Managing Mother-to-Child Transmission of HIV Infection in Developed-Country Settings

Abstract

This article reviews current understanding of the management of mother-to-child transmission of HIV-1 infection in the context of developed-country settings. The advent of highly active antiretroviral therapy has facilitated the virtual elimination of mother-tochild transmission of HIV infection in developed countries, reducing transmission rates to approximately 1-2%. This review describes the epidemiology of HIV infection among women of child-bearing age and the risk factors, timing and mechanisms of mother-tochild transmission, followed by a discussion of the identification of pregnant HIV-infected women and their therapeutic and obstetric management.This review will focus on the management of mother-to-child transmission (MTCT) of HIV-1 in developed-country settings. However, the vast majority of pediatric HIV infections acquired from mother to child take place in developingcountry settings, mainly in sub-Saharan Africa, which is home to 60% of people living with HIV infection worldwide. The World Health Organization (WHO) has published extensive guidelines on the use of antiretroviral drugs for treating pregnant women and preventing MTCT in resource-constrained settings [1] and on infant feeding, together with the United Nations International Children's Emergency Fund (UNICEF) and the United Nations Programme on HIV/AIDS (UNAIDS) [2]. Although evidence from clinical trials and studies in developing countries have identified effective interventions for prevention of MTCT in such settings, implementation of these and expansion of prevention of MTCT services remains a substantial challenge [3][4][5][6], as does prevention of HIV infection in women of childbearing age (Box 1).

Mother-to-child HIV transmissions in Israel, 1985–2011

“…The benefits of HAART in both preventing MTCT and reducing the progression of disease are well established, yet, the intervention should be weighed against concerns about drug toxicity and possible adverse pregnancy events. Previous publications have reported premature delivery and pre-eclampsia which was associated with prolonged use of antenatal of HAART [4, 16, 17].…”

“…Maternal characteristics, such as older age and the use of illicit drugs, have been associated with perinatal HIV transmission [3]. Additionally, vaginal delivery ( vs. caesarean section), prolonged duration of rupture of membrane (PROM) and possibly invasive obstetric procedures might also increase transmission risks [4]. Breastfeeding, especially when performed non-exclusively, is associated with a higher risk of MTCT [5], and mothers are therefore recommended to use formula feeding.…”