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Title: The Prevention of Parent-to-child Transmission Programme: is it fair to women?
Authors: Nataraj, S
Ramanathan, M
Issue Date: Dec-2014
Publisher: Indian Journal for Medical Ethics
Abstract: In February 2014, the Government of India launched a multi-antiretroviral drug regimen to treat infected women and infants in efforts to reduce parent-to-child transmission (PTCT) of the human immunodeficiency virus (HIV) (1). The announcement has been long awaited because the multidrug regimen can reduce the risk of transmission during childbirth from 30%–35% to less than 2% with replacement feeding (2). Multidrug regimens to prevent PTCT have been used in high-income countries since the 1990s and in many low- and middle-income countries (LMICs) since 2010, when the World Health Organisation (WHO) removed the single-dose nevirapine (SdNVP) regimen from its list of recommended treatments. However, until now, India has been one of the few countries where infected pregnant women and their infants received the SdNVP, which reduces the risk of transmission to 16% in combination with breastfeeding, and to 11% in combination with replacement feeding. Meanwhile, new recommendations from the WHO suggest that for maximum efficiency, antiretroviral therapy (ART) should be given to all HIVpositive pregnant women irrespective of their CD4 counts (3). However, India will initiate the multidrug regimen among women with CD4 count ≤350 cells/mm3 as per the recommendations of 2010 (4). This delay in switching to a multidrug regimen has been ascribed to the need to strengthen infrastructural and human capacity to handle the clinical and monitoring requirements of CD4 counts and treatment adherence involved in this regimen for women and infants (5). Unlike the SdNVP regimen, the multidrug regimen is initiated in HIV-positive women 14 weeks after conception and is continued until after the woman has stopped breastfeeding. Infants are recommended the one daily dose of NVP for about six weeks after birth. As effective as the multi-drug regimen is in preventing transmission from infected women to infants, the switch does not address the important aspect of preventing infection in women in the first place. This should be an integral component of the programme’s design and is the most effective way to ensure zero risk to infants, while protecting the mothers as well. We examine the impact of the Prevention of Parent to Child Transmission programme on women in India, especially because it is the only initiative in the country that targets women outside sex work for HIV prevention and care. We locate our discussion in the wider context of the subjugation of women’s autonomy and well-being in national health policies and practices related to population and reproductive health. Women account for 39% of all infected people in India but the overwhelming majority – over 90% – have been infected after marriage by husbands with a history of unsafe pre-marital or extra-marital sex and/or injecting drug use (7). Most often, the infection occurs early in the marriage but is usually identified only when the woman seeks antenatal care during pregnancy. In many cases, husbands too become aware of their HIV status only after the wife has tested positive (8). Thus, for most women marriage is the only risk factor (9). However, in stark contrast to the attention paid to preventing mother-to-child transmission, the issue of preventing husband-to-wife transmission still remains unaddressed, and women continue to be at risk. We draw attention to the ways in which women’s bodies are used to meet national and international goals to prevent mother-to-child transmission while their rights to autonomy and HIV prevention are overlooked, and the role of men in preventing transmission to women is ignored.
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