Mother-to-child transmission
	Keeping all mothers healthy
	Caring for women who know they are HIV positive

It is estimated that at the end of 1999, over 12 million women in sub-Saharan Africa between the ages of 15 and 49 were living with HIV. As more and more women become HIV positive, the number of pregnant women with HIV also increases. In some areas, the proportion of pregnant women who are HIV positive is very high. For instance, information collected in a number of antenatal clinics in major urban centres in Botswana, Rwanda and Malawi between 1996 and 1998, found that more than 30 in every 100 pregnant women were HIV positive.

Mother-to-child transmission

In developing countries, between one in three and one in four babies born to HIV-positive women are born with HIV themselves. Some of these babies become infected during pregnancy, but most become infected during the birth itself.

There appears to be a greater risk of HIV transmission during pregnancy and childbirth if the mother has a high viral load, or if her immune status is poor. Her viral load will be higher if she: 
 

	has become HIV positive just before or during her pregnancy
	is continuing to be exposed to the HIV virus through unprotected sex in pregnancy
	has symptomatic HIV.

A woman's immune status may be linked to a high viral load and can be assessed by taking a CD4 count. The lower the CD4 count, the lower her immune status. 

Poor diet, having another STI such as gonorrhoea, chlamydia or syphilis or having other infections such as malaria also appear to increase the risk of transmission from an HIV-positive mother to her baby. In general, the better the health of the mother, the less likely she is to transmit HIV to her baby.

Keeping all mothers healthy

All women need care and advice to help them remain healthy during their pregnancy.

Protect women from HIV 
The only completely reliable way to stop mother-to-child transmission of HIV is to prevent all girls and women becoming HIV positive.

Involve fathers 
Talking to the male partner about HIV and parent-to-child transmission, and explaining to him what he can do to keep the pregnancy safe, can encourage him to practise safer sex and protect the health of his baby. 

Promote safer sex 
Even after becoming pregnant, women should continue to practise safer sex (use a condom) unless they are absolutely certain that their partner is not HIV positive. Continuing to use condoms will also prevent STIs. Keeping to one sexual partner makes sex safer.

Test for, and treat, all infections 
An essential part of care for all pregnant women is to look for, ask about and treat, any infections the woman may have, especially STIs, tuberculosis (TB) and malaria.

Prevent malaria 
In areas where malaria is common, malaria prophylaxis is an important part of antenatal care. It is even more important for women who are HIV positive, because an infection can increase the risk of transmission (see below). Pregnant women should take whichever antimalarial drug is recommended in their area, and sleep under an insecticide-treated bed net where possible.

Promote a well-balanced diet 
Eating a good diet, including all the necessary vitamins and minerals, is important for all pregnant women, but especially those who are HIV positive. It is difficult for many women to decide what they eat - poverty, custom or their status may mean they have few choices. Education about which local foods are most nutritious and the importance of pregnant women being well fed, needs to be ongoing. In many parts of sub-Saharan Africa, traditional foods are often more nutritious and cheaper than popular western diets.

Encourage rest 
For many pregnant women, particularly where hard physical tasks are part of their daily routine, getting enough rest can be difficult. Supporting women to look after themselves during their pregnancy, including resting whenever they can, is important.

Discourage smoking and the use of alcohol and other drugs 
Smoking cigarettes, drinking alcohol and the use of some drugs and herbal remedies can harm the unborn child. HIV-positive women need to be especially careful, because anything that damages their health can lower their CD4 count.

Avoid invasive medical procedures 
Because of the risk of HIV and other infections being passed to the baby, procedures such as amniocentesis should be avoided unless they are really necessary (see Section 4, page 10).

Avoid blood transfusions 
Blood transfusions are still a source of HIV infection in some parts of Africa and should be avoided unless they are absolutely essential.

Provide voluntary counselling and testing for HIV (see Section 3, page 7) Many women do not know their HIV status and may wish to find out during pregnancy. Knowing their status can help women to make decisions that reduce the risk of transmitting HIV to their baby. Confidentiality is essential if women are to be encouraged to take up services offered and avoid the risks of their status becoming public.

Caring for women who know they are HIV positive

For women who know they are HIV positive, additional care may be available.

Antiretroviral therapy 
 

Most women in sub-Saharan Africa do not have access to long-term combination ARV treatment for their own health or the necessary support services to ensure its correct use. If an HIV-positive woman is on combination therapy, she should continue to take it during pregnancy after talking to her doctor about any changes which might be needed.

Types of Antiretroviral Therapy  Antiretrovirals (ARVs) are drugs that fight the HIV virus. ARV therapy can help people with HIV stay healthy. Combination therapy  ARVs are usually given in combination, because different ARVs fight HIV in different ways and are therefore more effective when used together. This is known as combination therapy. (see Resources for where to find more information on ARVs). Reducing mother-to-child transmission  Short courses of treatment (using a single drug, known as monotherapy) can be given to women in the late stage of pregnancy and/or during labour and delivery, in order to reduce the risk of passing HIV to the baby. Sometimes drugs are also given to the baby in the first week of life. This short course treatment will not be of any benefit to the mother's own health, but will not harm it either. (See Section 4, pages 10 and 11 for more information). Post exposure prophylaxis for healthworkers  ARV drugs can also be used for post-exposure treatment of health workers, in the event of an accidental needle-stick or other injury (see Section 6, page 18).

 
 
Treatment of HIV-related infections 
Even if combination ARV therapy is not available for women, many women do have access to treatments for HIV-related infections such as TB and Herpes zoster. There are also plenty of locally available, relatively cheap and effective treatments for symptoms of opportunistic infections, such as diarrhoea, weight loss and skin infections. 

Health workers need to be aware of what treatments women in their community are using - including traditional treatments - so that they can promote ones which are effective and warn women against false and dangerous treatments.

Providing a safe, supportive environment in which to raise concerns and fears is an important part of care, and can also help HIV-positive women stay healthy.