New hope for preventing mother-to-child transmission of HIV

Juliet* speaks to her home visitation volunteer, Susan, who ensures that she is living a healthy life and taking her medication well. Susan is there to talk to Juliet about her struggles and concerns regarding HIV, medication and her positive daughter. (Madeline Dippel | The Media School)

KAMPALA, UGANDA — “When I was pregnant to my daughter, I went to the hospital and they advised counseling and testing,” said Juliet*  as she sat with her hands folded in her lap.

The testing was for HIV. She tested positive.

Had she been in a hospital that was a part of a pilot program using new drugs to prevent mother to child transmission of the HIV virus, her daughter would have been born negative instead of positive like her mom.

Juliet would have been given a single dose of Nevirapine during labor and her daughter would have been given a syrup of the same drug within the first 72 hours. This would have greatly reduced the chances of her daughter being born HIV-positive. Transmission is most likely when the mother’s viral load is high (the amount of the HIV virus in the bloodstream). When mothers are on antiretroviral drugs (ARVs) during pregnancy, their viral load drops to low levels and rates of transmission also drop to between one and five percent instead of 20 to 35 percent.

This antiretroviral drug intervention was the first pilot program specifically for prevention of mother to child transmission (PMTCT) in Uganda, beginning nearly 10 years after the United States began to practice prevention methods for mothers.

After she was born, Juliet’s daughter was started on lifelong ARVs almost immediately. Juliet’s viral load was not low enough to qualify for treatment in 2002, so she had to wait three years qualify for lifelong antiretroviral drugs.

“Fast forward to 2006, there was another policy that came into play,” said Dr. Emmanuel Mugisa, PMTCT coordinator at Baylor Uganda.

Now instead of waiting for the mother to go into labor, a short course of ARVs were administered starting in the third trimester of her pregnancy, he said. These drugs would be continued through labor and delivery until one week after the mother gave birth when the course of ARVs stopped. Rather than Nevirapine syrup, the baby was given an AZT (Zidovine) syrup for a week along with the mother.

It was not until 2010 when the World Health Organization (WHO) introduced Option A and Option B that pregnant women would have the option to immediately start on ARVs for life.

According to Dr. Moses Batwala at The AIDS Support Organization (TASO), an HIV-positive pregnant mother would be eligible if she had a CD4 count, the number of T-cells in the body, of >350 from 14 weeks throughout breastfeeding. Lifelong antiretroviral therapy (ART) would begin if the CD4 count was less than 350 or had a WHO stage three to four disease with six weeks of Nevirapine for the infant, attempting to halt transmission.

Option B provides long-term triple combination antiretroviral therapy during breastfeeding and six weeks of Nevirapine for the baby. If the mother had a CD4 count of less than 350 or a WHO stage three to four disease, she was given the combination antiretroviral therapy beyond breastfeeding.

According to the WHO, clinical stage three includes unexplained severe weight loss, persistent fever and chronic diarrhea for longer than a month, pulmonary tuberculosis and severe bacterial infections (i.e. pneumonia and meningitis). Clinical stage four includes Kaposi’s sarcoma (a type of cancer), chronic herpes, extrapulmonary tuberculosis and lymphoma.

Dr. Emmanuel Mugisa sits at his desk double-checking information about his HIV-positive clients, most of which are infants and their mothers. (Madeline Dippel | The Media School)

Beginning in 2012, WHO Option B+ was introduced, recommending lifelong antiretroviral therapy for all HIV-positive pregnant women or what is called “test-and-treat,” according to Dr. Mugisa. The woman is almost immediately counseled and prepared to start medication from that same day up to a week after being counseled.

“What is amazing is that the majority of these pregnant HIV-infected women will agree to start treatment immediately that same day,” said Dr. Mugisa

Mother to child infection rates dropped from 10 percent in 2010 to under four percent currently at Baylor Uganda. The goal of meeting the Global Plan’s milestone of reducing mother-to-child transmission to less than 5 percent was officially met in 2015—Uganda’s transmission rate in 2015 dropped to 2.9 percent.

With the continuing successes in PMTCT, there is no longer an emphasis on prevention, but elimination.

[*Juliet did not use her real name. Her identity is being concealed so she can avoid discrimination and harassment.]