3. Why reduce mother-to-child transmission of HIV?

For most people working in maternal and child health, the answer to this question is self-evident. However, it is worth reviewing just how much illness and death could be averted by reducing transmission from mother to child.

· 2.7 million children under the age of 15 have died of AIDS since the beginning of the epidemic. Over 9 in 10 were infected by their mother at birth or during breastfeeding.

· Another 1.1 million children are currently living with HIV, and 1600 more are infected every day. Almost all of those new child infections are in developing countries, 90% in sub-Saharan Africa alone.

· AIDS deaths are reversing gains in child health and survival. Forecasts for Zimbabwe in 2010, for example, show that AIDS is expected to push the infant mortality rate 138% higher and the under-five mortality rate 304% higher than they would have been in the absence of AIDS. In Cd’Ivoire, child mortality will rise by over two-thirds.

· Caring for HIV-infected children carries heavy costs for families and health systems. In Soweto, South Africa, for example, one-third of paediatric hospital admissions are HIV-related.

Sick children, healthy children and orphans

Another concern is the idea that introducing this strategy for the prevention of MTCT might exacerbate the problem of orphaned children, increasing the burden of care on families and society. It is widely assumed that children born to HIV-infected mothers do not survive long enough to become orphans. But this is a misconception: even in the absence of intervention the great majority are still alive at their fifth birthday and beyond and are highly likely to survive their infected mothers. The most likely effect of introducing the strategy, therefore, will be to alter the proportion of orphans who are HIV-infected compared with those who are uninfected.

The intervention does not therefore affect in any significant way the need for societies to make provision for their orphaned children. However, from the point of view of planning for care and allocating resources, it is important to recognize that, with measures to reduce MTCT, many fewer orphaned children will be HIV-infected and in need of medical care and support, many of them long-term. It is also worth noting that improving perinatal care and diagnosing HIV infection to permit early access to care may prolong the life of mothers. Thus, their children will have the care of their mothers and be spared the misery and vulnerability of orphanhood for longer.

The stigma of dead children

In many societies where children are highly prized, a woman who bears unhealthy children or whose children repeatedly die faces ostracism within the family and the community. This stigma can be avoided through interventions and family support that help her to bear and raise healthy children.