Obstacles to Nursing Interventions to Reduce Perinatal HIV Transmission

Catherine Hill
HIV infection and its subsequent diagnosis of AIDS have changed in status from a certain death sentence to a chronic disease able to be lived with. As a result of this change, many people are able to live relatively normal lives with this disease. This normalcy includes pregnancy and childrearing. The risk remains at the forefront for transmission of HIV from an infected mother to her baby. The majority of HIV infected women are of childbearing age. It is vital that nurses play a role in the education and care of these women to reduce the incidence of mother to baby HIV transmission.
The AIDS epidemic has a major effect on women’s health. About one half of the almost 40 million people living with AIDS globally are women, with more than 2 million pregnancies occurring annually to HIV positive women. (McIntyre, 2005) Groups of women at increased risk of HIV infection and subsequent transmission to their infants include adolescents, uneducated, undereducated and the uninsured. The global infection rate among pregnant women is highly variable with ranges between 1% to over 40%. Successful strategies to reduce the risk of mother- to- child transmission of HIV have almost eliminated pediatric HIV infections in developed countries and these strategies are beginning to have an impact in countries where HIV infections are still at epidemic proportions. The World Health Organization recommends a “four-pronged strategy” for prevention of mother-to-child HIV transmission that focuses on prevention of new infections and the prevention of unintended pregnancies in HIV positive women as well as interventions to reduce the risk of transmission to infants with appropriate care and support. (WHO, 2002).
The human immunosuppressant virus is spread by exposure to HIV infected blood or body fluids. The exact mechanism of perinatal transmission is unknown but exposure can occur at any one or all of three instances: before birth by micro transmission of maternal blood through the placenta, during labor and delivery by exposure to vaginal secretions and blood, and after birth through breastfeeding. The risk percentages are 5-10% during pregnancy, 10-20% during childbirth, and 10-20% through breastfeeding. (Kriebs, 2006). Studies have shown that 40-80% of the perinatal transmissions occur during the last two months of pregnancy or during labor and delivery. (Cibulka, 2006). The rate of HIV transmission to an infant through breastfeeding is estimated to be 14%. This rate can increase to as much as 29% among women who are in the acute stage of HIV infection; that is they have a high viral load. The incidence of HIV transmission increases with the length of time breastfeeding. Treating HIV infected mothers with HAART (highly active antiretroviral therapy) does not negate the possibility of HIV transmission, but it has been shown to significantly reduce it. The reported rates of mother-to -child transmission are less than 2% for women who begin treatment early in pregnancy, 12-13% for women who do not initiate treatment until labor, delivery or after birth, and 25% among women who do not receive any preventative care. (Kirshenbaum, 2004) Studies have shown that women who have not taken antiviral therapy during pregnancy have an increased risk of transmission by vaginal delivery and prolonged rupture of amniotic membranes. Elective cesarean section has been shown to reduce transmission rates among these groups. Use of illicit drugs, smoking, and the presence of sexually transmitted infections are all factors that increase the risk of mother-to-child HIV transmission as well as other obstetric risks.
Nurses involved with the care and treatment of pregnant women can play a very important role in reducing the incidence of mother- to- child HIV transmission. Although testing is a voluntary decision, counseling all pregnant women to be tested for HIV is a basic step. According to the CDC, HIV testing should be routine for all pregnancies with the option to op-out if desired. With this method HIV testing becomes a part of basic prenatal care. Those women who test positive should be further evaluated to determine their viral load. Reduction in viral load during pregnancy is achievable using HAART, (highly active antiretroviral therapy). According to Cibulka, (p2), HAART significantly reduces the likelihood of prenatal HIV transmission when combined with good perinatal care of both mother and child. Reducing an HIV mother’s viral load to less than 1000 copies/ml significantly reduces the likelihood of transmission. Studies have shown that HAART is safe to use after completion of the first trimester. Nurses must be knowledgeable about HIV infections and treatment options so they can offer counseling to pregnant HIV mothers regarding the risks and benefits of HAART treatment during pregnancy. Nurses are particularly important in their role as a preserver of patient confidentiality, support for the mother’s choice in route of delivery, and encouragement for maintaining healthcare and treatment after birth. General counseling and education about safe sex practices, lifestyle habits including smoking and illicit drug use, and the fundamental need for the pregnant women to tell the truth about lifestyle and habits is an important task of the prenatal nurse.
The role of the nurse in reduction of HIV transmission from mother to child can start well before a woman ever becomes pregnant. A nurse can be an advocate for all unborn fetuses by educating and counseling at risk populations in a public health setting. It is not necessary to wait until a woman seeks treatment. “Every perinatal HIV infection represents a sentinel health event, often indicating a woman who had undiagnosed HIV infection before pregnancy or did not receive appropriate interventions to prevent transmission of the virus to her infant. Therefore, to strengthen and sustain measures to maximally reduce preinatal transmission, public health activities should give priority to collection of data to identify where missed opportunities occur and target prevention efforts accordingly.”(Mofenson, et.al. 2006, p2). Public health nurses can reach out to adolescents and at risk populations through educational programs, school visits and public health clinics. Of the new AIDS cases reported in 2004, 27% were women over the age of 13. “ Enhanced primary HIV prevention strategies are needed to prevent new infections in women, which will, in turn, prevent perinatal HIV infections”(Mofenson, et.al.,2006, p4). Safe sex practices, education on condom usage, free condoms, and basic knowledge of how HIV is transmitted are fundamental elements in the fight against HIV transmission. It is imperative for the public health nurse to seek information from her clients rather than wait for those clients to offer information regarding habits and lifestyle. This can be a scary and delicate subject. If the nurse does not initiate a dialogue there is a good chance the topic could be ignored. Studies have shown that adolescents, especially males, underprivileged, and uninsured groups have limited exposure to preventative health care services and counseling on sexual behaviors. These services must be brought to these groups. Catching and educating the adolescent population before they become sexually active can significantly reduce the sequelae associated with risky sexual behaviors, which include teen pregnancy, HIV infection and transmission to the next generation.
Globally, HIV continues to be at epidemic proportions. According to Kriebs, approximately 40 million people are infected with HIV; of that 40 million 40-48% are women. The infection rate of children continues to rise. Nurses can have a far reaching effect on this global problem by actively participating in programs to test, treat and educate at risk groups in foreign countries.” Current studies show that too few women benefit from programs for preventing mother to child transmission of HIV” (Bassett, 2002, p3). Nurses can be trained to provide testing and counseling. A major obstacle to providing this service is funding. Also the stigma associated with HIV infection continues to be a deterrent to seeking treatment even in countries where the infection is rampant. These issues are hard to overcome. Nurses should advocate for universal testing of pregnant women and subsequent treatment for HIV infected mothers and their children. The World Health Organization is a natural partner for the nurse. The WHO has outlined a comprehensive program to prevent mother to child transmission that incorporates primary prevention of HIV among adults and prevention of unwanted pregnancy among women with HIV, as well as direct prevention of mother to child transmission. This programs success requires the willingness of rich countries to contribute financially, drug manufactures to provide medications at low cost, and a basic establishment of an infrastructure to provide clinical treatment and laboratory testing. This is surely a tall order to fill. Nurses must be a vital part of initiating this program.
As the number of HIV infections continues to rise worldwide, the number of opportunities to curb the spread of this infection also rises. Nurses can have a significant effect in the reduction of transmission of HIV infections to subsequent generations by being proactive in their care of the current reproducing population, especially those currently infected with HIV and those at greater risk for becoming infected. The task of nurses involves education and prevention of HIV infection, comprehensive treatment of pregnant women infected with HIV to reduce transmission of the virus to their offspring, and globally to increase knowledge of HIV prevention and treatments. Each opportunity seized will assist in the fight to curb the rise in HIV infections and lower the incidences of mother-to-child transmission.

Stopping or slowing the transmission of HIV from mother to child is a very significant task. Currently almost 40 million people are infected with HIV worldwide; of this group over 40% are women. The role of nurses in preventing the spread of HIV from mother to child is a very important one, but it is also a very difficult task with many obstacles.
Intervention 1: Nurses caring for pregnant women need to counsel and treat for HIV and
it’s transmission.
Disadvantage 1: Testing of pregnant women is not occurring at a consistent rate.
The CDC has recommended that HIV testing be conducted routinely on all pregnant women as part of their basic laboratory tests, however the testing rates vary greatly in the United States and worldwide. According to the CDC “ studies found that HIV testing rates for pregnant women vary widely and that a relatively high proportion of women of childbearing age were unaware that treatment is available to reduce the risk of perinatal transmission.” Bindman further states that “current HIV prevention efforts, such as HIV testing programs, are not reaching enough people with enough strength, and are not keeping pace with achievements of treatment programs for people already infected with HIV. For every one person who began antiretroviral therapy in 2006, six people were newly infected.” These inconsistencies in testing and treatment delivery can only be overcome if they become the standard of practice in all prenatal assessments.
Disadvantage 2: Certain subgroups are not receiving adequate prenatal care.
There are racial and socioeconomic subgroups within the population who continue to receive substandard or no prenatal care. These groups include lower socioeconomic classes including those who are already receiving protective and social services, adolescents, and Latinos. In one study these women identified substance use, the need for private and thorough communication with medical and Child and Family services personnel, and the need for positive social relationships as issuesto address to enable HIV positive mothers to engage in care. (Lindau, 2006) Studies continue to show that underprivileged, uninsured and adolescents have limited exposure to preventative health care services and counseling. These groups are also those that have a greater risk of acquiring HIV. This remains as a significant hindrance in the fight to stop the spread of HIV to subsequent generations.
Intervention2: Nurses in the global fight against HIV must be proactive.
Disadvantage 1: Political barriers
Nurses in the global fight against HIV must become advocates for their patients. Political obstacles are a significant barrier to this goal. Nurses trying to promote the prevention and treatment of infected women must be able to counteract the sometimes overpowering political attitude toward HIV and AIDS. “Public health professionals must become skilled at combating the substitution of politics for true science.” (Quinn, 2006) In Africa, where HIV and AIDS infect the greatest percentage of the population, the political impact of the AIDS epidemic has been relatively minimal. “AIDS occupies a commensurately marginal place in African political life. AIDS is never at the top of the list of issues of concerns for the population, according to polls taken in many African countries.” (De Waal, 2007) There is a great deal of personal denial by the individual and collective denial among the political forces about the impact AIDS and HIV transmission has on the society. Attempts to overcome this attitude have been largely state-controlled media based public education, which has been ineffective due to the oppressive nature of the political powers. (De Waal, 2007)
Disadvantage 2: Funding and its distribution
Financial concerns over how the funds are distributed in the fight against HIV transmission is also an obstacle. According to Bindman,” globally, resources should be distributed according to the scientifically proven needs of HIV patient populations, and not the ideology of the donors. Treatment efforts are difficult to integrate into prevention programs because marginalized populations are often denied equitable access to care and lack nutrition and transportation services.” The Global HIV Prevention Working Group reports that HIV prevention and education programs could prevent approximately 30 million of the expected 60 million global HIV infections expected by 2015. The funds must be allocated where they are needed most. Nurses can help by remaining active, outspoken and participatory in organizations responsible for distribution of funds and services.
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