Tuesday, January 24, 2012

To Reduce HIV Transmission From Mothers to Children, Reduce Transmission to Women

In the many articles about eliminating (or virtually eliminating) mother to child transmission of HIV (MTCT), the one strategy I haven't heard mentioned seems like it might be the simplest and most effective of all: eliminate, or at least reduce, HIV in mothers. It has been shown that even very high uptake of prevention of MTCT services will still not allow a country such as Zimbabwe to achieve virtual elimination, which would mean reducing the risk to less than 5%. Even an increase in uptake of services from 36% to 56% only resulted in a drop in MTCT from 20.3% to 18%.

The article states that only an estimated 53% of pregnant women globally got any kind of PMTCT treatment in 2009, which resulted in around 400,000 infants being infected, over 90% of which were in sub-Saharan Africa. But the problem with a lot of HIV programs, PMTCT programs being no exception, is that they are instances of 'vertical' healthcare. HIV related healthcare is, effectively, a parallel health service catering for one disease, while other health services, for better or for worse, cater for anything else the country's health system has the capacity to deal with. But this doesn't mean that HIV services are necessarily good, despite all their funding.

As a result, reproductive health services may or may not include HIV services and HIV facilities may or may not include other reproductive health services. While some HIV facilities may be relatively well funded, at least for their intended purposes, other health facilities are unlikely to be very well funded. In a country like Zimbabwe many people have some access to care but the quality of care is not high, unless you can afford private services. So PMTCT services often don't coordinate well with other services that pregnant woman receive; some receive services early in their pregnancy and drop out, others get later services, but still drop out.

The option of improving all health services and making HIV just one disease among many that reproductive health and general health facilities provide has never been popular in the HIV industry, not wishing to share the funding it receives, which often dwarfs what other serious health conditions receive. So quite a number of women are being infected during pregnancy, even late in pregnancy or just after giving birth. And it appears to be assumed that they were infected sexually, probably while already pregnant, though they may have been in the 'window' period when tested earlier, which could explain why they appeared to be HIV negative.

As a Ugandan woman working with safety in health facilities said to me: 'I refuse to believe that young women (the mean age in the Zimbabwean research was 24), finding themselves pregnant, whether for the first or fifth time, have unsafe sex with strange men on a regular basis; or that women who are in the late stages of pregnancy, or even women who have just given birth, have unsafe sex with strangers; or even that pregnant women have lots of sex with their husbands and resume sexual intercourse shortly after giving birth'.

So what is giving rise to this 1% incidence of HIV, the rate of new infections, during and just after pregnancy? Is it all heterosexual intercourse? If so, all the partners of women who seroconvert must also be HIV positive. Yet HIV rates among men are usually lower than among men; it is highly likely that many of the men are not HIV positive. When African women are found to be infected with HIV, even when their partner is negative, it is assumed that they were infected sexually. But is any effort made to find out if they had other HIV risks, such as unsafe healthcare? Some receive a lot of healthcare, and in some countries women who receive reproductive care are far more likely to be HIV positive.

It may not be a popular view, but the rate of new infections among women taking part in this research is very high, higher than it is in Kenya, Uganda or Tanzania; 1% incidence could result in 8% prevalence or more after only 10 years. In Kenya, Uganda and Tanzania, prevalence has remained static at about 6% for much of the last decade. Why are transmission rates so high in this population in Zimbabwe? Those infected clearly face non-sexual risks, but researchers don't seem to want to ask what those risks are, or to investigate them.

It is inconsistant, indeed futile, to aim to reduce HIV transmission from mothers to their children when it is not even known how the mothers are being infected because reducing infection in mothers is far preferable to waiting until they become pregnant and then offering them PMTCT, and may even be more easily achievable.

[There have been many cases of unexplained and/or unexpected HIV transmission among women, men and children in Zimbabwe and further instances in most other sub-Saharan African countries.]



Petit Poulet said...

For a young woman, nearly all of the medical interventions they encountered are focused around delivering a baby. Not a surprise that this population is prone to iatrogenic HIV infections.

Simon said...

Indeed, no surprise. And the medical interventions sex workers face are focused around vaccination against and treatment for sexually transmitted diseases in places where other sex workers, drug users and those at risk of being infected with sexually transmitted diseases go.