Of the many tragedies caused by the HIV/AIDS epidemic, perhaps none is more disturbing than that of children who contract the virus from their mothers at birth or through breastfeeding. Methods exist for preventing mother-to-child transmission; sadly, most of the methods so far developed are difficult to implement in the very poor countries where most mother-to-child transmission occurs.
About one-half to two-thirds of mother-to-infant transmission is believed to occur at the time of birth (Reggy, Simonds, and Rogers 1997). The risk of HIV transmission from mother to newborns can be reduced by two-thirds, from 25 percent to about 8 percent, by administering zidovudine (AZT) to the mother before and during birth, and to the nonbreastfed newborn for six weeks after birth (Connor and others 1994). The total drug and related medical costs for the AZT regimen currently recommended by the U.S. Centers for Disease Control and Prevention (CDC) for reducing mother-to-child transmission amounts to $1,045 per case treated in the United States (Mauskopf and others 1996). In Thailand, where some inputs are less costly, the total cost is about half as great (Prescott and others 1996). Even so, this is roughly 50 times the average per capita health expenditure of low-income countries in Sub-Saharan Africa, where about two-thirds of mother-to-child transmissions take place. And at roughly $3,000 per HIV infection averted, this approach to prevention does not compare favorably with other approaches discussed in chapter 3 and would be affordable only in middle- or upper-income countries.
Several research efforts are under way to find a lower-cost means of reducing mother-to-child transmission. One involves trying to identify the most efficacious part of the AZT regime, in order to reduce the total amount of AZT needed. Trials are also under way in industrial and developing countries to investigate various other medical approaches to reducing transmission (Biggar and others 1996, DeMuylder and Amy 1993). However, it is unclear whether any of these strategies, if found effective, would be affordable or technically feasible in many developing country settings.
Newborns of HIV-positive mothers who escape infection at birth may nonetheless be infected later through breastfeeding. As a result, public health officials have had to weigh the advantages of breastfeeding for child health against the possibility of HIV transmission. In areas where the primary causes of infant deaths are malnutrition and infectious diseases, UNAIDS recommends that women continue to breastfeed their children. If a woman is known to be HIV-positive, she should be provided with the means to make an informed choice about infant feeding methods. In areas where there are safe alternatives for infant feeding, however, children will be at less risk of illness and death if not breastfed (UNAIDS 1996a). While it may be possible to simply reduce the duration of breastfeeding, it is not known what impact this might have on reducing transmission, since there is no consensus on when the risk of transmission is highest within the breastfeeding period (background paper, Saba and Perriëns 1996).
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