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Programs aim to reduce MTCT in poor nations
Here’s a look at what can and is being done
There are no easy answers to preventing HIV transmission between HIV-infected mothers and their nursing infants, but a number of programs have developed strategies for reducing the risk among women in poor nations.
"Our strategies are to support existing systems and provide better services for pregnant and lactating mothers," says Carolyn Kruger, MSN, PhD, senior technical manager for country and regional programs at the Academy for Educational Development (AED) LINKAGES of Washington, DC.
"If there’s a maternal child clinic, we help district health teams provide better support services for antenatal mothers, care for prevention of malaria, education in preventing HIV, nutrition counseling, and helping them see the benefits of coming to clinics for labor and delivery so they can be managed safely," she says.
The truth is that most mother to child transmission (MTCT) programs involve interventions aimed at preventing transmission with antiretroviral treatment late in pregnancy, during labor and delivery, and immediately postnatal, says Ellen G. Piwoz, ScD, MHS, nutrition advisor for the support for analysis and research in Africa project and director of the center for nutrition at AED.
"Even those simple interventions aren’t that widely implemented in many countries," she says. "The coverage of those programs is still pretty limited."
However, some innovative strategies have been employed, including the following, Piwoz and Kruger say:
Since the World Health Organization (WHO) of Geneva and MTCT experts recommend that women who are unable to provide safe and affordable breast milk replacement to their infants should breast-feed exclusively for up to six months whenever their status is HIV-positive or unknown, some MTCT programs have begun to teach women how to make breast-feeding safer.
For example, women are taught how to properly position and attach their baby to their breast to avoid breast engorgement and resulting inflammation and cracked and bleeding nipples, Piwoz says.
"The way to prevent HIV transmission is to have good attachment and positioning, frequent suckling, and treatment of breast conditions," Kruger says.
Women are told to seek medical help if they have any problems with breast-feeding, Piwoz says.
She is involved in a study program in Zimbabwe in which some women knew their HIV status and others did not, by choice.
"We tested women when they entered the study and gave them the opportunity to learn their status," Piwoz says. "We counseled women on safer breast-feeding practices, including both women who knew their HIV status and those who didn’t because they lived in an area where one-third of women were infected."
But even women who were not infected or were of unknown status need HIV prevention counseling and risk-reduction strategies because if they become infected while breast-feeding, they could place their infants at risk of infection.
"Acute HIV infection results in a jump in viral load in the blood, and that higher viral load is associated with higher risk of HIV infection," Piwoz says.
"What we found was safer breast-feeding resulted in a reduction of HIV transmission among the population who didn’t know their HIV status," she notes. "Although in an ideal world, everyone will learn their status and want to know because of services available to protect their own health and the health of their children, we’re far from the ideal world."
If a woman follows the WHO guidelines and exclusively breast-feeds for six months, she still will need support to make the transition to replacement feeding.
Such support includes information on weaning and providing safe and nutritional alternative food, Kruger says.
"She can feed the infant heat-treated breast milk by bringing expressed milk to a boil, and it does kill the virus," she says.
A study presented at the 15th International AIDS Conference in Bangkok, Thailand, in July 2004, found that flash-heated expressed breast milk was a safe and practical infant feeding option.1
"African women are pretty good at expressing milk, but it’s not well known right now as an option," Kruger says. "And it does take resources — fuel — and fuel is hard to find in Africa."
A woman also could provide the infant with an HIV-negative wet nurse, Kruger adds.
"Breast-feeding with an HIV-negative wet nurse has drawbacks, and not all communities accept this," Kruger says. "The wet nurse has to be tested frequently and educated on HIV prevention."
A study in Kenya looked at the use of surrogate grandmothers as wet nurses and found that these older, HIV-negative women were able to re-establish a nutritious and adequate milk supply and that the practice was acceptable to mothers.2
Breast conditions contribute to increasing the risk of transfer of HIV to infants, so breast health is very important, Kruger says.
"If a mother is HIV-positive, and she wants to exclusively breast-feed her baby, she needs support in the community to do that," Kruger says.
Women who have difficulty breast-feeding may think there’s something wrong with their breast milk, when the amount of milk a woman produces is based on how often she breast-feeds, and women need emotional support to become successful at breast-feeding, Piwoz explains.
"We pay too little attention to the health of the mother," she points out.
"Keeping the mother healthy is the best road to child survival, in general, and keeping the mother healthy reduces the risk of the mother transmitting HIV to the child," Piwoz says,
Piwoz works in Southern Africa where if a woman is seen bottle feeding, it’s assumed the woman is HIV-infected.
"She may be assumed to be promiscuous, and it might be assumed that the baby does not belong to her husband," she says. "Women who stop breast-feeding early may hear gossip about being pregnant or HIV-positive."
Typically, in Southern African homes, the babies sleep with their mothers, and if they cry, the mother offers the infant a breast to nurse, says Piwoz.
"If the baby is in a home where no breast is offered, then there’s pressure on the mother to quiet the baby; and if she has not disclosed her HIV status to anybody, then she’s facing that pressure, which is not always easy to do," she explains.
Most programs do little to help women cope with the stigma and peer pressure, when this also is an important aspect of preventing HIV infection, Piwoz notes.
"The services for postnatal care of HIV-positive mothers are limited," she says. "Those programs are not well equipped to deal with infant feeding and nutrition issues, so we haven’t given women adequate support."
These MTCT programs are all relatively new, so this isn’t meant as huge criticism, Piwoz adds.
"The community is extremely important in dealing with these issues, so our challenge in all of the programs is how to develop community strategies, and we’re doing that with the communities themselves," Kruger says.
"We’re talking with the leaders, mothers and helping them understand the issues and how we can bring about behavior change so the epidemic can be decreased," she adds.
1. Israel-Ballard KA, Chantry CJ, Donovan R, et al. Viral, nutritional, and bacterial safety of flash-heated and pretoria pasteurized breast milk to prevent mother-to-child transmission of HIV in resource-poor countries. eJIAS 2004. Abstract: ThPeC7411.
2. Covington C, Abdullah M, Omar A, et al. Surrogate grandmother lactation to prevent mother-to-child breast milk HIV transmission in coastal Kenya. eJIAS 2004. Abstract: LbOrB11.