Report on the Global HIV/AIDS epidemic

Opening new doors with counselling and testing
Once a pregnant woman knows she has HIV and agrees to an antiretroviral regimen,
she should take a full course of drugs, be counselled about options for feeding her
infant and future reproductive options, and be supported in her choice of infant feeding
and family planning method.
Starting and completing a full course of treatment, even a one-month course of
AZT, has proved difficult in the pilot projects carried out so far. Those in Cote
d'lvoire and Cape Town reported starting rates of 37-85%, and in the latter only
18% of those who started AZT completed a full one-month course. The main
explanation was that the duration of pregnancy was often underestimated and
women started their drugs too late in pregnancy. These rates are likely to improve
with the introduction of much shorter courses of antiretrovirals, such as the nevirapine regimen.
Infant feeding presents further dilemmas. Controversy surrounds the competing
risks to the infant of HIV infection and replacement feeding in areas with poor
access to sanitation, infant formula milk powder and education. Another dilemma,
in countries where breastfeeding goes on in public, is that women and others in this
setting may come to associate replacement feeding with being HIV-infected.
Probably because of different perceptions about the risks of stigma and the health
risks to the child, the proportion of women who chose replacement feeding ranged
from 50% in Abidjan, Cote d'lvoire, to 60% in Botswana and 92% in Cape Town,
South Africa.
To decrease mother-to-child transmission more successfully, further information is
needed about HIV transmission and other health risks associated with various
types of infant feeding. A report from South Africa in 1999 argued for exclusive
breastfeeding; infants given "mixed feeding" appeared to have a higher risk of HIV
transmission than those given either breast milk alone or exclusive replacement
feeding. A randomized controlled trial in Kenya, which followed the children of HIVinfected women until the age of two years, reported a lower mortality rate among
those who had received replacement feeding, a difference due mainly to the higher
HIV infection rates among the breastfed infants.
The results of these relatively small and somewhat conflicting studies cannot be
regarded as final. Seven pilot projects that have been started in sub-Saharan Africa
and Central America, with the support of UNICEF and the other members of the
United Nations Interagency Task Team working on this issue (UNFPA, WHO and the
UNAIDS Secretariat), should help to optimize infant-feeding approaches. At the
same time, it is important to find ways of decreasing the risk of HIV transmission
through breast milk, as it is likely that a substantial proportion of HIV-infected
women will continue to wish to feed their infants in this way. Fortunately, at least
one clinical study is being planned to assess the efficacy of antiretroviral prophylaxis administered to infants during the breastfeeding period.
The pilot projects will also need to learn how to provide care and support, not just
for the HIV-infected mother and her infant but for the other members of her family.

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