Hiv/Aids

Preventing mother-to-child transmission of HIV in women of unknown HIV status

Single dose intrapartum and neonatal nevirapine for the prevention of mother-to-child transmission of HIV (MTCT) has been available free of charge to the developing world from the manufacturer since 2000. Yet only 189,000 courses have been distributed to the developing world, less than 5% of the estimated need. This may be because of the current policy requiring a positive HIV test in the woman, whereas in many situations, most women have not been tested. In places where voluntary counselling and testing (VCT) services are being set up, there can be a delay of up to 18 months between initiating the service and it being fully functional. In one study, it was estimated that an extra 300 infants were born with HIV during this interval, despite there being a ready supply of nevirapine. In places such as war zones, remote villages and exceptionally resource-poor settings, HIV testing is unlikely to become available. Even in places where testing is available, mothers may choose for social or other reasons not to be tested. By refocusing the policy on the prevention of MTCT rather than linking it to the necessity for testing, the aim of reducing such transmission could be more easily achieved. Basing treatment on the probability of diagnosis in this way is not a radical idea–close contacts in meningitis outbreaks, pregnant women at risk from schistosomiasis or malaria, and in many other situations, individuals are treated without a confirmed diagnosis, particularly when drugs are free of charge. The authors suggest that there is no reason why this same approach should not be adopted for preventing MTCT of HIV by treating all pregnant women in high-prevalence areas with nevirapine at delivery. It would be important, however, to ensure that such a policy did not undermine the expansion of VCT services, which are valuable in their own right.¹ Prevention of transmission through breastfeeding would also remain problematic.

1. Stringer JSA, Rouse DJ, Sinkala M, et al. Nevirapine to prevent mother-to-child transmission of HIV-1 among women of unknown serostatus. Lancet 2003;362:1850–53.

Contradictory evidence on whether or not hormonal contraceptives increase the risk of HIV acquisition in women

Two studies contain contradictory evidence on whether or not the use of hormonal contraception (in the absence of condom use) increases the risk for women of HIV infection. A ten-year prospective study in a cohort of 1,272 HIV negative sex workers in Mombasa, Kenya, who attended a sexual health clinic monthly, found that 248 of the women seroconverted for HIV at a rate of 8.5 per 100 patient-years of follow-up. Multivariate analysis which controlled for type of sexual behaviour, condom use and presence of STI s found that the women using hormonal contraceptives were at significantly increased risk of HIV infection (1.5, 95% CI, 1.0–2.1, p=0.03) with oral or injectable hormonal contraceptives.¹

A study among 161 women in Mombasa who became HIV positive and whose date of infection could be accurately estimated were followed for a median of 34 months after the time of infection. Those using the injectable Depo Provera were also found to be at increased risk of HIV infection. They were also at greater risk (two- to three-fold) of having early multiple viral strains, which is strongly associated with more rapid CD4 cell count decline and faster disease progression.² This author postulates three ways in which hormonal contraceptives might increase risk of HIV infection: thinning the genital epithelium, thereby reducing its effectiveness as a barrier; increasing the number of cells susceptible to infection; and direct effects on viral expression.

A study by the Rakai Project Study Group in Rakai, Uganda on the relationship between contraceptive use and HIV risk analysed data from more than 5,000 initially HIV negative sexually active women who had access to a range of contraceptive methods. During the study, 202 women became HIV positive, of whom 159 were not using any method, 12 were using the pill, 16 injectables and 15 condoms (inconsistently). After adjusting for numbers of sexual partners, marital status, age and the presence of genital ulcer disease, use of hormonal contraception did not affect the risk of HIV infection. Among the 350 women who reported consistent condom use, none became HIV positive.³

Differences in the study populations, number of sexual partners and STIs controlled for, as well as in the level of adjustments made to assess risk may account for the contradictory findings. Meanwhile, women at risk of HIV infection who wish to avoid pregnancy need to use condoms and possibly another contraceptive as back-up.

1.	Lavreys L, et al. Hormonal contraception and risk of HIV-1 acquisition: results of a 10 year prospective study. Antiretroviral Therapy 2003;8(Suppl.1):206. Summary on AIDSMAP, 15 July 2003.
2.	Dr. Baeten. Abstract 116. Presentation at: 10th Conference on Retroviruses and Opportunistic Infections. 12 February 2003. From: IPPF NewsNewsNews, 24 February 2003. At: 〈http:// www.ippf.org〉
3.	Kiddugavu M, Makumbi F, Wawer MJ. Hormonal contraceptive use and HIV-1 infection in a population-based cohort in Rakai, Uganda. AIDS 2003;17:233–40. Summary on AIDSMAP, 22 January 2003. At: 〈http://www.aidsmap.com/news〉.

Yeast infections in HIV-positive women

The yeast Candida albicans is carried in the genital tract of between 10% and 55% women. The change from asymptomatic infection to clinical disease is usually associated with factors such as pregnancy, diabetes, antibiotic use, high oestrogen oral contraceptives and tight synthetic underwear. This study of 184 HIV-positive women showed that 64 (35%) carried yeast in their vagina, of whom 19 (10%) showed symptoms of vaginal candidiasis (yeast infection). There was no association of carriage or clinical infection with race, antiretroviral or antibiotic use, condom use or vaginal pH. Self-report of clinical disease was highly inaccurate. Only 12% of those reporting infection had confirmed vaginal candidiasis, though they often had vaginal infection from other causes, and 10% of women who did not think they had a yeast infection were clinically diagnosed with one. Of the women with positive yeast cultures, only a CD4 count less than 100 cells/mm³ was predictive of disease. Thus yeast infection did not appear to be a significant marker of HIV progression until late in the course of AIDS.¹

Yeast infection is frequently recurrent. Two self-help methods commonly used to prevent and treat episodes are weekly intra-vaginal application of Lactobacillus acidophilus and weekly intra-vaginal application of clotrimazole tablets. A study of these methods in 164 HIV-positive women showed that the rate of infection was reduced by half using either of the two treatments compared with placebo, and that there was a significantly delayed time to a subsequent episode of yeast infection. This suggests that these methods may be acceptable alternatives to long-term, broad spectrum, antifungal therapy in HIV-positive women.²

1.	Williams AB, Andrews S, Tashima K, et al. Factors associative with vaginal yeast infections in HIV-positive women. Journal of the Association of Nurses in AIDS Care 1998;9(5):47–52.
2.	Williams AB, Yu C, Tashima K, et al. Evaluation of two self-care treatments for prevention of vaginal candidiasis in women with HIV. Journal of the Association of Nurses in AIDS Care 2001;12(4):51–57.

Placing HIV testing at the centre of prevention and care

As HAART drugs begin to become available, it is possible that a serostatus approach to HIV/AIDS in Africa, where every African adolescent and adult knows their own status, could improve current programmes in prevention and health-care. For example, HIV risk reduction strategies are of more value when both partners in a relationship know and are prepared to disclose their HIV status. The promotion of such an approach would need expanded versions of current testing programmes, such as routine testing during health checks along with counselling. To encourage individuals to learn their HIV status, clear messages need to be given, highlighting the risks of not knowing their status to the person themselves and their sexual partners and for babies of pregnant and breastfeeding mothers. At the same time, there is a need for clear explanations of how knowing their HIV status helps individuals reduce these risks by, for example, disclosure of status to sexual partners, appropriate use of condoms and seeking of medical advice and care by those who are HIV-positive and for pregnant women. The newer, simplified, rapid clinical tests should make universal testing easier, but policies need to re-focus on public health needs, to enable the appropriate expansion of prevention and treatment services.¹

1. De Cock KM, Marum E, Mbori-Ngacha D. A serostatus-based approach to HIV/AIDS prevention and care in Africa. Lancet 2003;362:1847–49.

Free antiretrovirals for Thailand's AIDS patients

The Thai government has launched a 1 billion baht (US$25 million) programme to provide free AIDS drugs and decrease the spread of HIV. The programme should reach 50,000 people and is aimed particularly at post-partum women and children. It will focus on those whose clinical symptoms are still at a relatively mild stage, but all infants under one year old will be eligible to receive drugs, regardless of their clinical condition. According to the Public Health Minister, Sudarat Keyuraphan, Thailand has already had some success in slowing the rate of infection through campaigns to promote the use of condoms. Now it will use generic versions of antiretroviral drugs, manufactured by its own Government Pharmaceutical Organization, for the programme.¹

1.	On ProCAARE, October 2003. At: 〈http://www.procaare.org/archive/procaare/200310/msg00004.php〉.

Priority-setting exercise for health care interventions in Uganda: PMTCT ranked lower than other major health problems

Health care interventions come with both a financial and a political cost which influence policy. Deciding which interventions to prioritise is particularly difficult in countries with a very low income. Five groups of stakeholders–members of the general population, health workers, district planners, patients living with HIV, and patients with hypertension–six to eight people in each category, were asked to prioritise nine interventions that can improve health. They were then given comprehensive information and group discussion time on the characteristics of each health problem, details of its prevalence and incidence and the coverage and cost-effectiveness of the relevant intervention. They then reconsidered their rankings, giving reasons for their decisions.

Using insecticide-treated nets for malaria prevention was consistently ranked top overall. Treatment for malaria, pneumonia and diarrhoea came next in the ranking, higher than the prevention of vertical transmission of HIV by administration of nevirapine at delivery. It was ranked fifth both before and after discussion, along with comments that treating adults with HIV should be a higher priority than vertical transmission. Those with HIV ranked MTCT sixth both before and after discussion, whereas the general population group ranked it second before they received information and fourth afterwards. This study shows that stakeholders are open to considering evidence in assessing the relative priority of different interventions that are competing for scarce resources. The authors call for their views to be incorporated into policymaking.¹

1.	Kapiriri L, Robbestad B, Norheim OF. The relationship between prevention of mother to child transmission of HIV and stakeholder decision making in Uganda: implications for health policy. Health Policy 2003;66:199–211.