HIV This Week

Pai NP, Klein MB. Rapid testing at labour and delivery to prevent mother-to-child HIV transmission in developing settings: issues and challenges. Womens Health (Lond Engl). 2009;5(1):55-62.

Worldwide, approximately 2.5 million children (95% CI: 2.2-2.6) are living with HIV infection. In 2007 alone, approximately 420,000 children (95%CI:350,000-540,000) were newly infected with HIV - a vast majority of these infections were acquired through maternal-foetal transmission. Many of these infections could have been reduced by timely diagnosis and the delivery of interventions aimed at preventing mother-to-child HIV transmission. This perspective examines the attitudes preventing women from accessing HIV testing early on during pregnancy and the issues and challenges that remain in the institutionalization of interventions to prevent mother-to-child HIV transmission at labour and delivery. Socio-cultural and economic factors prevent women from accessing testing at an opportune time during pregnancy. In addition, a lack of adequate infrastructure often prevents timely delivery of interventions to those who access testing at the last minute (i.e., during labour and delivery). In the wake of a paediatric HIV epidemic and the need for lifelong provision of antiretroviral therapy to infected children, a simple strategy for provision of round-the-clock rapid testing and counselling services in the labour rooms may be cost saving to the healthcare systems worldwide.

Editors’ note: Although studies of programmes of point-of-care rapid HIV testing in labour and delivery have been conducted around the world, the need for additional infrastructure resources, such as round-the-clock counsellors and user friendly and accurate rapid tests, has been an impediment to wider implementation. With only 33% of women needing antiretroviral prophylaxis in pregnancy worldwide actually able to access it, innovations are needed to improve coverage. Labour and delivery are not times conducive to reflection on the personal advantages and disadvantages of knowledge of serostatus but two-stage counselling (short prepartum and extended postpartum), attention to privacy and confidentiality, timely confirmation of results to reduce false-positives and false-negatives, and community-based education engaging partners and highlighting the importance of preventing HIV transmission to infants could identify more babies in need of intrapartum and post-exposure prophylaxis and more mothers needing tailored infant feeding counselling in addition to evaluation for antiretroviral treatment, and care and support.

Lazarus R, Struthers H, Violari A. Hopes, fears, knowledge and misunderstandings: responses of HIV-positive mothers to early knowledge of the status of their baby. AIDS Care. 2009;21(3):329-34.

Little is known about how HIV-positive mothers experience and react to knowing the HIV status of their baby as diagnosed by the polymerase chain reaction (PCR) test at 4-6 weeks. This qualitative study drew on interviews with 20 mothers of HIV-negative and 18 mothers of HIV-positive babies after receiving their baby’s PCR results. Thematic analysis combined exploration of themes that appeared significant to the participants and those relevant to health care. Amongst the themes identified were the following: The period before getting the results involved active mental preparation and was emotionally stressful. Most women accepted the results, but some had doubts about their reliability. Mothers of HIV-negative babies were relieved, but mothers of HIV-positive babies were generally very distressed and expressed a sense of responsibility and guilt. Both groups of mothers had similar hopes for the future of their babies, but the timelines of mothers of HIV-positive babies tended to be shorter. Most women experienced significant levels of stress, but were able to call on support networks and use various individual coping mechanisms to manage their stress. Most women were formula feeding their babies, but regretted not being able to breastfeed. Many women had not planned their current baby and most did not intend to have more children, but many of the latter had not taken active steps to prevent further pregnancy. The findings provide pointers to shortcomings in health worker communication and suggest that more effective communication should take account of normative community views and be more closely attuned to the changing needs and experiences of HIV-positive mothers.

Editors’ note: This study in the urban township of Soweto in Johannesburg, South Africa supports the notion that HIV-positive mothers prefer learning their babies’ status early at 4 to 6 weeks rather than waiting for 12 or more months until maternal antibodies disappear. The need for improvement in health care worker communication is evident from the fact that most of the mothers of infected children planned to replacement feed although breastfeeding offers more benefits to HIV-positive infants than risks of re-infection. As well, although most women said this baby had been unplanned and they would not want to have another, health care workers concentrated on condoms as means of reducing risk of transmission to partners, rather than as contraceptives, and some discouraged sterilisation as a more permanent fertility control option. This is a good example of how data collected using qualitative, in-depth interviews guided by a set of open-ended questions posed to end-users can underscore the need for training and enhanced service delivery.