morbidity.

Efficacy and safety of cesarean delivery for prevention of mother-to-child transmission of HIV-1
Cesarean section before labor and before ruptured membranes ("elective cesarean section", or ECS) has been introduced as an intervention for the prevention of mother-to-child transmission (MTCT) of HIV-1. The role of mode of delivery in the management of HIV-1-infected women should be assessed in light of risks as well as benefits, since HIV-1-infected pregnant women must be provided with available information with which to make informed decisions regarding cesarean section and other options to prevent transmission of infection to their children. The review aims to assess the efficacy (for prevention of MTCT of HIV-1) and the safety of ECS among HIV-1-infected women.

Vaginal disinfection for preventing mother-to-child transmission of HIV infection
This review aims to estimate the effect of vaginal disinfection on the risk of MTCT of HIV and infant and maternal mortality and morbidity, as well as tolerability of vaginal disinfection in HIV-infected women.

Interventions for preventing late postnatal mother-to-child transmission of HIV
A large proportion of MTCT of HIV occurs postnatally, through breast milk transmission. This review aims to collate and assess the evidence regarding interventions to decrease late postnatal MTCT of HIV, and to determine the efficacy of such interventions in decreasing late postnatal MTCT of HIV, increasing overall survival, and increasing HIV-free survival.

Integrating prevention of mother-to-child HIV transmission (PMTCT) programmes with other health services for preventing HIV infection and improving HIV outcomes in developing countries
In high-income countries, the mother-to-child (MTCT) rate is less than 1% through perinatal prevention of mother-to-child HIV transmission (PMTCT) interventions. In low- and middle-income countries, PMTCT programme coverage remains low and consequently transmission rate high. The World Health Organisation recommends integration of PMTCT programmes with other healthcare services to increase access and improve uptake of these interventions. This review assesses the effect of integration of perinatal PMTCT measures with other health care services on coverage and service uptake compared to stand-alone PMTCT programmes and healthcare services or partially integrated PMTCT interventions.

Male involvement for increasing the effectiveness of prevention of mother-to-child HIV transmission (PMTCT) programmes
Despite efforts to increase the uptake of prevention of mother to child transmission of HIV (PMTCT) services, coverage is still lower than desired in developing countries. A lack of male partner involvement in PMTCT services is a major barrier for women to access these services. This review examines the impact of interventions which aim to enhance male involvement to increase women’s uptake of PMTCT interventions in developing countries.

Vitamin A supplementation for reducing the risk of mother-to-child transmission of HIV infection
Observational studies of pregnant women in sub-Saharan Africa have shown that low serum vitamin A levels are associated with an increased risk of mother-to-child transmission (MTCT) of HIV. Vitamin A is cheap and easily provided through existing health services in low-income settings. It is thus important to determine the effect of routine supplementation of HIV positive pregnant or breastfeeding women with this vitamin on the risk of MTCT of HIV, which currently results in more than 1000 new HIV infections each day world-wide. This review aims to assess the effect of antenatal and or postpartum vitamin A supplementation on the risk of MTCT of HIV as well as infant and maternal mortality and morbidity.


Acknowledgements: Ms Tara Horvath (co-Managing Editor Cochrane Group) for drafting the text and supplying the list of reviews; and the Cochrane HIV/AIDS Group for comments and edits.

References

1. Joint United Nations Programme on HIV/AIDS (UNAIDS). Report on the global AIDS epidemic, 2012. Available at  http://www.unaids.org/en/media/unaids/contentassets/documents/epidemiology/2012/gr2012/20121120_UNAIDS_Global_Report_2012_en.pdf (accessed 28 November 2012).

2. UNAIDS. Countdown to Zero: The Global Plan towards the elimination of new infections among children by 2015 and keeping their mothers alive. Available at http://www.unaids.org/en/media/unaids/contentassets/documents/unaidspublication/2011/20110609_JC2137_Global-Plan-Elimination-HIV-Children_en.pdf (accessed 28 November 2012)

3. Anglemyer A, Rutherford GW, Baggaley RC, Egger M, Siegfried N. Antiretroviral therapy for prevention of HIV transmission in HIV-discordant couples. Cochrane Database of Systematic Reviews 2011, Issue 8. Art. No.: CD009153. DOI: 10.1002/14651858.CD009153.pub2.

Image credit: Mauro Fermariello/Science Photo Library, P980/0225

Date published: 30 November 2012

Contact: Cochrane Editorial Unit (editorial-unit@cochrane.org)

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