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PEDIATRICS Vol. 114 No. 1 July 2004, pp. 328-329

Missed Opportunities for Perinatal HIV Prevention Among HIV-Exposed Infants Born 1996-2000, Pediatric Spectrum of HIV Disease Cohort

Ani E. Hyslop, MD, MPH
11785 Beltsville Dr
Calverton, MD 20705

To the Editor. —

With interest I read the article "Missed Opportunities for Perinatal HIV Prevention Among HIV-Exposed Infants Born 1996–2000, Pediatric Spectrum of HIV Disease Cohort" by Peters et al.1 It is a remarkable achievement that the rate of transmission has dropped so dramatically in the United States. Comparing the social and health systems in the United States to those in sub-Saharan Africa, where the magnitude of the problem is exponentially larger (2.6 million children aged 0–14 years vs 10 000 children2 [it is assumed that a large proportion of these children are perinatally infected]) and the resources are exponentially lower, one wonders if the same results can be achieved there. I would like to highlight some key differences in prenatal care, hospital delivery, and breastfeeding practices between the United States and sub-Saharan Africa that will impact the success of prevention of mother-to-child transmission in sub-Saharan Africa. To illustrate the differences, I will use data from recent Demographic and Health Surveys (DHS) from 11 of the 12 sub-Saharan African countries* that are included in the US Presidential Initiative on Mother to Child HIV Transmission (www.usaid.gov/about_usaid/presidential_initiative).

Peters et al showed that the "key to prevention is to provide prenatal care and to diagnose HIV infection before delivery."1 In the United States, 96% of pregnant women receive prenatal care,3 and Peters et al found that 91% of their singleton cohort received prenatal care. Data from DHS show that between 26% and 95% of women in the 11 countries had at least 1 prenatal visit with a health professional during their most recent pregnancy. In the 3 countries that had percentages <80% (Ethiopia 26%, Nigeria 64%, and Mozambique 71%), there will be significant missed opportunities for prenatal intervention.

If prenatal intervention is missed in the United States, the next opportunity to intervene for an HIV-positive pregnant women is when she delivers in a hospital. In the United States, practically all (99%) deliveries take place in a hospital.4 The situation is quite different in sub-Saharan Africa. For 10 of the 11 countries noted here, between 5% and 68% of women delivered in a health care facility. South Africa was a notable exception, with 84% of women surveyed having delivered their last born in a health care facility.

Breastfeeding is another context in which interventions to prevent mother-to-child transmission of HIV differ between the United States and sub-Saharan Africa. Although not stated in their article, it is assumed that either none of the women in the cohort or very few breastfed their infants. In the United States, there is no social pressure to breastfeed (27% of women reported any breastfeeding at 6 months5), nor is there a large financial barrier to the purchasing of formula. In contrast, in sub-Saharan Africa, the risk of diarrheal disease and malnutrition can outweigh the risk of HIV transmission; there can be a stigma associated with not breastfeeding; and the cost of formula can be prohibitive. DHS data from these countries show that, except in South Africa (70%) and Namibia (85%), >95% of infants are breastfed at 6 months of age.

Improving access to and utilization of medical prenatal care and facility-based delivery care in sub-Saharan Africa and creating an environment in which not breastfeeding is possible will be key to preventing missed opportunities for perinatal HIV prevention.

FOOTNOTES

* Data are from STATcompiler at www.measuredhs.com: Cote d’Ivoire DHS 1998/1999; Ethiopia DHS 2000; Kenya DHS 1998; Mozambique DHS 1997; Namibia DHS 1992; Nigeria DHS 1999; Rwanda DHS 2000; South Africa DHS 1998; Tanzania DHS 1999; Uganda DHS 2000/2001; and Zambia DHS 2001/2002. The last DHS in Botswana was done in 1988, and the data are not included here. Back

REFERENCES

  1. Peters V, Liu K-L, Dominguez K, et al. Missed opportunities for perinatal HIV prevention among HIV-exposed infants born 1996–2000, pediatric spectrum of HIV disease cohort. Pediatrics. 2003;111(5 pt 2) :1186 –1191
  2. UNAIDS. 2001 HIV estimates. Available at: www.unaids.org/html/pub/Global-Reports/Barcelona/TableEstimatesEnd2001_en_xls.htm. Accessed June 1, 2004
  3. National Center for Health Statistics. Fastats prenatal care. 2000. Available at: www.cdc.gov/nchs/fastats/prenatal.htm. Accessed June 1, 2004
  4. Curtin SC, Park MM. Trends in the attendant, place, and timing of births, and in the use of obstetric interventions: United States, 1989–97. Natl Vital Stat Rep. 1999;47(27) :1 –12.
  5. Li R, Zhao Z, Mokdad A, Barker L, Grummer-Strawn L. Prevalence of breastfeeding in the United States: the 2001 National Immunization Survey. Pediatrics. 2003;111(5 pt 2) :1198 –1201
PEDIATRICS (ISSN 1098-4275). ©2004 by the American Academy of Pediatrics



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V. Peters, K.-L. Liu, B. Gill, P. Thomas, K. Dominguez, T. Frederick, S. K. Melville, H.-W. Hsu, I. Ortiz, T. Rakusan, et al.
Missed Opportunities for Perinatal HIV Prevention Among HIV-Exposed Infants Born 1996-2000, Pediatric Spectrum of HIV Disease Cohort
Pediatrics, September 1, 2004; 114(3): 905 - 906.
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