Supplement
Reducing the risk of mother-to-child human immunodeficiency virus transmission: past successes, current progress and challenges, and future directions

https://doi.org/10.1016/j.ajog.2007.06.048 Get rights and content

Prevention of mother-to-child transmission (PMTCT) of human immunodeficiency virus (HIV) in the United States and Europe has been a tremendous success, such that transmission rates of less than 2% have been achieved. Some key successes have also been demonstrated in resource-poor countries; however, the translation of successful interventions into public health policy has been slow because of a variety of factors such as inadequate funding and cultural, social, and institutional barriers. The issue of HIV and infant feeding in settings that lack culturally acceptable, feasible, affordable, safe, and sustainable nutritional substitutes for breast milk is a continuing dilemma. An effective preventive infant HIV vaccine would be an optimal approach to reduce HIV acquisition in the first year of life among breast-feeding infants. The challenges to eliminate new perinatal HIV infections worldwide will depend on both sustaining and expanding PMTCT interventions and effective primary HIV prevention for women, adolescents, and young adults.

Section snippets

U.S. Experience

In 1992, at the peak of the U.S. perinatal epidemic, close to 2000 babies in the United States became HIV infected, whereas currently fewer than 200 infants become HIV infected annually (see related article is this issue by McKenna et al). The dramatic success in reducing perinatal HIV transmission across the United States was due in large part to the rapid translation of research trial findings into practice. This was achieved through the combined leadership of the U.S. Public Health Service,

Remaining Gaps and Challenges in Perinatal HIV Prevention Efforts in the US

Despite the dramatic reductions in perinatal HIV and pediatric AIDS seen over the past decade, babies in the United States are still becoming HIV infected. Some of the ongoing issues and program gaps include practitioners who continue to offer HIV testing only to those women they consider at high risk despite CDC recommendations for routine HIV screening for all pregnant women unless they decline; lack of retesting to identify the subset of women who test negative early in pregnancy but then

International Experience in PMTCT

Internationally, following the results of PACTG 076, a number of randomized trials were undertaken to see whether simpler short-course regimens deliverable in resource-limited settings could also significantly reduce the risk of perinatal HIV transmission. The first of these studies’ results were announced in 1998 and included 2 CDC short-course ZDV trials in Thailand and West Africa in which pregnant women were given either oral ZDV or placebo from 36 weeks through labor/delivery. In the

International Trials Aimed at Reducing Transmission among HIV-Infected Women Who Breast-feed

Current international trials are directed at maximally reducing the risk of transmission among breast-feeding HIV-infected women in resource-limited settings in which breast-feeding is the norm and in which not breast-feeding is associated with high infant mortality. A number of different trials are currently underway or about to begin in east, west, and southern Africa. Strategies being assessed include the following: (1) use of 2 antiretrovirals such as short-course zidovudine/lamivudine or

Current Challenges and Program Gaps Internationally

Despite the impressive efficacy of the short-course PMTCT regimens in research clinical trial settings, the translation into public health policy in resource-limited international settings has been disappointingly slow, compared with the rapid widespread implementation seen from the mid-1990s in resource-rich settings. This is due to a variety of factors including weak and crumbling health care infrastructure in some settings, lack of integration of PMTCT programs into maternal child health

Future Directions for PMTCT in the US and Internationally

In the United States, the translation of PMTCT research into practice has been 1 of the major successes in public health efforts to prevent HIV infection. However, lessons from experiences with other diseases such as tuberculosis demonstrate that when successful public health efforts are taken for granted, the gains may be temporary. To sustain achievements, not only do the efforts that led to the declines in perinatal HIV transmission need to continue, but ongoing surveillance of the scope and

References (34)

  • US Public Health Service recommendations for human immunodeficiency virus counseling and voluntary testing for pregnant women

    MMWR Morb Mortal Wkly Rep

    (1995)
  • E.R. Cooper et al.

    Combination antiretroviral strategies for the treatment of pregnant HIV-1 infected women and prevention of perinatal HIV-1 transmission

    J Acquir Immune Defic Syndr Hum Retroviral

    (2002)
  • Elective caesarean-section versus vaginal delivery in prevention of vertical HIV-1 transmission: a randomised clinical trial

    Lancet

    (1999)
  • The mode of delivery and the risk of vertical transmission of human immunodeficiency virus type 1—a meta-analysis of 15 prospective cohort studies

    N Engl J Med

    (1999)
  • Committee opinion: scheduled cesarean delivery and the prevention of vertical transmission of HIV infectionNo. 234

    (2000)
  • M. Bulterys et al.

    Rapid HIV-1 testing during labor: a multi-center study

    JAMA

    (2004)
  • J.L. Gerberding et al.

    Dear colleague letter

    (2003)
  • Cited by (97)

    View all citing articles on Scopus

    The views expressed herein are those of the authors and do not necessarily represent the views of the Centers for Disease Control and Prevention.

    View full text