The M in MTCT: questions about HIV-positive mothers

Allan Rosenfield, dean of the Columbia School of Public Health, delivered a politically and ethically charged keynote to a July 10 symposium session on mother-to-child transmission (MTCT) of HIV. “Where is the ‘M’ in MTCT?” he asked rhetorically, before posing a series of ethical questions which were heatedly taken up by subsequent presenters and the standing-room-only audience. Some of his points:

  • “The short course of ZDV preventive therapy uses the woman’s body to confer treatment to the child, but gives no benefit to the woman,” he began. “The short course therapy might increase viral resistance to drugs in the woman. If [she] never [gets] any other treatment, this is not important. But if she does, we may be increasing viral resistance to treatment. One thing we don’t want to do with MTCT is make the woman’s condition worse while reducing transmission. And I would say we don’t have enough information on that.”
  • “Breastfeeding is even more complex,” Rosenfield went on. “Which is the greater risk to the child?” he asked, referring to the lack of clean water and resulting diarrhoeal diseases and potential nutritional status deficits due to not receiving breast milk versus the risk of HIV transmission via the mother’s milk.
  • He posed “one final moral dilemma,” asking, “If we’re not going to treat the mother for her disease, and the likelihood is that the father already has the disease or has died, MTCT [prevention] does increase the number of orphans” He wondered aloud at the wisdom of creating “a generation of homeless children with no future.”
  • “The issue here is inequity.” The impact of poverty must be addressed and prioritised by countries, he concluded, saying that the public health community must address the long-term issues while making the best decisions possible on short term programmatic issues surrounding MTCT.

Source: International Association of Physicians in AIDS Care.

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