Preventing mother-to-child transmission of HIV in developing countries: recent developments and ethical implications

Various regimens of antiretroviral (ARV) therapy during pregnancy and labour have been found to be effective in reducing the risk of mother-to-child transmission of HIV. Cost and late identification of women with HIV infection during pregnancy in many developing countries have been the impetus to study inexpensive, short-course ARV regimens. Recently, it was shown that a single dose of nevirapine given orally once during labour to the mother and once to the infant greatly reduces the risk of HIV transmission. As a result, it has been proposed that in high HIV prevalence areas, this drug regimen be offered routinely to all pregnant women and their infants, without the need for an HIV test. This is seen as a cost-effective alternative to trying to make voluntary HIV testing and counselling universally available to pregnant women, which would require improved antenatal uptake and care, high uptake of HIV testing and high rates of return to learn results before women could make decisions regarding ARV prophylaxis. The ethical dilemmas arising from both these options are currently under debate, against a backdrop of concerns about breastfeeding and breastmilk substitutes, what to do about the increasing numbers of AIDS orphans and how to prevent HIV transmission to women in the first place.