AFRO-NETS> Mother to Child Transmission Plus

[Janet Feldman <kaippg@earthlink.net>]

Mother to Child Transmission Plus
---------------------------------
 
Presented at the Elizabeth Glaser Paediatric AIDS Foundation Con-
ference in Cape Town, South Africa, August 2003
 
MOTHER TO CHILD TRANSMISSION PLUS
 
Ashok Rau Executive Trustee/CEO 
The Freedom Foundation - India 
Head Office: Bangalore- India
mailto:freedom@bgl.vsnl.net.in
 
In India, perinatal transmission is a cause for concern as one in 
every four infected persons is a woman. As per NACO (National 
Aids Control Organisation) surveillance statistics, States with 
high sero-positivity, increasing numbers of women attending ante-
natal clinics are testing positive for HIV. Perinatal transmis-
sion accounts for 2.04 percent of all HIV infections in India. 
Infection rates among pregnant women also show considerable 
variation ranging from 0 to 2.6 percent. In 2002 certain pockets 
in South India there have (2002) reported antenatal infection 
rates as high as 9.9 percent.
 
A rights-based approach to preventing mother to child transmis-
sion of HIV is unique for several reasons. First, in a developing 
country like India this approach is particularly important at 
this juncture as the rights of women have been ignored tradition-
ally. Contextually the rights of a HIV+ve mother have also been 
systematically negated throughout the epidemic. While there have 
been some attempts to compensate for this negligence theoreti-
cally in literature, it is still not the practice in most devel-
oping regions in the world, by and large the rights of the foetus 
have been prioritised over the mother's in the context of perina-
tal transmission.
 
Second, India and other developing countries have had a poor 
track record of a social justice system leading to inadequate so-
cietal infrastructure to accommodate and systematically address 
issues of poverty, gender disparity and inequality.
 
At the present rate of transmission of MTCT globally it is im-
perative that we present a strong argument for protecting and 
promoting the rights of all the people in the child's life, in-
cluding the mother, her partner and any other breadwinner or 
caretakers, whose well being will enable the fulfilment of both 
the mother's and the child's development needs and rights. This 
need has been further demonstrated by the kind of crises some Af-
rican countries are confronted with regarding the issue of HIV+ve 
orphaned children. India and other developing countries will soon 
have a similar fallout, if the issue of MTCT is not holistically 
addressed.
 
Third, the emphasis is now on technology driven rights which 
means the focus is on increasing access to information and tech-
nologies that develop as science progresses, this thus enhances 
the ability of survival and wellbeing of both the mother and 
child. Women's lack of access to information, education and 
knowledge from an early age is an important factor in their vul-
nerability to HIV infection as well as their inability to demand 
their rights to new and developing technologies; any form of dep-
rivation or non inclusion of these issues in any MTCT programme 
can and will be constituted as a violation of fundamental rights 
of the mother and child. Though I have raised these issues in the 
Indian context, it is applicable contextually for all developing 
countries, especially countries in Africa, where percentages are 
staggering.
 
A paradigm shift is required to reduce perinatal transmission, 
one that moves from the clinical approach to a framework of em-
powerment and social justice. This will entail promoting the 
health and education of girls and women throughout their life 
span rather than simply during pregnancy and childbirth, such 
that they can make informed choices with regard to their health 
at every stage of development.
 
As a matter of clinical perspective, we all know that mother to 
child transmission (MTCT) can occur in three ways: during preg-
nancy, during labour and delivery or after childbirth, through 
breast-feeding. Before the effect of antiretroviral (ARV) therapy 
in reducing the risk of vertical transmission was known, termina-
tion of pregnancy among HIV positive women was the only means to 
curtail the spread of the HIV epidemic among infants and chil-
dren. In the absence of any intervention measures, the risk of 
vertical transmission is between 25 and 35 percent. Administra-
tion of ARV therapy is known to have reduced the risk of infec-
tion to the child by over 90 percent. In addition, changes in de-
livery practices, such as performing caesarean sections, and al-
tering infant feeding patterns, namely, discouraging breast feed-
ing also reduce the risk of transmission from mother to child.
 
Along with a discussion on abortion, we need to examine the ethi-
cal issues around testing and treatment of HIV positive pregnant 
women. The discussion on testing revolves around three approaches 
i.e. mandatory testing, routine screening and voluntary counsel-
ling and testing and the human rights implications of each. De-
spite resource constraints, it is critical to obtain the informed 
consent of pregnant women and it is essential for the health care 
institution to maintain confidentiality of test results. The is-
sue of treatment raises questions about how long medicines must 
be provided in order to protect the rights of both the mother and 
the child. Recognising that it is important not to pit the rights 
of the child against the rights of the mother, providing treat-
ment not only to the mother but also other breadwinners and care-
takers in the family and increasing their longevity, will also 
improve the health and well being of the child, we need to keep 
in mind that in the long run "care and support will mitigate 
prevention". Again, although infrastructure and resource con-
straints are likely to affect treatment decision-making in the 
context of India and other developing countries, emphasis must be 
placed on promoting the spectrum of rights that work concurrently 
to ensure the rights of the mother, the child and other family 
members.
 
In India and other developing countries, the need to addresses 
the alternatives available to breast feeding given the potential 
of transmitting HIV through breast milk, could be clinically es-
sential, but cultural and traditional dictates apart from eco-
nomical constraints pose major challenges. While some contend 
that it is unethical to feed babies with milk infected with HIV, 
others argue that breast feeding recommendations for HIV positive 
women in developing countries must balance the risk of HIV trans-
mission with the well known nutritional and health benefits of 
breast feeding, particularly where access to clean and safe 
drinking water and affordable substitutes is limited. Ultimately, 
adherence to human rights principles and respect for women's 
right to self determination would imply that the decision whether 
to breast feed or not must be left to each mother once she has 
been informed about the potential risks and benefits of both.
 
Finally we need to discuss policy measures that have been imple-
mented around the world to reduce MTCT. However, it is clear that 
the prevention of perinatal transmission requires far more than 
simply access to clinical measures to reduce the risk of trans-
mission to the child. A comprehensive response to MTCT must ad-
dress shortcomings in the larger health systems that impair a 
person's access to information, education, treatment and long-
term care. In addition, the experience of discrimination that HIV 
positive pregnant women face in the health system in most devel-
oping countries contributes extensively to their lack of access 
to appropriate and adequate prenatal services. The most persua-
sive argument in favour of a comprehensive MTCT plus programme, 
which includes routine counselling, provision of voluntary test-
ing and ARVs to the mother and to the child after birth and dur-
ing post natal care, is purely economic; it would cost any coun-
try or state considerably less to implement a MTCT plus programme 
than the lifetime medical, social and economic costs by failing 
to implement such a programme.
 
We believe that we have a small window of opportunity on prevent-
ing unintended infections of HIV from our women and our children. 
We must learn from our children in Africa. It is time to listen, 
to see and acknowledge our mistakes. We must accept that we have 
a moral and ethical responsibility to save our women and chil-
dren, the survival of our communities depends on us having the 
humility to accept this responsibility. The ICASA Conference, the 
Orphan care Conference and other forums in the region, might be 
the initial platforms for raising these issues, we must now sound 
loud and clear on this note. If action is the magic word, then, 
WE MUST ACT NOW!! 

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