Despite many efforts, the knowledge of pregnant women on mother-to-child transmission of HIV is low. By receiving information on HIV from health care providers while pregnant women attend antenatal care, they are more likely to be knowledgeable on MTCT of HIV. Strengthening women education and by reaching previously inaccessible parts of the community, integration of HIV, prevention of MTCT, and ANC service, is highly recommended. Moreover, strengthening discussion of MTCT with community health practitioners, especially those who execute the Primary Health Care Services is important. Primary Health Care workers will find more interest in their work if they continue learning after qualifying and continue developing their skills. Continued learning may be achieved through refresher course, in-service training course and internet education study.
The HIV and AIDS pandemic is one of the most serious health crises in the world. an estimated 78 million people have become infected with HIV and 35 million people have died from AIDS-related illnesses since the start of the epidemic and end in 2015. In 2015 only, there were 36.7 million [34.0 million–39.8 million] people living with HIV, while at the end of 2015, 1.1 million people died from AIDS-related causes worldwide, compared to 2 million in 2005. It is assuming that passing HIV microbe from infected mother-to-child is 15% to 45%. Therefore when there is PMTCT interventions, it can reduce this risk to below 5%.
Before the introduction and implementation of PMTCT, Mother—to—child transmission (MTCT) of HIV is a major public health challenge, and maternal knowledge on HIV transmission during pregnancy and its prevention is important in reducing childhood HIV acquisition. It is up to one point six million children who are newly infected with HIV and which have been prevented since 1995 due to the establishment of PMTCT services. Of these, 1.3 million are estimated to have been averted in the five years, between 2010 and 2015.
Despite the difference significant progress in PMTC, in 2015 23% of pregnant women living with HIV did not have access to ARVs and 150,000 children (400 children a day) became infected with HIV.
Mother-To-Child-Transmission (MTCT) is the transmission of HIV virus from an infected woman to her unborn child during pregnancy, delivery and breastfeeding. Vertical transmission of HIV occurs when an infected mother’s blood mixes with that of the baby during vaginal delivery (Kourtis et al., 2006; Adogu et al., 2013). 25-35% of breastfed infants born to infected women will be infected.
Abiodun et al., (2007) reiterated that there are cases of Mother-To-Child–Transmission of HIV/ AIDS despite the effort in implementing PMTCT. Mothers are still lacking knowledge about MTCT especially transmission through breastfeeding. Only 10% of 100 pregnant women had knowledge regarding mother to child transmission of HIV/AIDS, 13% of pregnant women knew that breastfeeding while suffering from HIV/AIDS may put the baby at risk of contracting the virus (Maputle, 2008)
Risk of transmission without interventions
Without intervention (ARV prophylaxis or treatment) up to 40% of infants born to mothers infected with HIV can become HIV-infected.
Among the 40 (out of 100) that become infected, 5 to 10 are infected during pregnancy, 15 during labour and delivery, and 5 to 15 during breastfeeding.
Risk factors for transmission:
A great deal is known about specific factors that may put a woman at higher risk of transmitting HIV to her baby. These factors might be related to mother, infant, or the type of virus. These risk factors could be present during pregnancy, labour and delivery, and breastfeeding.
- The most important risk factor for MTCT is the amount of HIV virus in the mother’s blood, known as the viral load. The risk of transmission to the baby is greatest when the maternal viral load is high, which is often the case with recent HIV infection or advanced HIV and AIDS.
- Mixed feeding is also an important risk factor. Artificial feeding increases the risk of intestinal illness and a weakened intestine associated with (contaminated) breast milk increases the chances of HIV crossing the intestinal barrier.
The intrapartum risk of MTCT is multi factorial involving viral, maternal, placental and foetal factors as well as the delivery process.
- Viral factors:
- Viral load. The higher the viraemia the higher the risk of transmission
- Presence of resistance to antiretroviral drugs.
- Transmission rates are higher with HIV 1 than HIV 2 infection.
- Maternal factors: The following maternal factors positively influence MTCT.
- Maternal immune deficiency.
- Symptomatic disease in the mother
- Poor nutritional status of the mother.
- Presence of sexually transmitted infections and other genital ulcers during labour.
- Placental factors: disruption from any cause increases the chance of feto-maternal transfusion thereby increasing the risk of HIV infection.
- Intra partum Haemorrhage
- Obstetric factors:
- Vaginal delivery
- Invasive obstetric procedures during labour like External Cephalic Version, foetal scalp electrodes and foetal blood sampling.
- Instrumental deliveries like vacuum extraction or forceps.
- Prolonged duration of rupture of foetal membranes (4 hours and above).
- Prolonged labour
- Episiotomy and lacerations.
- First born of multiple pregnancies.
- Foetal factors:
- Prematurity (Preterm birth)
- Foetal genetic characteristics
Prevention of Mother-to-Child Transmission of HIV
One of the goals of the June 2001 Declaration of Commitment of the United Nations General Assembly Special Session on HIV and AIDS (UNGASS) is to reduce the proportion of infants infected with HIV by 20% by 2005 and 50% by 2010. In the 2003 AIDS Policy, the Nigerian national goal for PMTCT is to reduce the transmission of the HIV through MTCT by 50% by the year 2010 and to increase access to quality HIV counselling and testing services by 50% by the same year. To achieve this goal, a comprehensive four pronged strategy to prevent HIV infection among infants and young children has been developed, which promotes implementation in an integrated manner within the health care delivery system. These strategies are:
- Primary prevention of HIV infection in women of reproductive age group and their partners.
- Prevention of unintended pregnancies among HIV positive women.
- Prevention of HIV transmission from HIV infected mothers to their children.
- Care and support for HIV infected mothers, their infants and family members.
Strategy 1: Primary prevention of HIV infection in women of reproductive age group and their partners
The best way to prevent HIV infection in children through mother-to-child transmission, including transmission through breastmilk, is to prevent HIV infection of parents-to-be. About 70% of the global HIV burden is borne by sub-Saharan Africa, where the main mode of HIV transmission is heterosexual contact.
The following factors are known to increase the risk of HIV infection in women:
- Multiple sex partners
- Immaturity of the genital tract
- Vaginal ectopy
- Sexually transmitted infections (STIs)
- Poor nutritional status
Other factors contributing to women’s vulnerability to HIV include:
- Lack of information
- Sexual relationships with men who have multiple sex partners
Primary prevention strategies include the following components:
- Safer and responsible sexual behaviour and practices
- Delaying the onset of sexual activity until marriage
- Practicing abstinence
- Reducing the number of sexual partners
- Using condoms
This approach has come to be known as the “ABC” approach:
A = Abstinence – Refrain from having sexual intercourse
B = Be faithful – Be faithful to one partner
C = Condom use – Use condoms correctly and consistently
Recent reports of increasing new HIV infections transmitted from husbands to wives indicate a continued need to educate people about safer sex practices and other behaviour changes. For example, being faithful to one partner not infected with HIV is a risk reduction behaviour that has been proven to be significant in slowing the spread of HIV infection.
Behaviour change communication (BCC) efforts aim to change the behaviours that place individuals at risk for becoming HIV-infected or spreading HIV infection. BCC recognises that behaviour change is not simply a matter of increased knowledge; many factors, including family, church, and community influence change. BCC attempts to create household, community, and health facility environments in which individuals can modify their behaviour to decrease risk.
Especially among young women, the successful implementation of “ABC” outlined above may require support from organised programmes. Healthcare workers can help women address these challenges through education and community linkages.
Condoms can help prevent HIV transmission when used correctly and consistently, especially in high-risk settings. Programmes that promote condom use for HIV prevention should also focus on condom use for PMTCT.
- Provision of early diagnosis and treatment of STIs
The early diagnosis and treatment of STIs can reduce the incidence of HIV in the general population by about 40%. STI treatment services present an opportunity to provide information on HIV infection, MTCT, and referral for testing and counselling.
- Making HIV testing and counselling widely available
HIV testing and counselling services need to be made available to all women of childbearing age because PMTCT interventions depend on a woman knowing her HIV status.
- Provision of suitable counselling for women who are HIV-negative
Counselling provides an opportunity for a woman who is HIV-negative to better understand how to protect herself and her infant from HIV infection. It can also serve as powerful motivation to adopt safer sex practices, encourage partner testing, and discuss family planning.
Strategy 2: Prevention of unintended pregnancies among HIV-positive women
It is every woman’s fundamental right to decide for herself, without coercion, whether or not to have children. The responsibility of the government and health services is to provide HIV-positive women and their partners with comprehensive information and education about the risks associated with childbearing. This should be part of routine information about HIV and AIDS, to ensure that HIV-positive women and their partners have real choices of action, and to respect and support the decisions they reach. This means:
- Providing good quality, user-friendly, and easily accessible family planning services so that HIV-positive women can avoid pregnancy if they choose
- Promoting condom use, either alone or combined with a more effective method of contraception (dual method) for dual protection from HIV and other STIs and from unplanned pregnancy as an effective strategy to prevent HIV infection in all sexually active women
- Integrating dual protection messages into family planning counselling services
- Offering contraception to replace the birth-spacing effect of breastfeeding in women who choose replacement feeding because of their HIV infection
In many countries in sub-Saharan Africa, bearing healthy children provides social status and access to family resources. These accesses are denied to women whose HIV-infected children fail-to-thrive and die. To that extent, interventions to reduce HIV transmission from mother-to-child can help a woman consolidate her social position, despite her HIV infection.
Strategy 3: Prevention of HIV transmission from women infected with HIV to their infants
Specific interventions to reduce HIV transmission from an infected woman to her child include:
- HIV testing and counselling
- Antiretroviral prophylaxis and treatment
- Safer delivery practices
- Infant-feeding counselling for safer infant-feeding practices
When an ARV drug is given to mother and infant to prevent MTCT, it is referred to as ARV prophylaxis.
How do these interventions work?
- Identify women infected with HIV.
- Reduce maternal viral load.
- Curtail infant exposure to the virus during labour and delivery.
- Curtail infant exposure to the virus through safer feeding options.
In industrialised countries where women infected with HIV receive triple drug ARV therapy and do not breastfeed—and where elective caesarean sections are safe, feasible, accessible and commonly performed—the rate of MTCT has been reduced to about 2%.
ARV prophylaxis can reduce MTCT by 40–70%. The impact is greater (closer to 70%) when women do not breastfeed, because current ARV prophylactic regimens only prevent HIV transmission during late pregnancy and labour and delivery.
Testing and counselling of pregnant women
In Nigeria, the high fertility rate, the premium placed on children as objects of parental hope for future survival, and the acceptance of antenatal care, enhance the cultural endorsement of testing and counseling for PMTCT of HIV in antenatal settings. The aim of testing and counselling is to help the woman take necessary action to ensure that she does not become infected with HIV. However, if she is already infected, the aim is to help her protect her own health, the health of the unborn child, of her sex partner and of her family.
ARV prophylaxis to mother-child pair
ARV prophylaxis given to a pregnant woman who is HIV-infected does not confer long-term benefits to the woman herself. Pregnant women with advanced HIV infection require combination ARV treatment to reduce the risk of AIDS-related illnesses. As treatment becomes more available, there should be integration between prophylaxis and treatment services.
Several potent regimens, either as monotherapy or combination therapy are currently in use as ARV prophylaxis. These regimens are discussed in detail in module 4.
Modification of obstetric practices
(i) Modification of routine obstetric practices for all women:
Recognition of HIV infection in pregnant women is the key to the prevention of childhood HIV infection. Issues of access to and affordability of antenatal care are crucial and must be addressed if interventions are to make any significant impact. All doctors, midwives and community healthcare workers who attend to pregnant women should be trained in HIV and PMTCT testing and counselling to effectively include HIV antibody testing among the routine booking investigations. Rapid test kits should always be available for free HIV testing. In resource-constrained settings, the introduction of any fee, no matter how small, will prevent many willing patients from determining their HIV status. Syndromic management of STIs in the antenatal setting should be strengthened. Iron and folic acid supplementation, tetanus and malaria prophylaxis should be given to all pregnant women irrespective of their HIV status.
(ii) Specific modification of obstetric care for HIV positive women:
All HIV-positive women should be given optimal health care to ensure a safe delivery. An HIV-positive woman identified in pregnancy should have a full physical examination with focus on HIV-related symptoms and illnesses and signs of opportunistic infections especially tuberculosis (TB).
In addition, apart from the routine laboratory investigations conducted on all pregnant women, other investigations for HIV-positive women should include FBC, CD4 count LFT’s, Renal function test, Lipid profile and Viral load. Details of management considerations for HIV-positive women are addressed in module 4.
Invasive procedures such as chorionic villus sampling, amniocentesis and cordocentesis should be avoided. External cephalic version should be avoided as it may also increase the risk of HIV transmission to the foetus.
Where CS is performed (either elective or emergency) in HIV-positive women, they should receive prophylactic antibiotics. If CS is performed after prolonged labour or prolonged ROM, longer courses of antibiotics should be considered.
Modification of infant feeding practices and support for mother’s choice
Breastfeeding is an important route of HIV transmission from mother-to-child. HIV-positive mothers should be counselled about this risk and where possible should try to avoid or limit breastfeeding. For HIV-negative mothers or mothers with unknown HIV status, exclusive breastfeeding remains the best infant-feeding choice.
In the context of PMTCT of HIV, the challenge is to strengthen and support mothers and partners to make breast milk substitutes acceptable, feasible, affordable, sustainable and safe (AFASS). Much as it is important to respect and support HIV-positive mothers in their decisions regarding infant feeding, they should be well-informed about the various feeding options available to prevent their infants from becoming infected through breastfeeding. (See Module 5)
Strategy 4: Provision of treatment, care, and support to women infected with HIV, their infants, and their families
Programmes for the prevention of HIV in infants and young children will identify large numbers of women infected with HIV who will need special attention. Medical care and social support are important for women living with HIV and AIDS to address concerns about both their own health and the health and future of their children and families.
If a woman is assured that she will receive adequate treatment and care for herself, her children, and her partner, she is more likely to accept HIV testing and counselling and, if HIV-positive, interventions to reduce MTCT.
It is important to develop and reinforce linkages with programmes for treatment, care, and support services to promote long-term care of women who are HIV-infected and their families.
HIV-related treatment, care, and support services for women
Services for women include the following:
- Prevention and treatment of opportunistic infections
- ARV treatment
- Treatment of symptoms
- Nutritional support
- Reproductive health care, including family planning, cervical screening, and counselling
- Psychosocial and community support
- Palliative care
Care and support of the infant and child who are HIV-exposed
Infants and children who are HIV-exposed require regular follow-up care, especially during the first 2 years of life, including immunisations, HIV testing, and ongoing monitoring of feeding, growth, and development
Children whose mothers are infected with HIV are at higher risk than other children for illness and malnutrition for many reasons:
- They may be infected with HIV and become ill, even when adequate health care and nutrition are provided.
- Those who receive replacement feeding lack the protective benefits of breastfeeding against diarrhoeal diseases, respiratory infections, and other complications.
- If the mother is ill, she may have difficulty caring for the children adequately.
- Families may be economically vulnerable due to AIDS-related illnesses and deaths among adult relatives.
Knowledge Attitudes and Practice of Health Workers:
Internationally, studies evaluating attitudes of health care providers toward HIV/AIDS patients have suggested that current negative attitudes of health care workers toward people with HIV—compounded by fear of infection in the workplace, perceptions of risk, and lack of understanding of HIV—perpetuate the prevalence and manifestation of stigma toward this population (Chen et al., 2004; Juan et al., 2004; Quach et al., 2005; Reis et al., 2005). For example, a study examining discriminatory attitudes and practices by health care workers in Nigeria found that providers inadequately trained in HIV/AIDS care and ethics were more likely to agree that it was acceptable to refuse treatment to infected patients and were more likely to have done so (Reis et al., 2005).
HIV/AIDS-related stigma has been recognized as one of the largest challenges to improving HIV/AIDS care around the world. Studies suggest that provider stigma may be affecting the quality of care and patient decisions to seek health care services. (Juan et al., 2004) One study shows that discriminatory behavior and stigma toward them do exist and may be attributable to poor HIV/AIDS-related knowledge and high perceived risk of infection (Quach et al., 2005)
Stigma has been defined as “… a real or perceived negative response to a person or persons by individuals, community or society…[that] is characterized by rejection, denial, discrediting, disregarding, underrating and social distance” (Reis et al., 2005)
HIV-related stigma and discrimination defined as: a process of devaluation that significantly discredits an individual either living with or associated with HIV/AIDS (The Joint United Nations Programme on HIV/AIDS, 2011). Delivery for HIV positive women were refused by 62% of the doctors and 80% of the patients were referred to other institutions. People living with HIV were experienced that 88% of the doctors refused to conduct surgery and 85% of doctors were also accepted about rejection of surgery. Only 3% of doctors accepted that they had performed surgeries/Invasive procedure for HIV patients. We recommend that seminars, workshops should be organized on a continuous basis for health care workers on universal precautions, stigma and discrimination reduction. The institution should also make available materials needed to protect workers against the risk of acquiring pathogenic infection in the course of providing health services to their patients. (Jeevitha et al., 2013)
Benefits of Prevention of Mother to Child Transmission of HIV:
In some parts of sub-Saharan Africa without any interventions most children that acquired HIV through MTCT die within the first two years of life. The increasing number of AIDS-related deaths in under- fives in Nigeria may reverse the gains made in child survival. The cost of care and support for HIV infected children places heavy financial burden on families, communities and the health care system.
PMTCT of HIV benefits the mother, infant, family, community and the health system.
Benefits to the Mother
- Identifies HIV positive mothers for targeted interventions to reduce risk of
transmission of infection to their babies and to access care and support services
- Promotes positive behaviour change
- Reduces HIV risk behaviour
- Increases use of dual protection methods of family planning and STI prevention
- Helps to plan for the future
- Promotes Infant feeding support system
- Promotes access to early preventive and medical care
- Helps personal and financial decision making
Benefits to the Infant
- Decreases numbers of HIV infected infants
- Promotes early diagnosis and intervention for the HIV exposed infants
- Improves child health and survival
Benefits to the Family
- Promotes communication between couples and testing of both partners
- Provides opportunity for testing other family members
- Contributes to reduction of stigma and discrimination
- Helps to plan for the future
- Provides infant feeding support system
Benefits to the community
- Promotes the understanding and acceptance of the HIV and AIDS epidemic and those living with HIV and AIDS
- Promotes uptake of risk reduction practices leading to reduction in the incidence of HIV
- Promotes acceptance and uptake of HIV testing and counselling
- Contributes to reduction of stigma and discrimination
- Helps to plan for the future
- Provides infant feeding support system
Benefits to the health system
- Decreases the disease burden on the health system
- Gives an opportunity to strengthen the health system.
Mother and Child
The healthcare providers had deficient knowledge and practice of PMTCT and still had gaps in certain areas. In Primary Health Care setting, most of the health care providers could not correctly answer the four pillars of PMTCT. And they are poorly informed on practical issues in the prevention of MTCT of HIV. They are therefore handicapped to play an effective role in this important aspect of prevention of mother to child transmission of HIV. Their attitude was fairly appropriate. There is need for improved knowledge through structured educational intervention. Resources needed for practice should always be made available and the environment should be much more conducive for practice. Most of these healthcare providers willingness to update their knowledge and improve their knowledge and improve their attitude and practice of PMTCT.
Bajunirwe F, Muzoora M (2005). Barriers to the implementation of programs for the prevention of mother-to-child transmission of HIV: A cross-sectional survey in rural and urban Uganda. BioMed Central Health Services Research 2(10). Accessed from http://www.aidsrestherapy.com/content/2/1/10 on 30/11/2011.
Brunner Suddarth (2008): Textbook of Medical-Surgical Nursing; Eleventh Edition.
Chen WT, Han M, and Holzemer WL (2004): Nurses’ knowledge, attitudes, and practice related to HIV transmission in northeastern China. AIDS Patients Care and STDs 18 (7):417– 422.
Cambridge University Press (2005): Advance learner. Dictionary 2nd edition. Mobile Systems Version 2.11. Visit: www.mobi.system.com
De Cock KM, Fowler MG, Mercier E, de Vincenzi I, Saba J, Hoff E (2000). Prevention of mother-to-child HIV transmission in resource-poor countries: translating research into policy and practice. Journal of American Medical Association. 283(9):1175-82.
Druce N, Nolan A(2007). Seizing the big missed opportunity: linking HIV and maternity care services in sub-Saharan Africa. Reproductive Health Matters.15 (30):201-203.
Doherty TM, McCoy D, Donohue S (2005). Health system constraints to optimal coverage of the prevention of mother-to-child HIV transmission programme in South Africa: lessons from the implementation of the national pilot programme. Africa. Health Science. 5 (3): 213- 218.