HIV Transmission from Mother to Child

Nearly 5 million children have died from AIDS before reaching age 15 since the onset of the epidemic, and an estimated 2.7 million children are living with HIV. Another 800,000 were infected in 2001 alone—about 90% in sub-Saharan Africa (432).

The overwhelming majority of children with HIV were infected from their mothers, during pregnancy, childbirth, or breastfeeding. Prevention of mother-to-child transmission of HIV is now a high priority of HIV/AIDS programs. Without treatment, rates of transmission from mother to infant are between 15% and 20%, according to European and US studies. Breastfeeding can lead to an additional 10% to 20% risk of HIV transmission, based on studies in Africa (415).

Breastfeeding?

Debate continues about whether and when to recommend breastfeeding versus bottle feeding, especially in countries where poor sanitation makes bottle feeding risky. UN agencies now recommend that bottle feeding starting at birth may be a safer choice than breastfeeding for a mother who is infected with HIV—but only if it is nutritionally adequate and safely prepared and given, and if an uninterrupted supply of alternative foods is available (415).

Recent studies, however, suggest that infants who are exclusively breastfed up to three months might have less risk of getting HIV from their mothers than those who receive other fluids and foods in addition to breast milk (428, 438). One explanation is that the immune factors of breast milk protect infants from HIV but that contaminants in other fluids and foods counteract this benefit by damaging the infant's stomach (428). If confirmed by further research, these studies suggest that exclusive breastfeeding up to three months could present an alternative to HIV-positive mothers who want to breastfeed their infants. Many prefer to avoid bottle feeding because of the stigma associated with it—an admission in some communities that one has HIV—and because the price of formula feeding may be too costly.

CONASIDA

"Don't allow your child to be born with the AIDS virus...Get tested," says this poster from Mexico. Mother-to-child HIV transmission is a growing problem.

What Can Be Done?

WHO recommends a three-sided strategy to prevent transmitting HIV from mother to child. The first is to prevent the mother's infection, especially among young women. The second is to prevent unintended pregnancies among HIV-positive women, and the third is to expand access to antiretroviral therapies.

Education programs can reduce transmission from mother to child by helping young people understand and avoid the risks of HIV infection and pregnancy. These programs can reach youth in schools, preferably before onset of sexual activity. Family planning programs can do more to help women with HIV avoid unintended pregnancy. Young women who are contemplating pregnancy should consider being tested for HIV. For young pregnant women who are infected with HIV, a health care provider should discuss feasible feeding options.

Where available, the antiretroviral drug Nevirapine, which has been shown to reduce the risk of transmission by nearly 50% (416), should be made available. The use of such antiretroviral drugs to prevent transmission of HIV between mother and child has been intensely studied. In developed countries the combined use of antiretroviral drugs, elective cesarean sections, and bottle feeding from birth has reduced the risk of HIV transmission from infected mother to child to less than 2% (415).

How Culture Can Hurt

Around the world a variety of cultural practices and traditions increase young people's risk for HIV/AIDS. For the most part, these practices and traditions affect young people more than adults—and affect young women even more than young men.

Women's Status

In many societies women are expected and taught to subordinate their own interests to those of their partners. With such expectations, young women often feel powerless to protect themselves against HIV infection and unintended pregnancies. Often, adolescent girls endure sexual coercion and abuse. In Kenya 40% of sexually active female secondary school students said that they have been forced or tricked into sex (3). In Cameroon 40% of female adolescents reported that their first intercourse was forced (313). Young women sometimes give in to having sex for fear that, if they refuse, they will be raped anyway (205).

Wife abuse is widespread. In some countries more than 40% of women have been assaulted by their partners (119). Gender-based violence is closely linked to HIV/AIDS (220). In Rwanda, for example, HIV-positive women with an HIV-positive partner were more likely to report sexual coercion in their relationship than were women without HIV (380). In Tanzania partner violence was 10 times higher among young HIV-positive women than HIV-negative women (220). Many women do not dare even to bring up the topic of condoms for protection against HIV infection for fear that they will be physically abused (381).

Marriage Practices

In many cultures the premium placed on having children often leads to childhood marriage and early childbearing. Girls as young as age 10 are given to older men in marriage in order to cement friendships and economic ties between families. When girls are married to older men, they can be vulnerable to HIV infection because their husbands usually have already had a number of sexual partners. Social, political, and religious barriers often hide young wives from the world (423), while their husbands frequently have other sexual partners (12).

Polygyny, the practice of a man having multiple wives, occurs in some countries. In Africa, when the husband seeks a new, often younger, wife, he may have sexual contact with a number of women in the process and thus risk bringing HIV home (7, 12, 41). In some cultures wife inheritance is practiced—a tradition in which a wife is given to her brother-in-law upon her husband's death. Thus either partner can be at risk of HIV infection if the other is infected. Younger widows are at particular risk because they are more likely to seek and be sought by other sex partners (6, 277, 321).

In some societies payment of bridal dowry is necessary when a man and woman marry. In parts of Africa the man pays the dowry to the woman's family. Once the marriage is sealed with the dowry, the woman is considered "paid for" and often cannot leave her husband, should marital problems ensue. Even if her husband's behavior places her at risk of HIV infection, the woman may not be able to protect herself (119).

Rites of Passage

Cultural rites of passage from childhood into adulthood, although traditionally serving to unite communities, can increase risks for HIV. For example, traditional male or female circumcisions are sometimes carried out using unsterilized equipment. Researchers think that male circumcision reduces risks for HIV transmission by removing part of the foreskin that is particularly vulnerable to HIV (see next side-bar). In some communities, however, circumcision ceremonies often are accompanied by post-initiation sexual experimentation, which increases risks for HIV (174, 350). For example, among the Maasai of East Africa the relationship among male peers is so close that, after circumcision, the initiates share wives and girlfriends (350).

Sexual Practices

Some sexual practices such as dry sex—the insertion of foreign objects to dry the vagina or to make it tighter —can cause cuts and scratches that create openings for HIV to pass through (321). Other practices, such as virginity testing of women, may place such a high premium on chastity before marriage that unmarried women practice anal sex instead, putting themselves at even greater risk for HIV/AIDS than if they had vaginal sex (341).

Male Circumcision and HIV/AIDS: Are Adolescents the Key?

Male circumcision is associated with lower rates of HIV acquisition, according to epidemiological and ecological studies. Male circumcision is the surgical removal of the foreskin (prepuce) of the penis (379). Uncircumcised men are two to eight times more likely to have HIV infection (112, 253, 394).

In addition, evidence suggests that male circumcision also protects against other STIs, including chancroid, syphilis, genital herpes, and gonorrhea. It also appears to reduce the risk of penile carcinoma and urinary tract infections (252).

The most compelling evidence about HIV and male circumcision comes from Uganda. In a study of 187 discordant couples in which the woman was infected with HIV but the man was not, no circumcised man became infected with HIV over a 30-month trial period. Among the uncircumcised men 29% became infected. Among the 223 discordant couples in which the man was HIV-positive but the woman was not, circumcised men were less likely to transmit the virus to women, but this protective effect declined at higher viral loads (101).

Worldwide, about one-quarter of men are circumcised, mostly in North America, in countries of the Middle East and Asia with large Muslim populations, and in parts of Africa (252). In Jewish and Islamic communities circumcision is performed as a religious ritual shortly after birth (175). In many African cultures it is performed among adolescents as a coming of age rite. In addition, it is practiced as a medical procedure to treat infections, injury, or anomaly of the foreskin (379).

Researchers believe that the foreskin provides a ready portal of entry to HIV and other pathogens. The inner surface of the foreskin is rich in special cells called Langerhans cells. These cells are particularly vulnerable to HIV and appear to be the primary means through which HIV enters into the penis (348). Also, the foreskin is more susceptible to trauma during intercourse, which can make it vulnerable to HIV (112). Differences in religion, sexual practices, or hygiene associated with ethnic groups that favor circumcision do not appear to explain the association between circumcision and HIV infection (17, 394).

The Importance of Age

The age at which a person undergoes circumcision appears to be particularly important. In the Rakai region of Uganda, for example, circumcision before the age of 12 years was significantly associated with decreased risk of HIV, but circumcision at 13 years or older was not. HIV prevalence was 7% for men who were circumcised at the age of 12 years or younger, 15% for men circumcised at 13 years or older, and 14% for uncircumcised men (178). Similar findings have been reported by other researchers (51).

Experts increasingly are calling for circumcision to become part of a public health strategy to reduce HIV acquisition (17, 112, 252). If this call were heeded, evidence suggests that adolescents, especially those under the age of 12 years, would be an important starting point. To substantially reduce HIV transmission, males would need to be circumcised before they reached sexual maturity (51) and before they commence sexual relations.

Other scientists urge caution until the evidence is clearer. Gathering confirmatory evidence would involve conducting clinical trials to circumcise young boys, a situation presenting difficult ethical issues (101). Little is known about the impact and cost-effectiveness of male circumcision as a public health strategy. A recent experts meeting found it premature to recommend circumcision in noncircumcising communities (379).

Moreover, circumcision is not an absolute protection against AIDS. Circumcised men are still at risk (40). Therefore, some scientists recommend that programs considering male circumcision for HIV prevention should also include other effective measures, such as condom promotion, behavior change, and STI prevention (112).

Dual Protection: Avoiding Pregnancy and HIV/AIDS

Condoms are the only contraceptive method that provides dual protection—that is, protects against both pregnancy and most STIs, including HIV. Using condoms along with another family planning method for extra pregnancy protection also constitutes dual protection. Practicing sexual abstinence and avoiding penetrative sex are other ways to avoid STIs and pregnancy (138).

What Family Planning Programs Can Do

By promoting dual protection, family planning programs can help prevent unintended pregnancies among youth and at the same time contribute to controlling the spread of HIV/AIDS (21, 95). WHO has urged family planning programs to do more to address prevention of HIV/AIDS and other STIs (417). Programs can stress that condoms can be effective against HIV and some STIs when they are used correctly and can assure that good-quality condoms are widely available at reasonable cost (291).

Family planning programs can best encourage condom use among young people by promoting positive attitudes towards condoms at the time people are starting sexual activity—before young people establish patterns of high-risk behavior. Programs also can serve as important links to HIV testing and counseling (74). This link may be crucial because people need to know that they and their partner are not infected before they stop using condoms and begin to use a different contraceptive method. Condom use is likely to be most consistent at the beginning of relationships and then to decline once the partner is perceived as "safe" (197, 279).

The dual protection strategy of using condoms to protect against infection and another method for contraception faces obstacles, however, particularly among young people. For many people, use of one method—much less two—can be difficult enough. Many adolescents cannot afford two methods or cannot obtain them both. Also, adding a second method may impair consistent use of the first (47, 319).

Despite obstacles, more young people are using condoms (162). Studies around the world document these increases. In Tamil Nadu, India, the proportion of young men who used condoms with casual relationships rose from about 45% in 1996 to nearly 70% in 1998 (162). In Brazil the percentage of young men who reported using condoms the first time they had sex rose from only 5% in 1986 to 50% in 1999 (162). Also, in Uganda ever-use of condoms rose from 15% in 1989 to 55% in 1995 among men ages 15 to 19 and from 6% to 39% among women in the same age group (14). Condom use appears to be more acceptable among younger men than among older men (162).

The adolescents who use condoms more consistently are those more likely to have the self-confidence to insist on condom use with their partners, to take personal responsibility for condom use, to have greater control over their impulses, and to begin condom use when they are young (66, 86, 197, 302). Other attributes associated with consistent condom use include having talked with parents about condoms, associating with peers who encourage condom use, having high educational aspirations, high parental income, generally adopting a healthy lifestyle—for example, not drinking alcohol or taking drugs (181, 191).

Queensland AIDS Council

"Cover up when it heats up," urges this Australian poster promoting condoms for safer sex among youth. Condoms provide dual protection against pregnancy and HIV/AIDS.

Assessing Condom Effectiveness

A recent expert workshop assessing research on the effectiveness of male condoms concluded that condoms have been proved effective in preventing "HIV transmission in both men and women who engage in vaginal intercourse." The researchers concluded that male condoms were also proved effective in "reducing gonorrhea among men" (262). It is generally accepted that, when used correctly all the time, condoms prevent most STIs, including HIV (440). They offer less protection, however, against herpes, human papilloma virus (HPV), and other STIs that can be transmitted through skin-to-skin contact between parts of the body not covered by condoms (95).

Scientists estimate that male condom effectiveness for pregnancy prevention in the "best case," that is, when used correctly and consistently, is 3 pregnancies per 100 women in the first year of use and in typical use is 14 pregnancies (117). The female condom appears to be somewhat less effective than the male condom in preventing pregnancy (138). Its effectiveness against HIV and other STIs has not been fully assessed, however.

Microbicides?

If microbicides were available, they could offer dual protection (417). Microbicides are chemical products that, for dual protection, would be administered vaginally before sexual intercourse to kill HIV and other STI pathogens and at the same time disable or kill sperm. Unfortunately, no microbicides exist for use today. While over 50 such products are in various stages of testing, none is expected on the market within the next five years (293, 294).

Developing microbicides is challenging. For example, the product must not irritate the vaginal lining. Nonoxynol-9, the widely-used spermicide, was thought to be effective against HIV. Recent research, however, found that when the product was used by sex workers—who would use it much more frequently than most other women—nonoxynol-9 was associated with vaginal lesions, thereby increasing the likelihood of HIV transmission (161). Even if a microbicide were found to be safe and effective for adults, its safety, efficacy, and acceptability for adolescents would still need to be assessed.

Children Orphaned by AIDS: A New Challenge

The HIV/AIDS pandemic has dramatically increased the number of orphans. UNAIDS estimates that by 1999, the date of the most recent estimate, 13.2 million children under the age of 15 had lost either their mother or both parents to AIDS (162).

Around the world, such calamities as war, famines, and diseases make orphans of about 2% of all children under age 15 (360). In countries hardest hit by HIV/AIDS, however, 8% to 34% of children have been orphaned by AIDS (118, 207). UNAIDS considers children to be orphaned by AIDS if either their mother or both parents have died of AIDS. The worst may be yet to come. In models of the epidemic, the number of children orphaned by AIDS peaks 7 to 10 years after HIV prevalence peaks (118), or a projected 20 to 30 years after the onset of the AIDS epidemic (38).

Nine of every 10 children orphaned by AIDS are in sub-Saharan Africa (118, 162). Already, over 1 million children in each of four countries—Uganda, Nigeria, Ethiopia, and Tanzania—have been orphaned by AIDS. In 12 other sub-Saharan countries at least 200,000 children have been orphaned by AIDS, from 230,000 in Burundi to 900,000 in Zimbabwe, according to UNAIDS (162).

Some children, including many orphaned by AIDS, are infected with HIV themselves. Most contracted the virus from their mothers (see related side-bar, HIV Transmission from Mother to Child). The life expectancy of such children varies widely, studies have found (211, 245, 275). In the US about 20% died by age four (376). In Malawi, where treatment is much less available, 89% died by age three (349).

Children orphaned by AIDS, like other orphans, face many hardships, especially when a household loses its primary wage earner (69, 118). Some will have witnessed the prolonged illness and deaths of their parents or other family members (99). When parents get AIDS, the household's focus usually shifts from caring for children to caring for the sick adults (135, 360). Often, grandmothers, aunts, or older sisters take responsibility for orphans (162, 207, 340). When family members cannot help, orphans may go to foster homes, church-run facilities, orphanages, or other institutional care.

Many children orphaned by AIDS drop out of school. In Benin, for example, only 17% of children whose parents have died attend school compared with 50% whose parents are both still living (361). Older children often drop out of school to care for younger siblings, with females working in the household and males looking for jobs (9, 88, 118, 369). Also, children orphaned by HIV/AIDS may be kept out of school because they are stigmatized (360).

Whether children legally can remain in their residence after the death of their parents influences whether or not the family will stay together (90). Protecting the legal rights of children orphaned by AIDS regarding inheritance, housing, health care, and schooling can help lighten their burdens. Some children orphaned by AIDS live without any adult care, but there are no reliable estimates of their numbers (69, 88, 332). When no adult takes in the children, the older children in the family typically take on parenting roles for their younger siblings (270). In Ethiopia orphaned children as young as eight years take care of their siblings (69). Children who must head their own households face many difficulties, including stigmatization, poverty, malnutrition, lack of health care, and lack of social support (69, 118, 330).

Many children orphaned by AIDS take to the streets to escape their loss, to run from abusive or oppressive living conditions, to find work, or to seek independence (248, 369). By leaving home, however, they often enter the street culture, with its violence, exploitation, crime, drugs, hunger, and disease. Tenuous living conditions and economic troubles make such children targets for sex work, sexual and physical abuse, pornography, cheap labor, and other exploitation (256, 358).

Responding to the Crisis

Countries and communities have begun to respond to help children affected by the AIDS crisis. In some cases communities have come together spontaneously to assist (118). The responses include a variety of strategies (162):

Finding job opportunities. In Uganda the Women's Effort to Save Orphans (UWESO) organizes programs to generate income for children orphaned by AIDS (307, 400).

Encouraging education. In Zambia free community schools help meet the needs of children orphaned by AIDS. There are no school fees, and the schools accept children with interrupted or no previous schooling (360).

Offering services. In Chennai, India, the Community Health Education Society, an NGO, provides shelter and health services to children orphaned by AIDS and to others affected by AIDS (333).

Developing partnerships. In Botswana the National Orphan Programme, established in 1999, links government, community, and private organizations to address such issues as child support, custody, guardianship, and financial support. The program intends to develop a comprehensive national orphans policy based on the International Convention on the Rights of the Child (360).