[The reduction of mother-child transmission of HIV infection in developing countries: potential intervention strategies, obstacles to implementation and perspectives. The Reduction of Mother-Child Transmission of HIV Infection in Africa Group].

Mother to child transmission (MCT) of Human Immunodeficiency Virus (HIV) is the main cause of the spread of the HIV epidemic in the pediatric population. It is estimated that to date, three million children worldwide have been infected by HIV. The epidemic burden in developing countries is dramatic. Ninety-five percent of the world's HIV-infected women are living in developing countries. In industrialized countries, antiretroviral treatment of pregnant women and newborns with azidothymidine (AZT, ACTG 076 regimen) and discouraging breast feeding by HIV-infected mothers are effectively reducing MCT of HIV. However, there are three major obstacles to the systematic application of these strategies in developing countries: (a) difficulties in implementing the complex AZT administration and its corollary the avoidance of breast feeding; (b) the complexity of the logistics of the ACTG 076 regimen; (c) cost. Indeed, in developing countries the socioeconomic situation of the populations are precarious and health structures and services are underdeveloped. In addition, the anxiety and the reluctance of general population in the face of the HIV problem and the high prevalence of maternal anemia reduce the acceptability and safety of AZT treatment for pregnant women in developing regions. Only interventions that are applicable, acceptable, safe, affordable, of low cost and integrated into health system will be able to reduce HIV MCT. We now know that MCT occurs mostly during the perinatal period and the maternal viral load in blood, in cervical secretions and in breast milk appears to be the main determinant of transmission. Maternal vitamin A deficiency may also favor MCT of HIV. It is however possible that this association is confounded by the relationship between advanced maternal HIV disease (a known risk factor for transmission) and vitamin A deficiency. In spite of these uncertainties concerning determinants of MCT of HIV, several interventions have been designed. The first involves treating the mother with antiretroviral drugs for the perinatal period. The second is vaginal disinfection by application of virucidal antiseptics during the perinatal period. The third is to give vitamin A supplements to pregnant women and children. Finally, passive immunotherapy with anti-HIV antibodies applied to pregnant women and/or new born, may be beneficial. The feasibility, safety and efficacy of these potential interventions have not yet been demonstrated in developing countries. In view of the dramatic spread of HIV infection in these countries, the evaluation of these interventions is of utmost priority. These trials are necessary because of the public health emergency but should be performed in strict respect of human rights and medical ethics.