Tale of Two Epidemics. Part 3

The availability and acceptance of voluntary and confidential HIV counseling and testing services are critical in enabling pregnant women to determine their HIV infection status and to be able to access preventive interventions, and additional resources will be required in many settings to introduce such programs. The Joint United Nations Programme on HIV/AIDS and nongovernmental organizations such as the Elizabeth Glaser Pediatric AIDS Foundation Call to Action program are providing funding for infrastructure development for MTCT prevention programs at sites in the developing world. Additional partnerships between donors; international, national, and local governments; and nongovernmental organizations will be essential to the development of effective and sustainable MTCT prevention and care programs

However, inadequate funding and poor health care infrastructure are not the only obstacles. Even in settings where HIV counseling and testing services are available, the social stigma associated with HIV infection inhibits many women from using such services to learn their HIV infection status and, therefore, from taking steps to prevent transmission of HIV to their infants. The lack of availability of treatment for HIV infection or its complications in many resource-limited countries leads to an individual and societal perception that there is no benefit to be gained from knowledge of one’s HIV infection status, which further increases the stigma associated with HIV infection

There have been some successes in implementing prevention programs in resource-limited countries, with one of the key elements being support of the program by the health ministries and government. Thailand became the first resource-limited country to implement a national MTCT prevention program, which includes support of routine voluntary counseling and HIV testing for pregnant women and offers short-course zidovudine prophylaxis and infant formula to HIV-infected women. Other countries, such as Botswana and Cote d’Ivoire, are also in the process of implementing national MTCT prevention programs

Prophylactic use of antiretroviral drugs for which a single genetic mutation can confer drug resistance, such as nevirapine or lamivudine, has been a concern. Nevirapine resistance has been detected at 6 weeks postpartum in 18% of women receiving single-dose, intrapartum drug, but resistant virus did not persist as detectable quasi species at 12–18 months postpartum. The clinical significance of this finding is uncertain; theoretically, with reestablished predominance of wild-type virus, the efficacy of single-dose nevirapine prophylaxis for subsequent pregnancies is likely to be maintained. In addition, the response to therapy containing nonnucleoside reverse-transcriptase inhibitors in an individual for whom long-term therapy has previously failed, compared with an individual who has transient detection of resistance mutations after exposure to a single dose of nevirapine, may differ. Although further study is needed to evaluate response to future prophylaxis and treatment in women who have received single-dose nevirapine, the World Health Organization concluded that the established benefit of single-dose nevirapine in preventing MTCT outweighs the theoretical risks.