State of the Art Articles

 

Voluntary and confidential counselling and testing

1. Ladner J., Leroy V. et al. A cohort study of factors associated with failure to Return for HIV post-test counselling in pregnant women: Kigali, Rwanda, 1992-1993.

This paper evaluates factors predicting the likelihood that pregnant women who are counselled and tested for HIV will return for HIV post-test counselling and test results. Within the context of a prospective cohort study on the impact of HIV infection on pregnancy outcome started in July 1992, HIV-1 antibody testing was offered to all pregnant women attending the antenatal clinic of the Centre Hospitalier de Kigali. Of the 1,233 women screened, it was found that the primary reason that women did not return for post-test counselling was fear of a positive HIV test result. This confirmed the need for innovative approaches for HIV testing and counselling programs as well as the need to take into account psychosocial and cultural factors associated with HIV in African populations.

2. Kassler W.J., Dillon B.A. et al. On-site, rapid HIV testing with same-day results and counselling.

As follow-up visits for results of HIV testing is poor, a new rapid HIV antibody test which offers results on the same day of the initial visit, has the potential to boost the effectiveness and efficiency of HIV counselling and testing. This paper assesses the use of rapid testing with same-day results in public clinics by using the Single Use Diagnostic System HIV-1 rapid assay for three months at an anonymous testing clinic and a sexually transmitted disease clinic in Dallas, Texas. It was found that not only did clients prefer same-day results of HIV testing, this rapid testing method yielded a substantial increase in the number of people learning their HIV status without increasing the costs or decreasing the effectiveness of counselling and testing.

3. Msellati P., Hingst G. et al. UNICEF Interim Project, Abidjan 1998-1999: Transition Phase between a Research Project and a Public Health Programme in the Prevention of the HIV-1 Transmission. Abidjan, Cote d'Ivoire, January 2000.

This first operational programme for PMTCT of HIV in Cote d'Ivoire is the basis for implementing the UNICEF pilot programme on the reduction of MTCT of HIV in Cote d'Ivoire and possibly in other French-speaking African countries. It showed that HIV testing is feasible under good conditions in antenatal care units and is well accepted by pregnant women. There is a demand for HIV testing in the community. The impact of VCCT has yet to be measured, but the pre- and post-test counselling allowed informing more than 2,000 women in six months on HIV and AIDS and disclosing their HIV serological status to them. It was found that in the urban context of Abidjan, it is feasible to develop alternatives to breastfeeding for HIV women with well organised support. Additionally, a significant number of young women under 18 are already HIV infected in Abidjan. A specific approach to the prevention of HIV and family planning is necessary for this population group.

Antiretroviral Drugs 1. Jackson B., Fleming T.R. A phase IIB randomised, controlled trial to evaluate the safety, tolerance, and HIV vertical transmission rates associated with short course Nevirapine (NVP) vs. short course Zidovudine (ZDV) in HIV-infected pregnant women and their infants in Uganda.Executive summary. HIVNET 012 Protocol Team. July 1999.

This preliminary report compares and evaluates the effect of oral Nevirapine and oral Zidovudine on the prevention of vertical transmission of HIV-1 infection in pregnant women to their infants. Several data, relevant to safety and tolerance of the regimens, such as frequency of Caesarean section, time of membrane rupture, maternal and infant baseline data and time of breastfeeding, are assessed in detail and compared by treatment. The results show the percentage of infants that were HIV-infected or had died for the ZDV and NVP groups: They were 12.2% and 8.8% at 3 days; 23.1% and 12.8% at 6-8 weeks, and 27.6% and 14.4% at 14-16 weeks. Comparing the NVP vs. ZDV regimen, both have similar low rates of adverse effects in mothers and infants. Yet, the authors suggest that a regimen of a single oral 200 mg dose of NVP given to the mother at onset of labour and a single 2mg/kg dose given to the infant within 72 hours after birth significantly reduced the risk of perinatal transmission in a breastfeeding population during the first 14 weeks of life. Since long-term toxicity for both treatments is still unknown, the continuation of follow-up of the infants should be seen as a priority for further research.

2. Expert Meeting Regarding Short Drug Regimen and Infant Feeding. Montreal, August 31, 1999.

The overview of existing studies and their results which were presented at the expert meeting on short drug regimen and infant feeding, lead to the recommendation of the five most effective regimens in breastfeeding populations, subject to prior evaluation of the given country or individual situation. Considering cost and practicability, the use of Nevirapine appears to be the regimen of choice. The need of further exploration of existing concerns regarding the risk of mitochondrial dysfunction, Steven-Johnson Syndrome or the development of resistance are discussed briefly. Infant feeding options and a list of ongoing or planned research are part of the document.

Infant Feeding and HIV

1. HIV and Infant Feeding. Guidelines for decision-makers. WHO/FRH/NUT/CHD/98.1; UNAIDS/98.3; UNICEF/PD/NUT/(J)98-1.

2. HIV and Infant Feeding. A Guide for Health Care Managers and Supervisors. WHO/FRH/NUT/CHD/98.2; UNAIDS/98.4; UNICEF/PD/NUT/(J)98-2.

3. Coutsoudis A, Pillary K, Spooner E., Kuhn L., Coovadia HM. Influence of infant-feeding patterns on early mother to child transmission of HIV-1 in Durban, South Africa: a prospective cohort study. Lancet August 1999; 354:471-76.

The possibility of HIV-transmission through breastmilk has led to widespread recommendation to avoid breastfeeding by HIV-infected women in developing countries especially in particular circumstances. This study examines three different types of feeding-exclusive breastfeeding, no breastfeeding at all, and mixed feeding-and analyses the impact of feeding-type on HIV transmission to the infant. The authors argue that despite the high risk of HIV-transmission through exclusive breastfeeding, breastfeeding still carries a significantly lower risk of transmission than mixed feeding. Policies regarding infant feeding by HIV-positive mothers need to be reviewed in this light.

4. UNAIDS. Prevention of HIV Transmission from mother to child. Strategic Options. August 1999. [ 5. De Cock K., Fowler M.G., Mercier E., Alnwick, D. et al. Prevention of mother to child transmission of HIV-1 in resource poor countries: Translating research into policy and practice. A policy statement developed collaboratively by CDC, UNAIDS, UNICEF and WHO. JAMA Vol. 283, No.9, March 1 2000.

This article reviews current knowledge concerning MTCT of HIV-1 transmission in developing countries, including through breastfeeding. Results from several completed antiretroviral and other interventions to reduce MTCT (ACTG trial, Bangkok study, Abidjan breastfeeding cohort, West-Africa study and Petra study) are summarised and presented in a table. If stratified by breastfeeding, all of these regimens have shown to reduce MTCT, leading to the conclusion that short-course ZDV or combination therapy is efficacious in reducing MTCT. A number of other interventions relevant to resource-poor settings are examined, yet have not shown efficacy. In this context, further research requirements, leading to results which should facilitate the implementation of intervention programs are discussed. The application of current research knowledge has led to impressive reduction in HIV disease, including new paediatric HIV infection, in developed countries. By contrast, increasing levels of infection, especially in children, characterise the situation in developing countries, and achievements in child survival have been erased by the HIV epidemic. The authors urge to translate the positive research findings into public health policy and practice in resource-poor settings, calling for focused efforts which could result in much public health benefit.

6. UNAIDS. Questions and answers. Mother to child transmission of HIV. Background briefs for media interviews. August 1999.

This document was prepared to assist staff in responding to questions by media and other inquiries about mother to child transmission of HIV.

7. WHO Collaborative Study Team on the Role of Breastfeeding on the Prevention of Infant Mortality. Effect of breastfeeding on infant and child mortality due to infectious diseases in less developed countries: A pooled analysis. Lancet. February 5, 2000; 355; p.451-455.

This comprehensive pooled analysis of six existing studies of the effect of not breastfeeding on risk of infant and child mortality due to infectious diseases was conducted to help policy makers determine whether or not to promote breastfeeding in areas of high HIV prevalence since breastfeeding presents both the risk of HIV transmission as well as protection against infections disease mortality. Data from studies from Brazil, the Gambia, Ghana, Pakistan, the Philippines and Senegal were pooled.

8. Paolo G. Miotti, Taha E.T. Taha et. al. HIV Transmission Through Breastfeeding: A study in Malawi. Journal of the American Medical Association (JAMA) Vol. 282, pp. 744-749. Aug. 25, 99.

This study assesses the level of risk and the timing of infant HIV-infection throughout the breastfeeding period. It was developed as a response to the need to understand the mechanisms of HIV transmission in breastmilk in order to formulate useful public health policy recommendations. Although comparison with previous studies is limited, the article analyses existing data in the context of this paper. The trend data of the present study show a higher risk of HIV transmission in the one to five-months period than after five months, but there are no data about the risk in the first month. The authors speculate that transmission rate could be substantially higher in the first month due to the high cell content of colostrum and early milk. The high early transmission rate could also be explained by the immaturity of the infants' immune system. Transmission risk due to breastfeeding remains high throughout breastfeeding time. However, any conclusions regarding early weaning and its timing should be made with great care, taking into account the risks and the benefits of breastfeeding, including the social implications for mothers avoiding to breastfeed. Other factors which may contribute to a higher HIV transmission rate, such as the degree of maternal experience with breastfeeding, confirm the need for educational efforts. This study reinforces the complexity of the issue of HIV transmission in breastmilk. Before implementing policy regarding breastfeeding, early weaning or no breastfeeding at all, a detailed risk-benefit analysis must be established.

9. Valeriane Leroy, Marie-Louise Newell et al. International multicentre pooled analysis of late postnatal mother-to-child transmission of HIV-1 infection.Lancet. 1998;352:597-600.

This study examines the risk and the timing of MTCT of HIV-1 in the late postnatal period. The findings show that the risk of late postnatal transmission is substantial for breastfed children born to HIV-1 infected mothers. In four cohorts from developing countries, late postnatal transmission occurred in 49 (5%) out of 902 children. The authors suggest that if breastfeeding had stopped at age four months, transmission would have occurred in no infant, and in three infants, if it had stopped at six months. Therefore, there is a need for policies on how best to advise HIV-1 infected mothers in developing countries about the risk of transmission through breastfeeding. Counselling of HIV infected women is needed for the decision whether to breastfeed or not to breastfeed as well about the length of breastfeeding time. The risk of HIV transmission in breastfeeding should be balanced against the effect of early weaning on infant mortality and morbidity and maternal infertility.