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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



  
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 counselling, 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.


  

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.

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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.

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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.

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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.


 

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 counselled 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.