What about the mother?
This refers to your article on concerns regarding the Prevention of Mother to Child Transmission (PMTCT) trials. (1) NACO’s programme to prevent mother to child transmission of HIV, although ambitious, was awaited by obstetricians all over the country, particularly in the high prevalence states, for five-six years. Many institutes have evidence that seropositivity of HIV amongst women who come in for prenatal care is above 1%, sometimes as high as 4-7%.
It is recommended internationally that all pregnant women should be counselled about the risk of perinatal transmission of HIV, the effect on the foetus, clinical manifestations of HIV infection, preventive measures, the availability of screening tests, the non-availability of curative drugs and vaccines, and the existence of antiretroviral drugs. After this, they should be offered testing. This can be described as the most reasonable and effective approach to prevent transmission of HIV from mother to foetus. (2)
One of the primary aims of counselling pregnant women on HIV is to inform them about the disease, its mode of transmission and means of prevention. This will lead to primary prevention of the disease. Such counselling is given in antenatal clinics where more than 90% of patients receive universal counselling.
Another aim of the PMTCT Programme is to improve antenatal care. This is also being done, and social workers, nursing staff and counsellors are now counselling women on nutrition, immunisation, contraception and breast feeding, besides HIV-AIDS. This is a welcome change. Antenatal waiting rooms are also getting a face-lift, thanks to the PMTCT programme.
However, though the programme is well conceived, the choice of intervention, particularly the ante-retroviral therapy, cannot be justified.
Once a pregnant woman is found to be HIV positive (sometimes this is known as early as in the first trimester) she is not supported with any intervention till the onset of labour. The drug Nevirapine is offered when a patient has received no antenatal care and has come to the hospital at the onset of labour. In the PMTCT programme, except for emergency admissions, most women are supposed to be aware of their sero-status during the antenatal period.
Why should women not be given the advantage of better antiretroviral therapy, a safer mode of delivery and good infant feeding options? The short course ante-retroviral therapy with Zidovudine has been successfully tried in Thailand as well as by NACO in their initial feasibility trials. It is surprising that NACO recommends Nevirapine as a final intervention programme saying that this the most it can give pregnant women who are HIV positive. The amount spent on training, workshops and meetings could be better utilised by giving the target beneficiary the best treatment rather than the poor compromise chosen by NACO.
Shuchita Mundle, Obstetrician and Gynaecologist, 39 Gajanan Nagar, Wardha Road, Nagpur 440 015.
- Rajalakshami TK. Programme to prevent mother to child transmission of HIV: Some concerns. Issues in Medical Ethics 2002; 10: 92-93.