HIV and AIDS is one of the major causes of death in children throughout the world. According to Labbok (2003) of 580,000 deaths from HIV and AIDS in children under 15years of age, 500,000 have been in Africa. 80-90% of such deaths are due to MTCT and 200,000 were secondary to breast feeding.
Increasing number of children have HIV infection, especially in the countries hardest hit by the pandemic. In 2002, an estimated 3.2 million children under 15 years of age were living with HIV and AIDS; a total of 800,000 were newly infected and 610,000 died. HIV and AIDS have been estimated to account for about 8% deaths in children under 5 years of age in Sub Saharan Africa. In areas where the prevalence of HIV in pregnant women exceeded 35%, the contribution of HIV and AIDS to childhood mortality was as high as 42% .
World wide in 2001, 1.8 million women became infected with HIV and approximately 800,000 children also became infected, the majority of them via MTCT. Breast feeding is an important mode of transmission during the post-partum period, accounting to nearly one third of entire MTCT of HIV. In East Africa, it is estimated that 10-20% of women are HIV positive2.With the HIV epidemic showing shift towards women and young people, the increasing seroprevalence among women will lead to an increase in the MTCT .
Of great concern in this HIV era is the issue of breast feeding. Besides being an intense personal concern, the issue of HIV transmission through breast feeding is also of public health importance especially in countries where both fertility rates and HIV infection rates among pregnant women are high. Now it is widely recognized that HIV is transmitted to an infant during breast feeding with an average of approximately one out seven infants born to an HIV–infected mother becoming infected through breast feeding up to 24 months . Efficiency of HIV transmission through breast milk ranges between 16-29%. Of the 30% of babies who get infected vertically, the relative frequency of timing of transmission is as follows: 2% early in gestation, 3% late in gestation, 15% during labour, 5% early in post-partum period, and 5% in late post-partum period . Although WHO,unicef and other United Nations agencies currently recommend that HIV-positive mothers avoid breast feeding if replacement feeding from birth is acceptable,feasible,affordable,sustainable and safe (AFASS),it is not practically possible to adopt this policy in resource limited countries like Uganda. Thus, research is necessary to make this feasible.
This article summarizes research findings regarding MTCT of HIV particularly through breast feeding.
Knowledge on the role of breast feeding in MTCT of HIV
In order that interventions on the prevention of MTCT to become effective ,it is important to know the level of knowledge, attitude and practices of women in relation to MTCT of HIV and breast feeding. According to community based cross-sectional study done among mothers aged 16-40 years in Dar es Salaam, only 25% of the population knew that breast feeding could be source of HIV transmission. Among women who knew about HIV transmission through breast feeding, 54.1% indicated they will avoid breast feeding while 45.9% indicted they will continue breast feeding . The main reason given was stigmatization. Generally, the knowledge and attitudes regarding MTCT and breast feeding in developing countries are not well known. Thus, there is need to educate the masses on this issue. Unlike in developed countries where MTCT of HIV is known to most mothers, a lot still ahs to be done in developing countries where the vast majority of women are completely ignorant about it.
Prevention of MTCT
Current interventions aimed at reducing MTCT target the peripartum period but their application in populations where breast feeding is the norm presents considerable problem . Effective interventions used include reduction of maternal viral load through ARV therapy, the avoidance of exposure to contaminated maternal secretions through delivery by caesarean section, and avoidance of breast feeding. Washing the birth canal with antiseptic to reduce exposure to contaminated section also has some effect .
Several questions and challenges remain. For example, choice, availability, affordability, duration and long term safety of ARV agents to be used during pregnancy and early neonatal life, and the issue of transmission in situations where alternatives to breast feeding are not available .
The challenge is to find the most cost effective and feasible intervention to achieve zero percent transmission of HIV from an infected mother to her child.
Barriers to the effective prevention of MTCT of HIV
Pregnant women face many difficult decisions, including decisions around HIV testing, treatment options and infant feeding. A woman’s male partner(s), extended family, greater community and health care setting all influence her decision and ability to take advantage of MTCT prevention.
In developing countries, there is lack of access to medications in general and ARV drugs in particular. In addition, there is very little access to good health care for women both before and after birth, limited HIV counseling and testing, and high stigma and discrimination against HIV positive women.
In the developed world, it is recommended that HIV –positive mothers do not breast feed, as formula feeding is safe, well accept and readily available. Formula feeding requires clean water for mixing formula or sanitation and cannot afford formula, and therefore cannot avoid breast feeding.
What still needs to be done?
HIV is a preventable disease. MTCT is best prevented by effective, accessible and sustainable HIV prevention, diagnosis and treatment programs for women, men and their children. Structural interventions are also needed that increase access to HIV treatment treatments, clean water and formula. Education and empowerment for all women in every country are as essential as access to good medical care and nutrition for women and their children, whether they are HIV positive or HIV negative .
With the Sub Saharan African socioeconomic setting, exclusive breast feeding of the baby born to HIV-positive mother is inevitable lest the baby dies within the first days after birth. Replacement feeding is unacceptable, unaffordable, unsustainable, unsafe and not feasible in most of these countries. So the big question remains, “how can nutritionists and other health workers make breast feeding safer for every baby born to HIV positive mother and improve upon complementary feeding for such children?
Thus, there is greater need for urgent research on how to improve the local foods to make them nutritionally balanced and safer for complementary feeding and replacement feeding of such children.
Conclusion
Reducing vertical HIV transmission is challenging, particularly in developing countries where mothers with HIV-infection do not have access to long-term ARV regimens, formula feeding or other preventing strategies that mothers in wealthier countries routinely follow.
Thus, more research is required if reduction of MTCT during breast feeding is to be achieved. There is need to explore optimal duration of breast feeding, weaning recommendations and prominent ARV drug for mothers and infants based on the local conditions.
Reference:
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Journal of the American Medical Association, 2001; 286:2413-2420.
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