Mother to Child Transmission

In India, perinatal transmission is a cause for concern as one in every four infected persons is a woman. In States with high sero-positivity, increasing numbers of women attending antenatal clinics are testing positive for HIV. Perinatal transmission accounts for 2.04 percent of all HIV infections in India. Infection rates among pregnant women also show considerable variation ranging from 0 to 2.6 percent.

In 2002, Vijaywada, Andhra Pradesh reported antenatal infection rates as high as 9.9 percent.

A rights-based approach to preventing mother to child transmission of HIV is unique for several reasons. First, this approach is particularly important at this juncture as the rights of the mother have been systematically ignored throughout the epidemic. While there have been some attempts to compensate for this negligence, in literature, if not in practice, by and large the rights of the foetus have been prioritised over the mother's in the context of perinatal transmission. Second, there is a strong argument for protecting and promoting the rights of all the people in the child's life, including the mother, her partner and any other breadwinner or caretakers, whose well being will enable the fulfillment of both the mother's and the child's rights. Third, the emphasis is now on technology driven rights which means the focus is on increasing access to information and technologies that develop as science progresses.

Women's lack of access to information, education and knowledge from an early age is an important factor in their vulnerability to HIV infection as well as their ability to demand their rights to new and developing technologies. A paradigm shift is required to reduce perinatal transmission; one that moves from the clinical approach to a framework of empowerment. This will entail promoting the health and education of girls and women throughout their life-span rather than simply during pregnancy and childbirth, such that they can make informed choices with regard to their health at every stage of development.

Mother to child transmission (MTCT) can occur in three ways: during pregnancy, during labour and delivery or after childbirth, through breast-feeding. Before the effect of antiretroviral (ARV) therapy in reducing the risk of vertical transmission was known, termination of pregnancy among HIV positive women was the only means to curtail the spread of the HIV epidemic among infants and children. In the absence of any intervention measures, the risk of vertical transmission is between 25 and 35 percent. Administration of ARV therapy is known to have reduced the risk of infection to the child by over 90 percent. In addition, changes in delivery practices, such as performing caesarean sections, and altering infant feeding patterns, namely, discouraging breast feeding also reduce the risk of transmission from mother to child.

Along with a discussion on abortion, the article examines the ethical issues around testing and treatment of HIV positive pregnant women. The discussion on testing revolves around three approaches i.e. mandatory testing, routine screening and voluntary counselling and testing and the human rights implications of each. Despite resource constraints, the article argues, it is critical to obtain the informed consent of pregnant women and it is essential for the health care institution to maintain confidentiality of test results. The issue of treatment raises questions about how long medicines must be provided in order to protect the rights of both the mother and the child. Recognising that it is important not to pit the rights of the child against the rights of the mother, providing treatment not only to the mother but also other breadwinners and caretakers in the family and increasing their longevity, will also improve the health and well being of the child. Again, although infrastructural and resource constraints are likely to affect treatment decision-making in the Indian context, emphasis must be placed on promoting the web of rights that work concurrently to ensure the rights of the mother, the child and other family members.

The article also addresses the alternatives available to breast feeding given the potential of transmitting HIV through breast milk. While some contend that it is unethical to feed babies with milk infected with HIV, others argue that breast feeding recommendations for HIV positive women in developing countries must balance the risk of HIV transmission with the well known nutritional and health benefits of breast feeding, particularly where access to clean and safe drinking water and affordable substitutes is limited. Ultimately, adherence to human rights principles and respect for women's right to self determination would imply that the decision whether to breast feed or not must be left to each mother once she has been informed about the potential risks and benefits of both.

Finally the article discusses policy measures that have been implemented around the world to reduce MTCT. However, it is clear that the prevention of perinatal transmission requires far more than simply access to clinical measures to reduce the risk of transmission to the child. A comprehensive response to MTCT must address shortcomings in the larger health system that impair a person's access to information, education, treatment and long-term care. In addition, the experience of discrimination that HIV positive pregnant women face in the health system contributes extensively to their lack of access to appropriate and adequate prenatal services. The most persuasive argument in favour of a comprehensive MTCT programme, which includes routine counselling, provision of voluntary testing and ARVs to the mother and to the child after birth and during post natal care, is purely economic; it would cost the State considerably less to implement a MTCT programme than the lifetime medical, social and economic costs by failing to implement such a programme.