The first formally recognized finding of human immunodeficiency virus (HIV) in patients in 1981 in the USA and its spread across the globe started one of the biggest research topics ofhuman medicine. What is often referred to as acquired immune deficiency syndrome (AIDS) is a complex and divers’ system of viruses. HIV strains collected from all around the globe have shown to have a large variety. Human immunodeficiency virus type 1 (HIV-1), the retrovirus that affects humans, can be separated into three subcategories. The first being group N and O, which are rarer than the most common strain, group M. This group is found in an estimated 98% of all HIV-infected around the globe (Sharp & Hahn, 2010). Sub-Saharan countries still have an unproportional part of the global HIV infection compared to the rest of the globe. In2013 Sub-Saharan countries, despite only being home to around 12% of the global population, have been estimated to account for almost 71% of global HIV infections. The most common form of getting infected by HIV is by heterosexual contact, followed by mother to child transmissions (MTCT). Women are disproportionately affected by HIV. 58% percent of people living with HIV are women (Kharsany & Karim, 2016) and young women are twice as likely to acquire HIV as their male counterparts (UNAIDS (2), 2017). Antiretroviral therapy (ART) has made living with HIV possible. The once fatal disease can be treated with medicine, that allows an almost normal life by suppressing the virus and even vertical transmission can be prevented. The increasing availability of such drugs has caused a decline in AIDS related deaths in sub-Saharan regions over the years of around 39% from 2005 to 2013, however the total number of these deaths is still high, especially compared to other regions of the globe (Kharsany & Karim, 2016). ART coverage increased significantly in east and west African regions from around 24% to 54% from 2010 to2015. Over 10.3 million people were reached with that treatment (Department ofHealth, 2015).
Even with the slowly declining numbers of infected people and people with no access to treatments this still is a big issue that should be tackled and done more research on, especially the mother to child transmission ofHIV. MTCT contributes largely to the number of children affected by HIV by the age of ten and under. Estimates say around 1600 children infected by HIV get bom every day with a large proportion of them in sub-Saharan regions. Whilst in developed countries different treatments before, during and after birth have decreased transmission rates from 25-30% down to less than 2%, countries in the sub-Saharan area do not show such declining numbers due to social, cultural and economic barriers (McIntyre & Gray, 2009).
This paper aims to point out why this should be worked on more and why factors like education and reducing social stigma should be advanced in order to enable a faster decline of vertical transmission numbers. As the numbers above show, MTCT is still an issue in sub- Saharan countries that must be addressed. Furthermore, this paper is going to explain how the basic mechanisms ofMTCT work and how it possibly can be prevented in every stage of the pregnancy. Furthermore, this paper tries to explain why social, cultural and economic factors play such a big role in fighting against HIV and are challenges that must be tackeld. By the end it should be clear, how all these factors tie together and what future research could be done in order to reduce the numbers of people getting affected by HIV and especially infants and young people.
The mechanisms of vertical transmission
In2015 the Department ofHealth of South Africa conducted a study to determine the number of women attending public sector antenatal clinics in south Africa, which were HIV positive. In South Africa around 30.8% of these women were HIV positive with large
regional differences from 18.9% in West Cape up to 44.4% in KwaZulu-Natal (Department ofHealth, 2015).
Due to the lack of prevention ofMTCT, around one third of these women will infect their children with HIV-1 (McIntyre & Gray, 2009). From this research it is explained how children can get infected in three ways: before the child is bom in utero, during the birth and postnatally. The risk of getting infected in each of those stadiums is influenced by various factors.
The risk before the child’s birth, for example, is influenced by factors like clinical chorio- amnionitis, which is an inflammation of the placenta or the placental membrane that has shown to lead to a significantly higher rate of vertical transmission. But other factors like maternal cigarette smoking or intravenous drug use during the pregnancy have also shown some evidence to have an effect on MTCT (McIntyre & Gray, 2009). Another decisive factor that influences the risk of an infection is a low cluster of differentiation 4-level (CD4). CD4 in general is a measurement ofhow well your immune system is operating. Individuals, who are affected by HIV, have a low count, usually between 200-500, while healthy individuals have a number between 500-1200 (“CD4 count or T-cell count”, n.d.).
During the birth the child can be infected by getting in contact with blood or other secretes that contain the virus by small wounds or breaks in the skin. Also, the risk during birth is heavily influenced by the mode of delivery. An analysis of over 8500 births showed that woman who delivered their child with elective caesarean section reduced the risk of perinatal transmission by 50%. Twin birth children have shown to have different chances of getting infected based on the order in which the children are born. The first child has an infection rate of35%, while the second child only has an infection rate of 15%. Caesarean section delivery can lower these numbers from 35% to 16% and from 15% to 8%.
But even after the delivery children can infected with HIV. The most prominent factor for this is breastfeeding, which alone has been associated with an additional risk of 14-18% (McIntyre & Gray, 2009).
Prevention possibilities of mother to child transmission
In 1983 the first 21 infants with unexplainable immunodeficiency were found. This seemed to be the first evidence that HIV-1 could be passed on from infected mothers to their children (Centers for Disease Control and Prevention, 1983). Since then there has been a significant advance in the treatment, which has made a vertical transmission - in theory - very unlikely. However, this advance has only shown its real effects in the developed countries, while developing countries, which often have a large HIV burden, have not experienced much benefit from those advancements in medicine, as it can be seen in the difference in the earlier mentioned transmission rates. Only half of the women in sub-Saharan Africa, who are infected with HIV, get an ART treatment to prevent MTCT in the first place (Ondenge etal., 2014).
The prevention of the transmission has made a lot of progress ever since the first infants with HIV were found. For every stage that allows MTCT (in utero, birth, breastfeeding) different treatments have been found and developed over time.
Pre-pregnancy and family planning
The first step of preventing MTCT is even before pregnancy; by possibly preventing the pregnancy itself. Many prevention programs encourage women, who are tested HIV positive, to limit the number of unwanted children. Unwanted pregnancies play a big role in the number ofHIV positive infants, asa2014 study about the sexual and reproductive health ofHIV positive women found out. Nearly 60% of the participants said they had at least one unwanted pregnancy (Salamander Trust, 2014). Sub-Saharan countries do not only have the
highest number ofHIV individuals, but also the highest unmet need for contraception. About 20% of women in those regions have reported to have an unmet need for contraceptives (UNFPA, 2016). Despite integrating family planning services into HIV care and treatment services, there has yet been found no statistically significant evidence, that this had a positive influence on reducing unintended pregnancy, although these programs provide modern contraceptive methods and knowledge about the dangers of pregnancies with HIV (Haberlen, Narasimha, Beres & Kennedy, 2017).
Prevention in utero
As earlier mentioned, the CD4 count in the blood is linked to the risk of a vertical transmission. ARTs have made it possible to suppress the viral load in the blood, thus making a transmission more unlikely. ART programs have made a huge progress since more and more countries implemented protection of mother to child programs (PMTCT) into their healthcare systems. In 2014, 21 sub-Saharan countries provided ARTs to 77% of women living with HIV compared to 37% in 2009. This shows a good progress towards total ART cover, however, some countries still struggle to provide ART treatments on a national level, like Ethiopia, which implemented free ARTs in 2005 but still struggled to provide them in 2015 (UNAIDS, 2015).
Prevention during and after birth
One big step in preventing MTCT during the birth is by using elective caesarean section. As mentioned above, this has severe advantages compared to a natural birth, since the risk of the infant getting in touch with blood or other secretes that contains the virus is heavily reduced.
However, one of the biggest parts in preventing a vertical transmission starts after birth. The 2017 progress report by UNAIDS has stated, that about half of the infections that occurred that year, happened during breastfeeding. One of the biggest challenges is keeping the women with HIV in an effective ART treatment (UNAIDS, 2017). It seems that many women stop taking their ARTs after they give birth. The WHO gave different guidelines over the years on how to minimize the risk of vertical transmission, based on new findings in medicine. The general conduct was to avoid breastfeeding, if possible. However, in some regions this might not be an option due to various factors, like unavailability of certain replacement feedings. For women who had to breastfeed, the WHO set up a guideline on which medicine should be taken. One of the first effective medicine, that was found, was called Nevapirine in 1999 and it reduced the risk of vertical transmission by nearly 50% during the first 14-16 weeks after birth on breastfed children (Guay et al.,1999). But, as we have seen, widespread supply of such medicine did not happen until the mid 2000s and is still not available everywhere today. In2011,35 countries at the UN decided a global plan on elimination ofMTCT. Target of this plan are low- and middle-income countries, like Ethiopia and other sub-Saharan countries, which account for most HIV positive children. The main goals were to reduce HIV related deaths of infants by more than 50% and providing ART for all mothers and infected children in order to reduce HIV infections of infants by 90% (UNAIDS, 2015). As a UNAIDS report shows, their measurements seemed effective, at least in adult HIV patients. In 2018, the AIDS-related deaths were at a decade record low, with fewer than one million people dying of AIDS-related illness and over 21 million people on treatment, over two million more than in 2016. However, their set goal of reducing infant infections for 2018 was missed and only half of under 15-year old’swere on treatment by 2017 (UNAIDS (3), 2018).
Barriers on accessing ART
With the previous numbers in mind the question arises, why the numbers for children and young people have such trouble on declining. The answer to this question is far more complex than it might seem at first glance.