The HIV/AIDS epidemic is one of the
major factors affecting women’s health. Almost half of the 37.8million people
living with HIV globally are women and more than two million pregnancies occur
in HIV-positive women each year. The majority of these are in
resource-constrained settings where the
risk of maternal morbidity and mortality is also unacceptably high, and where
most of the 529,000 deaths from complications of pregnancy, childbirth and
abortion occur annually. HIV infection rates in pregnant women vary
considerably, ranging from below 1% to over 40% across countries. Africa still has the highest rates, although the HIV
prevalence in some Asian countries has risen significantly.
The true contribution of HIV/AIDS to
maternal mortality is difficult to measure, as the HIV status of pregnant women
is not always known, so existing data will be underestimates, but there is
increasing evidence that HIV/AIDS-related maternal deaths have increased
considerably. In some areas of high HIV prevalence, AIDS has overtaken direct
obstetric causes as the leading cause of maternal mortality. The potential
adverse effect of HIV and pregnancy on maternal health is not limited to the
period of 42days from delivery, the period normally covered by maternal
mortality data. For this reason, figures correlating HIV infection and maternal
mortality may under-estimate the true combined effects of the two conditions
and their interactions in the first year following pregnancy. The inter-related
nature of maternal mortality and HIV may not be clear at a health service
level, as they are often handled by different health workers and managers.
Access to antiretroviral treatment is
becoming more widespread through initiatives such as the World Health
Organization (WHO) “3 X 5”. Initiative and the Global Fund to fight AIDS,
Tuberculosis and Malaria. Pregnant women who quality for antiretroviral
treatment should be considered as a priority group for access to treatment,
both for the prevention of mother-to-child transmission and as an entry point
to family care, and the avoidance of
AIDS orphans.
Successful strategies to reduce the
risk of mother-to-child transmission of HIV have almost eliminated paediatric
HIV infection in developed countries and are proving successful in poorer
settings. Programmes for the prevention of mother-to-child transmission of HIV (PMTCT)
have increased in scale and coverage worldwide, but most pregnant women in high
prevalence areas still do not have access to HIV counseling and testing. WHO
recommends a “four-prolonged strategy” for PMTCT that focuses on the prevention
of new infections and the prevention of unintended pregnancies in HIV-positive
women as well as on interventions to reduce the risk of transmission to infants
and appropriate care and support.
The United Nations Millennium
Development Goals have goals on HIV and maternal health, which should be seen
as intersecting. The maternal health target is to reduce maternal mortality by
three-quarters between 1990 and 2015, and the HIV/AIDS target to have halted
and begun to reverse the spread of HIV/AIDS. All but 1% of maternal mortality
is in developing countries and is as much as 50 times higher in sub-Saharan Africa than other regions. The Declaration of Commitment
adopted by governments from 189 countries at the UN General Assembly Special
Session on AIDS (UNGASS) in June 2001 set a goal of reducing the proportion of
infants infected with HIV by 20% by 2005, and by 50% by 2010.
Pregnant women have been the focus
for increased access to voluntary counseling and testing (VCT) for HIV, due to
the raised awareness about and increasing availability of PMTT interventions.
Pregnancy also provides an opportunity to reach both women and men with HIV
prevention and care interventions. It is the only time that some women will
interact with health services, and the motivation to protect their offspring
provides an incentive for behaviour change. In some settings, pregnancy and the
post-partum period may also be a time of increased risk for HIV infection, as
culturally-mandated abstinence during or after pregnancy may result in men seeking
other partners.