Women and children issues
Vertical transmission of HIV infection can occur before, during or after
delivery, although most indirect evidence now suggests a limited role for the early
- With the advent of effective anti-retroviral therapy perinatal HIV infection has
become a preventable disease, using a long regimen of zidovudine during pregnancy, at
labour and in the neonatal period to reduce the risk by nearly 70%.
- Now, a cheaper short course of oral zidovudine has been shown to reduce
transmission by 50%.
- Reduction in maternal viral load at delivery was estimated to account for 80% of
the reduction in vertical transmission rate.
- Adherence to and tolerance of prenatal and intra-partum zidovudine therapy in a
randomised trial of a short course of zidovudine in a breastfeeding population in Cote
DIvoire, showed that women could take the antenatal component of the regimen well.
However, adherence to the intra-partum component was a problem. Zidovudine was found to be
well tolerated by both mothers and children, with little evidence of serious adverse
- Elective caesarean section delivery can also reduce vertical transmission by 50%,
even after allowing for other risk factors known to be associated with increased risk.
- Other approaches to interventions include cleansing of the birth canal, and the
administration of multivitamins. Post-natal transmission through breastfeeding remains a
problem, especially in countries where safe and affordable alternatives are not available
and antenatal prevalence tends to be the highest.
- Globally more than 40% of women do not have a skilled attendant during labour and
delivery, while more than 30% of women do not receive adequate antenatal care essential to
the general health and wellbeing of mothers and children.
- In a randomised-placebo controlled trial in Tanzania, the administration of
multi-vitamins, but not Vitamin A alone, was found to result in a decrease of adverse
pregnancy outcomes, measured as fetal deaths, low birthweight, preterm birth and small for
- Counselling to support women and to help them make informed decisions based on
their individual circumstances is essential. Studies in different geographical regions on
current breast-feeding practices and preferences are needed in addition to information on
the impact on HIV transmission of possible options for women such as shorter duration of
breastfeeding, mixed feeding, and breast milk substitutes.
- With respect to timely access to voluntary counselling and testing for pregnant
women, the advantages and disadvantages of same day results need to be explored further.
While rapid tests are now logistically and technically feasible, whether this approach is
appropriate for pregnant women will require further debate. Women often may want and need
to consult with spouses, family members and friends about whether to have an HIV test
and in some circumstances consent for such a procedure must be communal as opposed
Gay men and men who have sex with men issues
More and more public health interventions use a "community-based"
approach requiring that we have a clearer idea of what communities are and what they can
do. Gay communities, for example, are facing new, more complex problems of prevention
education with success, and this may be relevant for other populations.
- Some young gay men are at enhanced risk for HIV infection in some places and in
some epidemics. However, the strength of this association between sexual risk-taking and
age remains complex. A new study from Berlin, for example, reported that risk-taking was lowest
among the 16 to 21 age group, with only "sporadic" unprotected sex occurring.
- The use of "negotiated safety" as a successful safe sex strategy was again revealed in new
Australian data from a national telephone study. These successful negotiations point the
way to new and diversifying responses by our gay communities, something that may offer
prevention education guidance to problems of prevention yet to emerge among other
- This highlights the importance and utility of promoting voluntary counselling and
testing and providing access to this critical prevention resource to communities around
the world, as was emphasised in several of the presentations in the session on counselling
- The Amsterdam cohort study recently found that multiple loss and grief, while
related to depression, was not related to increased risk-taking and may actually increase
gay mens resolve to stay safe in their sexual practices.