What is mother-to-child transmission?

Mother-to-child transmission (MTCT) is when an HIV-infected woman passes the

virus to her baby. This can occur during pregnancy, labour and delivery, or
breastfeeding. Without treatment, around 15-30% of babies born to HIV positive
women will become infected with HIV during pregnancy and delivery. A further 5-
20% will become infected through breastfeeding.1

Is MTCT a major problem?

In 2008, around 430,000 children under 15 became infected with HIV, mainly
through mother-to-child transmission. About 90% of these MTCT infections
occurred in Africa where AIDS is beginning to reverse decades of steady progress in
child survival.2

In high income countries MTCT has been virtually eliminated thanks to effective
voluntary testing and counseling, access to antiretroviral therapy, safe delivery
practices, and the widespread availability and safe use of breast-milk substitutes. If
these interventions were used worldwide, they could save the lives of thousands of
children each year.

How can MTCT be prevented (PMTCT)?

An HIV positive mother and her HIV positive baby in India

Effective prevention of mother-to-child transmission (PMTCT) requires a three-fold

strategy.3 4
 • Preventing HIV infection among prospective parents - making HIV testing
and other prevention interventions available in services related to sexual
health such as antenatal and postpartum care.
• Avoiding unwanted pregnancies among HIV positive women - providing
appropriate counseling and support to women living with HIV to enable
them to make informed decisions about their reproductive lives.
• Preventing the transmission of HIV from HIV positive mothers to their
infants during pregnancy, labour, delivery and breastfeeding.
• Integration of HIV care, treatment and support for women found to be
positive and their families.

The last of these can be achieved by the use of antiretroviral drugs, safer infant
feeding practices and other interventions.

Antiretroviral drugs

Treatment for the mother

Women who have reached the advanced stages of HIV disease require a
combination of antiretroviral drugs for their own health. This treatment, which
must be taken every day for the rest of a woman's life, is also highly effective at
preventing mother-to-child transmission (PMTCT). Women who require treatment
will usually be advised to take it, beginning either immediately or after the first
trimester. Their newborn babies will usually be given a course of treatment for the
first few days or weeks of life, to lower the risk even further.

Pregnant women who do not yet need treatment for their own HIV infection can
take a short course of drugs to help protect their unborn babies. The main options
are outlined below, in order of complexity and effectiveness.

Single dose nevirapine

The simplest of all PMTCT drug regimens was tested in the HIVNET 012 trial,
which took place in Uganda between 1997 and 1999. This study found that a single
dose of nevirapine given to the mother at the onset of labour and to the baby after
delivery roughly halved the rate of HIV transmission.5 6 As it is given only once to
the mother and baby, single dose nevirapine is relatively cheap and easy to
administer. Since 2000, many thousands of babies in resource-poor countries have
benefited from this simple intervention, which has been the mainstay of many
PMTCT programmes.

When is single dose nevirapine appropriate?

A significant concern about the use of single dose nevirapine is drug resistance.
Around a third of women who take single dose nevirapine develop drug resistant
HIV,7 which can make subsequent treatment involving nevirapine and efavirenz (a
related drug) less effective.8 Studies have found that drug resistance resulting from
single dose nevirapine tends to decrease over time; if a mother waits at least six
months before beginning treatment then it may be less likely to fail.9 10 Nevertheless,
in some cases the drug resistant HIV persists for many months in some parts of the
body, even if it cannot be detected in the blood, and this may undermine the longer
term effectiveness of treatment.11

Whenever possible, women should receive a combination of drugs to prevent HIV

resistance problems and to decrease MTCT rates even further.

Among babies infected with HIV and exposed to single-dose nevirapine, around half
have drug resistance at 6-8 weeks old.12 other infants may become infected with
drug resistant HIV through breastfeeding.13

Because of concerns about drug resistance and relatively low effectiveness, there is
now general agreement that single dose nevirapine should be used only when no
alternative PMTCT drug regimen is available. Whenever possible, women should
receive a combination of drugs to prevent HIV resistance problems and to decrease
MTCT rates even further.

Nevirapine, however, is still the only single dose drug available to prevent MTCT.
Other "short course" treatments require women to take drugs during and after
pregnancy as well as during labour and delivery. This means they are much more
expensive and more difficult to implement in resource poor settings than nevirapine,
which can be used with little or no medical supervision at all. So, for now, single
dose nevirapine remains the only practical choice for PMTCT of HIV in areas with
minimal medical resources.

Combining AZT with single dose nevirapine

According to the World Health Organization (WHO) 2006 guidelines, the
recommended course of drugs for preventing mother to child transmission
(PMTCT) in resources-limited settings should be a combination of AZT and single
dose NVP. This approach is much more difficult to administer than single dose
nevirapine on its own, but it is also significantly more effective, and is less likely to
lead to drug resistance. AZT was first shown to reduce MTCT rates in 1994, and is
the best-studied drug for this purpose.

Under the 2009 guidelines, all HIV positive mothers, identified during pregnancy,
should receive an extensive course of antiretroviral drugs to prevent mother to child
transmission. For more information about the 2009 recommendations, please see
AVERT's 2009 WHO Guidelines page. If these extensive drugs are not available,
then the 2006 recommended course might be an option and a woman should begin
taking AZT after 28 weeks of pregnancy (or as soon as possible thereafter). During
labour she should take AZT and 3TC, as well as a single dose of nevirapine. Her
baby should receive a single dose of nevirapine immediately after birth, followed by
a seven-day course of AZT. The mother should continue taking AZT and 3TC for
seven days after delivery, to cut the risk of drug resistance still further.

The WHO says that PMTCT programmes are "strongly encouraged" to implement
the 2009 recommendations but acknowledges that this might not be possible for all
countries. In this situation, there are previous regimens that have been used and
might be implemented, these options are shown in the table below.

WHO guidelines for PMTCT drug regimens in resource-

limited settings

After birth: After birth:

Pregnancy Labour
mother infant
Daily NVP until
2009 single dose
AZT after AZT+3TC for 1 week after
Recommendations nevirapine;
14 weeks seven days breastfeeding has
option A AZT+3TC
finished
Triple ARVs
2009 Triple
until 1 week after 6 weeks of daily
Recommendations ARVs after Triple ARVs
breastfeeding has NVP
option B 14 weeks
finished
single dose single dose
2006 AZT after AZT+3TC for
nevirapine; nevirapine; AZT
Recommendations 28 weeks seven days
AZT+3TC for seven days
Alternative (higher single dose
AZT after single dose
risk of drug - nevirapine; AZT
28 weeks nevirapine
resistance) for seven days
single dose
Minimum (less AZT+3TC for single dose
- nevirapine;
effective) seven days nevirapine
AZT+3TC
Minimum (less
single dose single dose
effective; higher risk - -
nevirapine nevirapine
of drug resistance)

Under the 2006 recommendations, if a woman receives at least four weeks of AZT
during pregnancy, doctors may choose to omit her dose of nevirapine from the
recommended regimen. In this case she will not have to take 3TC during labour, or
to take any drugs after birth. However, her baby must still receive nevirapine, and
should also receive AZT for four weeks instead of one.

If the woman receives less than four weeks of AZT during pregnancy then her baby
should receive AZT for four weeks instead of one.
Triple combinations
The most effective PMTCT therapy involves a combination of three antiretroviral
drugs taken during the later stages of pregnancy and during labour. This therapy is
essentially identical to the treatment taken by HIV-positive people for their own
health, except that it is taken only for a few months, and the choice of drugs may be
slightly different. Triple therapy is usually recommended to women in developed
countries, and is becoming more widespread in the rest of the world and the WHO
2009 Guidelines, reflects this. AVERT.org has more information about HIV and
pregnancy, including a discussion of these more sophisticated regimens.

HIVNET 012 controversies

In mid December 2004 a news story appeared alleging that side effects from single
dose nevirapine during the HIVNET 012 studies had been covered up. It claimed
that US officials had been warned that nevirapine research "was flawed and may
have underreported thousands of severe reactions including deaths."

By the time this news story appeared, a committee from the US Institute of
Medicine was already engaged in a major independent review of the design,
conduct, results and validity of the HIVNET 012 study. After evaluating extensive
material from a variety of sources and reviewing primary source documents from
Uganda, the investigation reported its findings in April 2005.

The committee found that the original report on the HIVNET 012 study was
"sound, presented in a balanced manner, and can be relied upon for scientific and
policy-making purposes." The allegations about unreported deaths were found to be
completely untrue. Of the 306 mothers who received nevirapine, 16 experienced
serious adverse events, and only one was thought possibly to be due to nevirapine.14

The safety and effectiveness of single dose nevirapine has been confirmed by many
other clinical trails. Although long-term use of nevirapine has been linked to liver
damage, there is no evidence of any significant safety risk from a single dose to
prevent MTCT. The December 2004 press story (which seems to have arisen from a
personal feud between US officials) has been thoroughly discredited.14, 15, 16, 17
Numerous subsequent studies, including a large clinical trial in Thailand, have
reaffirmed that nevirapine is safe and effective at preventing MTCT.15
HIV and safer infant feeding

African woman breastfeeding

A number of studies have shown that the protective benefit of drugs is diminished
when babies continue to be exposed to HIV through breastfeeding.16 17

Mothers with HIV are advised not to breastfeed whenever the use of breast milk
substitutes (formula) is acceptable, feasible, affordable, sustainable and safe.
However if they live in a country where safe water is not available then the risk of
life-threatening conditions from formula feeding may be higher than the risk from
breastfeeding. An HIV positive mother should be counseled on the risks and benefits
of different infant feeding options and should be helped to select the most suitable
option for her situation.18

A baby fed on infant formula does not receive the special vitamins, nutrients and
protective agents found in breast milk. And the cost of infant formula often puts it
beyond the reach of poor families in resource poor countries, even if the product is
widely available. Many women also lack access to the knowledge, potable water and
fuel needed to prepare replacement feeds safely, or simply have no time to prepare
them. If used incorrectly - mixed with unsafe water, for example, or over-diluted - a
breast milk substitute can cause infections, malnutrition and even death.
Furthermore, if a mother chooses not to breastfeed in settings where breastfeeding
is the norm then this may draw attention to her HIV status and invite
discrimination, violence or abandonment by her family and community. Another
factor worth noting is the contraceptive effect of breastfeeding, which can help to
lengthen the interval between pregnancies.

Infant feeding advice for women with regular access to

antiretroviral drugs
For HIV positive women who choose, or who are advised to breastfeed, the World
Health Organization's (WHO) recommendations are based on whether a women has
access to antiretroviral drugs or not. If a woman has support and a regular supply
of antiretroviral drugs then she should exclusively breastfeed for the first 6 months
of an infant's life and then introduce mix feeding until the infant is able to have a
safe diet without breast milk. Mixed feeding (breastfeeding mixed with bottle
feeding of water or formula, or providing other foods) is only safe in this situation
because the mother or infant is taking antiretroviral.

Infant feeding advice for women who do not have regular

access to antiretroviral drugs
In situations where health services cannot supply women or infants with a regular
supply of antiretroviral drugs for an extended period of time women are
recommended to exclusive breastfeed for the first 6 months of an infant's life and
rapidly wean to avoid mix feeding. When antiretroviral drugs are not accessible,
mix feeding is not recommended because studies suggest it carries a higher risk than
exclusive breastfeeding. This may be because mixed feeding damages the lining of
the baby's stomach and intestines thus making it easier for HIV in breast milk to
infect the baby. When either the mother or infant has access to ARVs the risk of
HIV infection while mix feeding is reduced 19. If a HIV positive mother does not
have access to ARVs she is strongly recommended to rapidly wean. Unfortunately,
the best duration for this is not yet known and may vary according to the infant's
age and/or the environment 20 21.

Read more about HIV and breastfeeding.

Caesarean sections
A caesarean section is an operation to deliver a baby through its mother’s
abdominal wall. When a mother is HIV positive a caesarean section may be done to
protect the baby from direct contact with her blood and other bodily fluids.
However, as with formula feeding, there is a need to weigh the risk of HIV
transmission against the risk of harm due to the intervention.

If the mother is taking combination antiretroviral therapy then a caesarean section

will often not be recommended because the risk of HIV transmission will already be
very low. Caesarean delivery may be recommended if the mother has a high level of
HIV in her blood, but the procedure is seldom available and/or safe in resource poor
settings.

International PMTCT initiatives

There are a number of large-scale international initiatives to prevent mother-to-
child transmission of HIV. These include:

1. The President's Emergency Plan for AIDS Relief (PEPFAR)

2. The Call to Action Project
3. The UN Interagency Task Team on MTCT
4. MTCT-Plus
5. The Global Fund

The President's Emergency Plan for AIDS Relief (PEPFAR)

On June 19th 2002, US President Bush announced a new $500 million International
Mother and Child HIV Prevention Initiative to prevent the transmission of HIV
from mothers to infants and to improve health care delivery in Africa and the
Caribbean. The Initiative was later integrated into the President's Emergency Plan
for AIDS Relief (PEPFAR). In 2008 PEPFAR was reauthorized with the original $
15 billion funding now tripled to $ 48 billion over the next five years.

The original Initiative had the aim of reaching one million women with HIV testing
and counseling and providing preventive drugs to 80 per cent of HIV positive
delivering women by 2007. It aimed to reduce mother-to-child transmission by 40
percent in its fourteen focus countries, twelve of which are in Africa.

From fiscal year 2004 to FY 2007, PEPFAR has supported prevention of MTCT for
women during more than 10 million pregnancies with antiretroviral drugs being
provided in over 827,000 pregnancies. This has resulted in the prevention of an
estimated 157,000 infant HIV infections. 22

AVERT.org has more information about the President's Emergency Plan for AIDS
Relief in our PEPFAR page.

The Call to Action Project

The Elizabeth Glaser Pediatric AIDS Foundation initiated the Call to Action Project
(CTA) in September 1999 to help reduce MTCT of HIV in resource poor countries.
The CTA is a public-private partnership that receives funding from both private
sources such as the Gates Foundation and government grants. CTA has worked or
is now working at approximately 400 sites in nineteen countries worldwide, of which
twelve are in Africa.

The Foundation joined up with USAID in 2002 to rapidly expand PMTCT

programmes. Programmes that were funded by USAID are now part of PEPFAR,
while other CTA sites are still supported with private funding. By the end of 2003,
the Call to Action project had trained over 5,000 healthcare workers and provided
voluntary counseling to more than 625,000 women. As of March 31st 2008, the
project had reached more than 5.2 million women with access to PMTCT services
and had also provided more than 4.3 million women with HIV tests. 23

The UN Interagency Task Team on MTCT

The UN Interagency Task Team on MTCT involves UNICEF, UNFPA, WHO, the
World Bank and the UNAIDS Secretariat and works with the governments of
various developing countries to set up PMTCT programmes.

During the Task Team's pilot phase in Botswana and Rwanda, from April 1999 to
July 2001, counseling was provided to 220,000 pregnant women. Of these women,
138,000 were tested for HIV, and about 4,500 HIV positive women received
antiretroviral therapy to prevent MTCT. As of mid-2005, support was being
provided to 226 programme sites in sixteen countries, of which ten are in Africa.24

MTCT-Plus
The MTCT-Plus Initiative was established in 2002, and is coordinated by the
Mailman School of Public Health at Columbia University. The Initiative aims to
move beyond interventions aimed only at preventing infant HIV infection. It does
this by supporting the provision of specialized care to HIV-infected women, their
partners and their children who are identified in MTCT programmes. Funding for
the initiative is provided by a group of private foundations, including the Gates
Foundation, the Kaiser Family Foundation and the Rockefeller Foundation, as well
as by PEPFAR via USAID.

The MTCT-Plus Initiative provides operational funding, medications, training and

technical assistance at 13 sites in sub-Saharan Africa and at one site in Thailand.
Since its inception MTCT-Plus has provided care and treatment to more than
13,000 adults and children. 25

The Global Fund

The Global Fund to Fight AIDS, Tuberculosis and Malaria is a public-private
partnership that distributes grants worldwide to fund HIV/AIDS prevention and
treatment programmes. Grants are distributed over two years and most countries
receive some grants to fund PMTCT programmes.

In 2008 the Global Fund announced that 271,000 HIV positive pregnant women had
been reached with prophylaxis for PMTCT through Global Fund money in 2007.26

AVERT.org has more about The Global Fund.

Challenges faced by PMTCT programmes

Even where PMTCT services are available, not all women receive the full benefit.
Reasons for HIV positive pregnant women not accessing drugs include:

• Not being offered an HIV test

• Refusing to take an HIV test
• Not returning for follow up visits
• Not adhering to self-administered drugs

HIV testing is critical because women who do not know they are HIV positive
cannot benefit from interventions. However some women refuse to be tested because
they fear learning that they have a life-threatening condition; because they distrust
HIV tests; or because they do not expect their results to remain confidential, and
fear stigma and discrimination following a positive result.

Some women who test HIV positive do not return to clinics for follow up visits, or
fail to take the drugs they have been given. This can happen because they have had
negative experiences interacting with clinic staff, or because they have been poorly
informed about HIV transmission and how it can be prevented. Some women
having tested negative early in pregnancy can become infected during pregnancy;
without returning to clinics for retesting treatment is not accessed27. Also, some
women choose not to attend clinics because by doing so they might disclose their
HIV positive status. In the words of a woman from Cote d'Ivoire:

"My husband might see me with the medicines, and he will want to know what they
are for. That way he will find out about my [HIV positive test] result. Even the
location bothers me, because everyone who comes to the clinic knows what goes on
[at the programme]. As soon as a pregnant woman is seen coming here, it's known
right away that she is seropositive."28

One of the major problems in preventing mother-to-child transmission, it has been

argued, is making the provision of ARV drugs the focus of PMTCT efforts. Access
to other services such as counseling, care and treatment services, infant-feeding
guidance, and in particular sexual and reproductive health is ignored as a result.29
Therefore, it should not be assumed that the proportion of HIV-positive pregnant
women who are receiving antiretroviral prophylaxis to prevent their child becoming
infected – estimated at one-third in developing countries – are receiving
comprehensive PMTCT services.30

To achieve a high success rate, PMTCT programmes must have well-trained,

supportive staff who take great care to ensure confidentiality. They must be backed
up by effective HIV testing and counseling programmes and by good quality
HIV/AIDS education, which is essential to eliminate myths and misunderstandings
among pregnant women, and to counter stigma and discrimination in the wider
community. Under these conditions, antiretroviral drugs have the potential to save
many thousands of babies' lives.