Table of Contents  
ORIGINAL ARTICLE
Year : 2013  |  Volume : 6  |  Issue : 2  |  Page : 179-183  

Prevention of parent to child transmission of HIV: Urgent need to be addressed


1 Department of Community Medicine, Smt. Kashibai Navale Medical College, Narhe, Maharashtra, India
2 Department of Community Medicine, MAEER's MIMER Medical College, Talegaon Dabhade (Pune), Talegaon, Pune, Maharashtra, India

Date of Web Publication10-Apr-2013

Correspondence Address:
Dhrubajyoti J Debnath
Department of Community Medicine, Smt. Kashibai Navale Medical College, Narhe, Pune - 411 041, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0975-2870.110313

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  Abstract 

Context: An estimated 430,000 children were newly infected with HIV in 2008, over 90% of them through mother-to-child transmission (MTCT). Without intervention, the risk of MTCT ranges from 20% to 45% as per the World Health Organization (WHO). Aim: To find the uptake of Prevention of Parent to Child Transmission of HIV/AIDS (PPTCT) services during pregnancy. Setting and Design: Cross-sectional study. Materials and Methods: Ethical approval and informed consent was taken. Uptake of PPTCT services by the mother was obtained in 222 pregnancies. This was compared with the HIV status of children born to them. Statistical Analysis Used: Percentages. Results: In 25.7% pregnancies, the mothers were tested for HIV. One child was born was to a mother who had tested HIV negative in pregnancy. In 50% of the mother-child pairs, both mother and child received PPTCT. Where both the mother and child received PPTCT, only 13.3% children born were HIV positive as against 40% children who were HIV positive where neither mother nor the child had received PPTCT. Conclusion: Uptake of PPTCT services was low. In countries like India where the chances of parent to child transmission of HIV are likely to be more than in developed countries due to breastfeeding practices, the uptake of PPTCT services should be maximized to decrease the burden of pediatric HIV because even a single pediatric HIV infection counts. All the pregnant women need to be voluntarily tested twice for HIV in pregnancy, in which the second test for HIV may be in late pregnancy.

Keywords: Human immunodeficiency virus, mother-to-child transmission, prevention of parent to child transmission


How to cite this article:
Debnath DJ, Javadekar SS. Prevention of parent to child transmission of HIV: Urgent need to be addressed. Med J DY Patil Univ 2013;6:179-83

How to cite this URL:
Debnath DJ, Javadekar SS. Prevention of parent to child transmission of HIV: Urgent need to be addressed. Med J DY Patil Univ [serial online] 2013 [cited 2019 Jul 17];6:179-83. Available from: http://www.mjdrdypu.org/text.asp?2013/6/2/179/110313


  Introduction Top


An estimated 430,000 children were newly infected with HIV in 2008, over 90% of them through mother-to-child transmission (MTCT). Without intervention, the risk of MTCT ranges from 20% to 45%. With specific interventions in non-breastfeeding populations, the risk of MTCT can be reduced to less than 2%, and to 5% or less in breastfeeding populations. PMTCT strategic vision 2010-2015: preventing mother-to-child transmission of HIV is "Women and children alive and free of HIV" and goal is "to eliminate pediatric HIV infections and improve maternal, newborn, and child health and survival in the context of HIV." UNGASS Target 54 was "by 2010, reduce by 50% the proportion of infants infected by HIV by ensuring that 80% of pregnant women accessing antenatal care have HIV information, counseling, and other HIV prevention services available to them." In 2008, an estimated 1.4 million pregnant women in low- and middle-income countries were living with HIV, of whom 90% were from just 20 countries; all but one (India) are in sub-Saharan Africa. Male partners play an equally important role in the scale-up of PMTCT services. [1] The Joint Technical Mission on Prevention of Parent to Child Transmission of HIV/AIDS (PPTCT) (2006) estimated that out of 27 million annual pregnancies in India, 189,000 occur in HIV-positive pregnant women. In the absence of any intervention, an estimated cohort of 56,700 infected babies will be born annually. Pregnant women who are found to be HIV positive are given a single dose of nevirapine (sdNVP) at the time of labor; their newborn babies also get an sdNVP immediately after birth so as to prevent transmission of HIV from mother to child. [2]

We therefore conducted the study with the aim to find the uptake of PPTCT services during pregnancy.


  Materials and Methods Top


This was an observational cross-sectional study. Ethical approval was taken from the Institutional Ethics Committee prior to commencement of the study and informed consent was taken from the mothers of the children (fathers, in case the mother had expired) before administering the questionnaire.

Period of data collection was from July 2008 to June 2009.

Diagnosis of HIV infection was recorded as per the National AIDS Control Organization (NACO) guidelines. [3]

This is a part of a larger study. The study population consisted of children (<15 years of age) whose mother or father was infected by HIV and enrolled with two Non-Governmental Organizations (NGOs) in Pune, India.

The mothers of these children (fathers, in case the mother had expired) were interviewed with the help of pre-tested semi-structured questionnaire using face-to-face technique ensuring adequate privacy. In children whose mothers had expired, the same information was collected from their fathers. Important information from the medical records available with the parent was noted.

Parent(s) of 226 children less than 15 years of age could be approached. These 226 children belonged to 114 families and were cared by mother and or father or grandparent.

Four children had lost both the parents belonging to two families, and therefore could not be included in the study. Thus, 222 children belonging to 112 families could be included in the study. In 112 families (wherein either the mother or the father was alive), 10 biological mothers had expired and 53 biological fathers had expired.

Uptake of PPTCT each time the mother was pregnant was asked to the surviving mother (surviving father if the mother had expired). Thus, uptake of PPTCT during pregnancies of 222 children was obtained. The HIV status of the children was recorded.

The data obtained were entered in a Microsoft Office Excel sheet. To ensure confidentiality of the study subjects, a password was given to the excel sheet. The entered data were cleaned and then analyzed using Epi-info software version 3.5.3. Statistics used was percentage.


  Results Top


Out of 222 pregnancies, it was reported that in 165 (74.3%) pregnancies the mothers were not tested for HIV, in 30 (13.5%) pregnancies the mothers were tested HIV positive, and in 27 (12.2%) pregnancies the mothers tested HIV negative in pregnancy.

Out of 222 pregnancies, it was reported that in 165 (74.3%) pregnancies, the mothers did not undergo HIV test. Ninety-seven (58.8%) children born to these mothers were HIV negative, 21 (12.7%) children were HIV positive, and 47 (28.5%) children had unknown HIV status.

Out of 222 pregnancies, in 30 (13.5%) pregnancies, the mothers were HIV positive. Eighteen (60%) children born to these mothers were HIV negative, 8 (26.7%) children were HIV positive, and 4 (13.3%) had unknown HIV status.

Out of 222 pregnancies, in 27 (12.2%) pregnancies, the mothers were HIV negative in pregnancy. Nineteen (70.4%) children born to these mothers were HIV negative, 1 (3.7%) child was HIV positive, and 7 (25.9%) children had unknown HIV status.

Out of 30 mothers who said that they had tested HIV positive in pregnancy, in 15 (50%) mother-child pairs, both mother and child received PPTCT, and in 10 (33.4%) mother-child pairs, both mother and child did not receive PPTCT. In 3 (10%) mother-child pairs, mother received PPTCT but the child did not receive PPTCT. In 1 (3.3%) mother-child pair, mother did not receive PPTCT but the child received PPTCT. In 1 (3.3%) mother-child pair, mother received PPTCT, but it was neither known to the mother nor any records were available whether the child received PPTCT.

Out of 30 mothers who were tested HIV positive in pregnancy, in 15 (50%) mother-child pairs, both mother and child received PPTCT. Out of these 15 mother-child pairs in which both mother and child received PPTCT, 10 (66.7%) children were HIV negative, 2 (13.3%) children were HIV positive, and in 3 (20%) children HIV status was unknown.

Out of 30 mothers who were tested HIV positive in pregnancy, in 10 (33.3%) mother-child pairs, both mother and child did not receive PPTCT. Out of these 10 mother-child pairs where both mother and child did not receive PPTCT, 6 (60%) children were HIV negative and 4 (40%) children were HIV positive.

Out of 30 mothers who were tested HIV positive in pregnancy, in 3 (10%) mother-child pairs, the mother received PPTCT but the child did not receive PPTCT, and out of these, 1 (33.3%) child was HIV negative and 2 (66.7%) children were HIV positive.

Out of 30 mothers who were tested HIV positive in pregnancy, in 1 (3.3%) mother-child pair, the mother did not receive PPTCT but the child received PPTCT, child was not tested for HIV, and hence his HIV status was unknown.

Out of 30 mothers who were tested HIV positive in pregnancy, in 1 (3.3%) mother-child pair, the mother received PPTCT, but it was neither known to the mother nor any records were available whether the child received PPTCT. This child was HIV negative.


  Discussion Top


As seen from [Table 1], in 74.3% pregnancies the mothers were not tested for HIV and only in 25.7% pregnancies the mothers were tested for HIV. In India, the annual number of pregnancies is 27 million, of which 25 million proceed to delivery and birth. From 2005-2006 to 2009-2010, there was a noted increase in the number of pregnant women detected with HIV at PPTCT centers. Whereas in 2005-2006, 11,817 pregnant mothers were detected with HIV, the number increased to 16,860 in 2006-2007 and 20,250 in 2007-2008 at PPTCT centers. By 2008-2009, 21,349 pregnant women were tested at PPTCT centers in comparison with the 19,357 in 2009. Despite the scale-up in program, only 20% of the estimated annual pregnancies of 27 million were counseled and tested for HIV in 2009. [4]
Table 1: Mother's HIV status in pregnancy


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As seen from [Table 2], out of 27 pregnancies wherein the mothers were HIV negative, 1 (3.7%) child born was HIV positive. The mother of this HIV-positive child was later found to be HIV positive. This finding has significant implications. The reason of negative HIV test in pregnancy followed by testing HIV positive later in life may be because the mother would have been in the window period. Therefore, a second HIV test may be advised later in pregnancy.

As seen from [Table 3], only in 50% of the mother-child pairs, both mother and child received PPTCT. In India, there is progression over the years also in the number of mother-baby pairs receiving treatment although there is a gap when compared with the total number of mothers tested, highlighting possible missed cases to follow-up. [4] In this study, the records of the PPTCT regimen were available with only few of the parents. In 2008, almost half of HIV-infected pregnant women received antiretroviral medications for the prevention of MTCT. [5]
Table 2: Mother's HIV status in pregnancy and HIV status of child


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Table 3: Prevention of parent to child transmission of HIV (PPTCT) to mother-child pairs of those mothers who tested positive in pregnancy


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In 2009, only 53% of pregnant women identified as HIV infected worldwide received any antiretroviral (ARV) for PMTCT, resulting in approximately 370,000 new infant infections. [6] Many of these women received the ARV regimens previously recommended as a "minimum" intervention by WHO: an sdNVP to a pregnant woman in labor and her infant after birth. [6],[7] Although inexpensive and relatively easy to administer, sdNVP is less effective than currently recommended regimens (18-month transmission risks: 15-25%) [8],[9] and can lead to drug-resistant virus that complicates later therapy for both mothers and infected infants. [10],[11],[12]

Nevirapine halves the risk of peripartum transmission, but persists at clinically significant levels for days, potentially selecting HIV resistance mutations that may negatively affect the efficacy of nevirapine-based therapies when mothers and infected children subsequently require treatment for their own health. This poses an important public health challenge, since nevirapine-based therapies are the most widely available and affordable treatments in resource-limited countries, where more than 95% of infections in infants and children occur. [9],[13]

As seen from [Table 4], where both the mother and child received PPTCT, only 13.3% children born were HIV positive as against 40% children who were HIV positive where neither mother nor the child had received PPTCT.
Table 4: PPTCT to mother-child pairs of those mothers who tested HIV positive in pregnancy and HIV status of their child


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HIV can be transmitted during pregnancy, childbirth, or breastfeeding. Without intervention, the risk of transmission from an infected mother to her child ranges from 15% to 25% in developed countries and from 25% to 45% in developing countries. This difference is largely attributed to breastfeeding practices. [3]

The influence of breastfeeding, duration of breastfeeding, mixed feeding, and the HIV transmission from mother to child is not discussed in this paper.

Uptake of PPTCT services was found to be low. In developing countries like India where the chances of parent to child transmission of HIV are likely to be more than in developed countries due to breastfeeding practices, the uptake of PPTCT services should be maximized to decrease the burden of pediatric HIV because even a single pediatric HIV infection counts.

100% voluntary HIV testing of pregnant women at Integrated Counseling and Testing Centre (ICTC) and 100% coverage of PPTCT to mother and child is vital to drastically bring down the pediatric HIV infections. All the pregnant women may be voluntarily tested twice for HIV in pregnancy, in which the second test for HIV may be in late pregnancy. Also, if an HIV test was not carried out during pregnancy and woman presents in labor, voluntary HIV testing may be done during labor with a rapid test kit with pre-test and post-test counseling.


  Acknowledgment Top


We are thankful to Dr. Atul Kotwal for expert advice.

 
  References Top

1.World Health Organization. PMTCT strategic vision 2010-2015: Preventing mother-to-child transmission of HIV to reach the UNGASS and Millennium Development Goals. Available from: http://www.who.int/hiv/pub/mtct/strategic_vision.pdf. [Last accessed on 2012 Nov 10].  Back to cited text no. 1
    
2.Ministry of Health and Family Welfare, Government of India, NACO. Prevention of Parent to Child Transmission (PPTCT). Available from: http://www.nacoonline.org/National_AIDS_Control_Program/Services_for_Prevention/PPTCT/. [Last accessed on 2012 Nov 10].  Back to cited text no. 2
    
3.Ministry of Health and Family Welfare, Government of India, NACO. Guidelines for HIV Care and Treatment in Infants and Children November 2006. Available from: http://www.nacoonline.org/upload/Policies%20&%20Guidelines/4-%20Guidelines%20for%20HIV%20care%20and%20treatment%20in%20Infants%20and%20children.pdf. [Last accessed on 2012 Dec 18].  Back to cited text no. 3
    
4.UNGASS India. Country Progress Report March 31 2010. Available from: http://www.data.unaids.org/pub/Report/2010/india_2010_country_progress_report_en.pdf. [Last accessed on 2012 Nov 11].  Back to cited text no. 4
    
5.AIDS epidemic update: November 2009. Geneva: World Health Organization, United Nations Programme on HIV/AIDS. Available from: http://www.data.unaids.org/pub/Report/2009/JC1700_Epi_Update_2009_en.pdf. [Last accessed on 2012 Nov 11].  Back to cited text no. 5
    
6.World Health Organization. Towards universal access: Scaling up priority HIV/AIDS interventions in the health sector. 2010. Progress Report. Available from: http://www.who.int/hiv/pub/2010progressreport/report/en/index.html. [Last accessed on 2012 Dec 18].  Back to cited text no. 6
    
7.World Health Organization. Antiretroviral drugs for treating pregnant women and preventing HIV infections in infants in resource-limited settings: Towards universal access - recommendations for a public health approach. 2006. Available from: http://www.who.int/hiv/pub/guidelines/pmtct/en/index.html. [Last accessed on 2012 Dec 18].  Back to cited text no. 7
    
8.Kuhn L, Aldrovandi GM, Sinkala M, Kankasa C, Semrau K, Mwiya M, et al. Effects of early, abrupt weaning on HIV-free survival of children in Zambia. N Engl J Med 2008;359:130-41.  Back to cited text no. 8
    
9.Guay LA, Musoke P, Fleming T, Bagenda D, Allen M, Nakabiito C, et al. Intrapartum and neonatal single-dose nevirapine compared with zidovudine for prevention of mother-to-child transmission of HIV-1 in Kampala, Uganda: HIVNET 012 randomised trial. Lancet 1999;354:795-802.  Back to cited text no. 9
    
10.Lockman S, Shapiro RL, Smeaton LM, Wester C, Thior I, Stevens L, et al. Response to antiretroviral therapy after a single, peripartum dose of nevirapine. N Engl J Med 2007;356:135-47.  Back to cited text no. 10
    
11.Arrive E, Newell ML, Ekouevi DK, Chaix ML, Thiebaut R, Masquelier B, et al. Prevalence of resistance to nevirapine in mothers and children after single-dose exposure to prevent vertical transmission of HIV-1: A meta-analysis. Int J Epidemiol 2007;36:1009-21.  Back to cited text no. 11
    
12.Ciaranello AL, Perez F, Maruva M, Chu J, Engelsmann B, Keatinge J, et al. CEPAC-International Investigators. WHO 2010 Guidelines for prevention of mother-to-child HIV transmission in zimbabwe: Modeling clinical outcomes in infants and mothers. PLoS One 2011;6:e20224.  Back to cited text no. 12
    
13.Lallemant M, Jourdain G. Preventing mother-to-child transmission of HIV - protecting this generation and the next. N Engl J Med 2010;363:1570-2.  Back to cited text no. 13
    



 
 
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  [Table 1], [Table 2], [Table 3], [Table 4]



 

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