PCP HIV AIDS Toolkit/HIV Transmission/Handout I: MTCT

Handout I: Mother-to-Child Transmission (MTCT)
Mother-to-child HIV transmission (MTCT) is responsible for the majority of new HIV infections in children worldwide. Without intervention, approximately one third of infants born to HIV-positive mothers will become infected with HIV.

There are three ways in which HIV can be transmitted from mother to child:
 * During pregnancy
 * During labor and delivery
 * Through breast-feeding

The risk of MTCT is affected by several factors, including the stage of infection of the mother, delivery method (e.g., cesarean section or vaginal), the breast-feeding pattern and duration, presence of oral or breast lesions, gastrointestinal illness of the child, and whether the mother and child were given antiretroviral (ARV) therapy during labor and after birth.

While it is impossible to completely prevent mother-to-child transmission of HIV, it is possible to greatly reduce the risk of HIV infection of the infant.

During pregnancy, labor, and delivery:
 * During pregnancy, HIV can cross over from the mother to the baby’s bloodstream.
 * During labor and delivery, HIV infection can occur when blood or other infected maternal fluids pass into the baby’s body.
 * Delivery by cesarean section, and distribution of ARV treatment late in pregnancy and/ or during labor and delivery reduces the risk of HIV transmission.

Through breast-feeding:
 * Several conditions can increase the risk of MTCT during breast-feeding, such as the mother’s HIV viral load, the duration of breast-feeding, oral thrush in the infant, and the presence of bleeding nipples, breast inflammation, and mastitis.
 * Mixed feeding (feeding both breast milk and other foods or liquids) may also increase the risk of HIV transmission. Supplemental foods and liquids can cause gastrointestinal illness in infants, which can increase the risk of HIV infection.
 * Women who become infected with HIV while they are breast-feeding are more likely to transmit HIV to their infants through breast-feeding because of the higher viral load associated with acute infection.

Infant feeding options for HIV-positive women:
 * Lack of breast-feeding has been shown to expose children to an increased risk of malnutrition and life-threatening infectious illnesses other than HIV, particularly in the first year of life. This is especially true in developing countries, where more than one-half of deaths under the age of five are associated with malnutrition.
 * The risks associated with not breast¬-feeding vary according to the mother’s economic status, and the availability of appropriate replacement food and clean wa¬ter.
 * When deciding on the best infant feeding option for an HIV-positive mother, the increased risks of infant morbidity and mortality associated with replacement feeding must be weighed against the risk of HIV transmission.

The most recent guidelines from organizations such as WHO, UNICEF, UNFPA, and UNAIDS on infant feeding for HIV-positive women state:
 * When replacement feeding is acceptable, feasible, affordable, sustainable, and safe, avoidance of all breast-feeding by HIV-infected mothers is recommended. Otherwise, exclusive breast-feeding (where an infant receives only breast milk and no other liquids or solids, not even water) is recommended for the first months of life and should be discontinued as soon as the above conditions are met. Exclusive breast-feeding may reduce the risk of HIV transmission because unclean food/water can cause gastrointestinal illness in the infant, which creates an environment where HIV infection is more likely.
 * To minimize the risk of HIV transmission, breast-feeding should be discontinued as soon as possible, taking into account local circumstances, such as the individual woman’s economic situation and the availability of replacement feeding.
 * When HIV-positive mothers choose not to breast-feed from birth or stop breast-feeding later, they should be provided with specific guidance and support for at least the first two years of the child’s life to ensure adequate replacement feeding.
 * All HIV-positive mothers should receive counseling, which includes provision of general information about the risks and benefits of various infant feeding options, and specific guidance in selecting the option most likely to be suitable for their situation.

HIV testing issues for infants born to HIV-positive mothers

 * Early diagnosis of HIV infection in young children is important because HIV progresses more rapidly in young children.
 * Infants automatically acquire their mother’s antibodies and may carry them for two years or more.
 * Diagnosis of HIV infection in young children (younger than 18 months of age) is difficult because standard HIV tests are not able to differentiate between maternal and infant HIV antibodies. Hence, an infant may test positive for HIV, even if they are not infected with the virus, because they are carrying their mother’s HIV antibodies.
 * More sensitive HIV tests able to detect HIV infection in children younger than 18 months exist, but are more expensive and not available in all settings.