HIV/AIDs IN PREGNANT WOMEN

By Olor

INTRODUCTION
Human Immunodeficiency Virus (HIV) is a virus that causes Acquired Immuno- Deficiency Syndrome (AIDS), a chronic and life-threatening ailment/disease that damages the immune system by interfering with the body’s white blood cells, thus its inability to fight pathogens that causes various diseases such as respiratory infection, dermatitis etc. (Chen and Walker, 2010).

HIV/AIDS epidemics in sub-Saharan African countries in the early 1990’s, allowed the disease to become a quantifiable disease burden in global health during the observation of the prevalence of HIV/AIDS amongst pregnant women registered for, and attending antenatal clinic sessions (WHO, 2012; and Ortblad, Lozano & Murray, 2010).

The survey for HIV/AIDS prevalence was however repeated after about a year or two in the same clinic and the prevalence derived from the women attending antenatal care are being used as an alternative measure to estimate the levels of HIV/AIDS prevalence amongst adults of ages 15-49 (Asamaoh-odei, Garcia & Boerma, 2014; and Jeffrey et al, 2014).

However, it is essential to test HIV/AIDS during antenatal so as to identify women infected with HIV/AIDS thus commencing Anti- Retroviral Therapy (ART) to reduce the risks of mother to child transmission of the virus as well as to improve maternal health (Drake et al, 2014). HIV/AIDS may however be acquired during pregnancy as well as postpartum and may not be identified unless a repeat test is carried out. Regardless of the recommended guidelines to repeat HIV/AIDS tests in the third trimester or at delivery in areas where the virus epidemic is generalised, repeated tests are rarely implemented nor documented (Branson et al, 2006 and Tabu et al, 2013).

Gray et al in their studies acknowledged that a lack of re-conducting HIV/AIDS tests during pregnancy and postpartum signifies opportunities missed for identifying women that have recently been infected with the virus (HIV/AIDS) thus having an increased risk of infected pregnant mothers transmitting the virus to their unborn child (mother to child transmission), due to increased HIV/AIDS viral loads (low CD4 cell counts) as well as the commencement of anti- retroviral therapy to prevent perinatal mother to child transmission amongst women infected with HIV/AIDS who did not register/attend antenatal care and were not tested throughout pregnancy (Gray et al, 2005; Moodley et al, 2011 and Drake et al, 2014).

A systematic review carried out by Dunn et al in 1992, put a figure on the risks of mother to child transmission of HIV/AIDS through breastfeeding amongst women infected during postpartum, the risks of utero/intrapartum transmission amongst women infected with HIV/AIDS during pregnancy was however not inclusive (Dunn et al, 1992). Additionally, the review was carried out prior to the application/institution of anti- retroviral prophylaxis for the prevention of mother to child transmission and was not able to characterise the risks of mother to child transmission amongst women with cases of HIV/AIDS infections during the time of the prevention of mother to child transmission and antiretroviral therapy. Relatively, the contribution of maternal HIV/AIDS infection in pregnancy or at postpartum and the use of antiretroviral therapy by expectant and infected mother to prevent the transmission of the virus to the unborn child is unknown (Drake et al, 2014).

A good plan to eradicate HIV/AIDS transmissions from mother to child including the decrease of the incident of HIV/AIDS amongst women, especially expectant mothers as well as an increased uptake of mother and child antiretroviral therapy for preventing mother to child transmission of the virus was announced by the World Health Organisation (WHO) in 2012 (WHO, 2012). However, Drake et al in their systematic review believes that the achievement of the WHO objective would be hindered due to a lack of understanding of the risks of HIV/AIDS infection in expectant mothers as well as in the postpartum populace, and the continual risks of mother to child transmission in both the presence and absence of antiretroviral therapy. They performed a meta- analysis and systemic review to compare and synthesise the risk of HIV/AIDS infection in pregnancy and at postpartum as well as the risks of mother to child transmission of the virus amongst women with cases of HIV/AIDS and found that during pregnancy and postpartum are the periods when the risks of HIV/AIDS is persistent and relatively high and the risks of mother to child transmission elevated as well in women infected by the virus (Drake et al, 2014).

HISTORICAL/ PRESENT OVERVIEW OF HIV/AIDS IN PREGNANT WOMEN
Globally, women and majorly women of childbearing age make up about half the population of people living with HIV/AIDS (Jao et al, 2015). HIV/AIDS is more severe in sub-Saharan Africa with the Eastern and Southern regions recording a population of 19 million people living with HIV compared to other parts of the world where the population is less (UNAIDS, 2016).

Relatively, in most sub-Saharan African countries, the disease has been a public health issue with more than 60% of adults living with the virus (HIV/AIDS) being women (UNAIDS, 2016 and UNAIDS, 2008). Precisely, in South Africa, the prevalence of HIV/AIDS in young women is estimated to be three times more than young men (Pettifor et al, 2005 and Myer et al, 2010). HIV/AIDS is however higher amongst young women attending antenatal; and also prevalent amongst women infected with the virus as well as those at risk of the infection throughout sub-Saharan Africa (Westriech et al, 2012 and Schwartz et al, 2012).

According to the studies of Peters et al in 2012 – 2014, an approximated 1200 expectant mothers living with HIV/AIDS is reported yearly in the United Kingdom, with mother to child transmission rates of 0.27% described as “an all – time low” (Peters et al, 2014 and Kenny et al, 2012). Several studies have researched on pregnancy rates and the outcomes in women with prenatally infected HIV (Agwu et al, 2011; Brogly et al, 2007 and Jao et al, 2015) and have reported low pregnancy incidence rate as compared to women without HIV/AIDS (Kenny et al, 2012).

Prior to the studies of Peters et al, half of the expectant mothers living with prenatally infected HIV had a problem of adherence (Munjal et al, 2013) and some studies in the United States have shown an increased HIV/AIDS viral load at pregnancy but related rates of mother to child transmission of HIV in comparison to women with behaviourally acquired HIV (Thorne et al, 2007; Badell et al, 2013 and Munjal et al, 2013). The studies of Jao et al and Jao et al also found out that a child of a prenatally infected HIV mother has an independent risk factor of poor foetal and child growth in comparison to a child born to a behaviourally infected HIV mother (Jao et al, 2015 and Jao et al, 2012).

SOCIO-DEMOGRAPHIC FACTOR
Age: This is a contributing factor of adherence for the treatment of HIV/AIDS patients as several studies have shown that younger infected patients within the age range of about 12 – 16 do not or are less likely to adhere to anti – retroviral medications/therapy (Patterson et al, 2000 and Gifford et al, 2000).

Stigma: Aaron et al in their studies acknowledged that patients who tested positive to the virus (HIV/AIDS) voiced out their fear of isolation and rejection by friends and family; thus could however lead to withdrawal from tests and delay to seek care thus affects treatment adherence. However, correction of the delusion of HIV/AIDS might have a limiting effect on the stigmatization of infected individuals (Aaron et al, 2011).

Additionally, factors such as Socio-economic status, Low level of education, Culture, Marital status, psychological factors (such as anxiety, depression etc.) as well as mental health conditions are also contributing factors of HIV/AIDS transmission, mother to child transmissions, drug resistance etc. (Aaron et al, 2011 and Msamanga et al, 2006).

Vulnerability of women to HIV/AIDS infection
In developing world, women are at a greater risk of getting infected with HIV than males due to factors that are biologically or sociologically related (WHO & UNAIDS, 1998).

Biologically, the rate of transmission of HIV/AIDS from male to female is 2:3. This is however high compared to the transmission rate from female to male (Royce, Sena & Cohen, 1997 and Downs & De Vince, 1996).

Sociologically on the other hand, factors such as socio – cultural factor (where the cultures and communities in most sub – Saharan countries hinder the control of women over themselves), women are usually being blamed for the transmission of HIV thus shouldering a double burden: living with HIV/AIDS as well as caring for the family (usually infected families). Furthermore, gender inequalities, female genital mutilation as well as “widow cleansing” all have effects on leaving women vulnerable to the infections of HIV/AIDS (Ahluwalia, De Villis, & Thomas, 1998)

INTERVENTIONS
In achieving a comprehensive response for HIV/AIDS, responsibility by the health sector has to be taken in order to deliver positive interventions to aid in the prevention of new infections of HIV/AIDS as well as improving the quality of life of infected persons and averting untimely deaths in people (both children and adults) living with the virus (Nancy et al, 2011).

World Health Organisation (WHO)
World Health Organisation (WHO) comprehensively promotes an approach for the prevention of mother to child transmission of HIV/AIDS programmes through strategic goals such as:

• The prevention of new infections of the virus amongst women especially those within the age of child bearing.
• Prevention of pregnancies that are not intended amongst women living with HIV/AIDS.
• Prevention of the transmission of HIV/AIDS from an infected mother to her unborn child or during breastfeeding.
• Provision of suitable treatment, support as well as care for women infected & living with HIV/AIDS and their family (WHO, 2010).

However, the World Health Organisation identified countries such as Ghana, India, Botswana, Angola, Burundi, Cameroon, Chad, Cote d’Ivoré, Democratic Republic of Congo, and Ethiopia as top ten priority countries that make up about 75% of countries in utmost need of the services for the prevention of mother to child transmission of HIV/AIDS. The effective scale up of interventions in the aforementioned countries will thus prevent an estimated 250,000 new infection of the virus yearly (WHO, 2013).

United Nations programme on Acquired Immuno-Deficiency Syndrome (UNAIDS)
UNAIDS is a joint United Nations partnership innovation that strives to achieve a global access to prevent, treat, care and support people living with HIV/AIDS (UNAIDS, 2008 and Myer et al, 2010). UNAIDS, PEPFAR (President’s Emergency Plan For AIDS Relief), NACA (National Action Committee for AIDS), PMTCT (Prevention of Mother To Child Transmission) amongst other interventions, launched the framework “Start free, Stay free, AIDS free”, which called for a global sprint towards “super-fast – track targets” to eliminate HIV/AIDS amongst children, teenagers and women (the young) by the year 2020 (UNAIDS, 2016).

Infections relating to transmissions from mother to child was proposed to reduce by 40,000 by the year 2018 and 20,000 by 2020. Also, the various intervention programmes with their strategic plans/frameworks were also committed to attain a 95% treatment, support and care plan for expectant mothers living with HIV/AIDS by the year 2018 (UNAIDS, 2016).

PREVENTIVE MEASURES TOWARDS HIV/AIDS.
HIV could be transmitted from an infected expectant mother to her foetus/infant, thus accounting for the huge number of recent infections in infants (UNAIDS, 2016; Padian et al, 2011). Programmes such as “prevention of mother to child transmission provides antiretroviral therapy to infected expectant mothers to prevent the foetus and infants (after delivery) from getting infected by the virus. However, without antiretroviral, the possibility of the transmission of HIV/AIDS from mother to child is 15 – 45%; though antiretroviral and other intervention programmes can reduce transmission risks to less than 5% (WHO, 2016 and Dionne et al, 2016).

Other measures however includes:

• HIV/AIDS testing during antenatal
• Creation of awareness through media and organising campaigns in relation to HIV/AIDS testing, prevention and counselling.
• Educating the general public especially expectant and lactating mothers on HIV/AIDS and prevention of mother to child transmission of the virus
• Guidelines on keeping an infant born to an infected mother safe through antiretroviral and proper feeding (WHO, 2015; Mutel et al, 2011; UNAIDS, 2016 and Makoni et al, 2015).

BARRIERS OF PREVENTIVE MEASURES TOWARDS HIV/AIDS
Various barriers could hinder the effectiveness of the preventive measures set aside by various intervening bodies on the issue of HIV/AIDS in pregnant women and the general public. In order to increase access to the services of the intervening, this barriers have to be tackled. They include:

a. Knowledge about HIV/AIDS, mother to child transmission of the virus as well as the prevention of mother to child transmissions.
For instance, the study of Tatagan et al in 2011 believes that after a 92% testing of HIV/AIDS in pregnant women; 77% of the participants accepted that the risks of HIV/AIDS transmission to the foetus is increased due to unprotected sex and 61% of participants also accepted that mixed breastfeeding increased the risk of the transmission of HIV/AIDS to the child than breastfeeding exclusively (Tatagan et al, 2011).

Also, in Tanzania, a study carried out on over 10,000 women by Haile et al in 2016 showed that 46% of the participants accepted to have adequate knowledge of mother to child transmission and the prevention of the transmission. Pregnancy experience by the participant, exposure to HIV/AIDS education, living in urban settlements, and knowledge of where to get tested and being tested, were most of the factors that were associated with the knowledge displayed by the 46%.  However, women who tested positive and living with the virus are likely to be more knowledgeable about the transmission of HI/AIDS from mother to child than those who are/were negative when tested (Haile et al, 2016).

Contrarily, other studies such as that of Olugbenga-Bello et al believes that an increased level of the knowledge of HIV/AIDS and mother to child transmission & its prevention is associated with a reduced acceptability of the prevention of HIV/AIDs transmission to the foetus and infants. Their study of 2013 in the Southwestern region of Nigeria recognised that 99.8% of expectant mothers were cognisant of the virus and 92% are very knowledgeable about mother to child transmission, 91% had a knowledge of prevention of the transmission as well as a 71% negative views towards the prevention of mother to child transmission. All this was as a result of factors such as stigmatisation and discrimination towards the women infected/living with HIV/AIDS (Olugbenga-Bello et al, 2013).

b. Knowing HIV/AIDS statuses.
It is crucial for expectant mothers to have a knowledge about their HIV status so as to gain access to suitable health care services and treatment for themselves as well as their babies (Mkwanazi et al, 2008). Services associated with the prevention of mother to child transmission of HIV/AIDS adopted a strategy referred to as “opt out” (meaning that women could opt out actively or decline tests for HIV/AIDS after information and counselling about HIV/AIDS has been given/delivered) which is known also as “physician or provider-initiated testing and counselling (Balogun & Owoaje, 2016).

DISEASE CONDITIONS RELATED TO HIV/AIDS
Table 1: Opportunistic diseases globally common and disease conditions caused.

Class of Disease	Disease Condition Caused
Bacterial	Tuberculosis, Bacterial Pneumonia, septicaemia (blood poisoning).
Fungal	Candidiasis (thrush), Penicilliosis and Crytococal meningitis.
Protozoal	Pneumonia, taxoplasmosis, Leishmaniasis, Isosporiasis.
Viral	Herpes simplex and Herpes zoster (Shingles)

Complications in Patients with HIV/AIDS

Conclusively, during pregnancy and postpartum, HIV/AIDS risks is persistent at very high rates and the risks of mother to child transmissions of the virus are as well elevated in women with recent/ new infections. It is however crucial to prioritize, detecting and prevention of the incidents of HIV/AIDS in pregnancy thus decreasing the risks of mother to child transmission. However, there is a shift in the occurrence of HIV/AIDS towards older and less fertile women (menopausal age range) as well as a decrease amongst pregnant women than its occurrence in women generally.

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