Report prepared for the university of saskatchewan faculty association

Mother to Child
Transmission of HIV:
Prevention, Treatment, and Education
Report Prepared for the Saskatchewan Prevention Institute Mother-to-Child Transmission of HIV: Prevention, Treatment and Education . 3 1. Introduction . 3 2. Introduction to HIV/AIDS . 3 2.1 HIV Transmission . 5 2.2 HIV Testing . 6 2.3 Symptoms of HIV . 7 2.4 HIV Treatment . 7 2.5 Diagnosis of AIDS . 8 3.1 Modes of Maternal Tranmission of HIV . 8 3.2 Factors that Increase the Risk of Vertical Transmission . 9 3.3 Factors that Reduce the Risk of Vertical Transmission . 10 3.3.1 Anti-HIV medications . 10 3.3.2 Methods of delivery . 12 3.3.3 Other elements of care . 12 3.4 HIV Testing during Pregnancy . 13 3.5 After-Care for Babies of HIV Positive Women . 14 3.6 Further Prevention of Maternal Transmission of HIV . 15 3.6.1 HIV transmission and sexual assault . 16 4. Barriers to HIV Transmission Prevention and Prenatal Care . 16 4.1 Social Determinants of Health . 16 4.2 Stigma and Discrimination . 17 4.3 HIV Testing and Treatment . 18 5. Public Health Education about HIV and Pregnancy . 18 5.1 Basic Education about HIV, AIDS, and Pregnancy . 18 5.2 HIV Education in Schools . 19 5.3 Education for Vulnerable Women . 20 6. Education about HIV and Pregnancy for Health Professionals . 21 6.1 Reducing Stigma and Discrimination . 22 6.2 Pre-Service, In-Service, and Train-the-Trainer Models . 23 6.3 Designing Training Models . 24 7. Conclusions . 25 References . 26 Appendix A: List of Resources for Health Care Professionals . 32 Mother-to-Child Transmission of HIV: Prevention, Treatment and Education

1. Introduction
Unlike in other parts of Canada, rates of Human Immunodeficiency Virus (HIV) are on the rise in Saskatchewan. According to the Saskatchewan Ministry of Health (2009), there has been a steady upward trend in the numbers of Saskatchewan youth testing positive for HIV since 2001. In 2008 alone, there were 173 new cases of HIV identified in Saskatchewan. While 54% of the overall cases were identified in males, female cases exceeded male cases in the younger age group (i.e., 15 to 29 years of age). In other words, the group with the largest increases in HIV infection rates were women of childbearing age. This fact is an important one to consider when thinking about the prevention of HIV transmission, particularly the prevention of mother-to-child transmission of HIV. Without effective education, prevention, and treatment efforts, including those directed at women who are or may become pregnant, HIV infection rates will likely continue to rise in Saskatchewan. Recognizing the importance of understanding HIV in the context of pregnancy, the Saskatchewan Prevention Institute conducted a review of the literature in this area. The following literature review will focus on ways to ensure the best possible outcomes for pregnant women who live with HIV and for their newborns. The review includes findings and recommendations on mother-to-child transmission, transmission prevention, and health promotion around these topics. The information from this review will then be used by the Saskatchewan Prevention Institute to create appropriate training tools and effective information resources on HIV and pregnancy for health professionals, support organizations, and the general public throughout Saskatchewan. 2. Introduction to HIV/AIDS
Before proceeding, it is important first to have a basic understanding of HIV/AIDS, including the meanings of acronyms used in this area. As indicated previously, HIV is an acronym for Human Immunodeficiency Virus. This name highlights the fact that HIV can only be transmitted from one human to another human, and that it is a virus that causes a deficiency in the immune system (Positive Women’s Network Society, 2001). More specifically, HIV infects the CD4 positive T cells, which are the key components of the human cellular immune system (Joint United Nations Programme on HIV/AIDS; UNAIDS, 2008). CD4 cells are a type of lymphocyte, or white blood cell (AIDS.org, 2009). These cells are responsible for signalling other immune system cells to fight infections in the body. When HIV enters these cells, it impairs or destroys them, resulting in a deterioration of the immune system. According to UNAIDS, the immune system is considered deficient when it is no longer able to fight off infections and diseases" (ie. When the number of CD4 cells is less than 200, meaning 200,000 cells per mL of blood. The lower limit of 'normal' is 500.) HIV is a progressive disease that continually causes changes and damage to an individual’s immune system. When individuals’ CD4 cells drop below 200,000/ml and they contract one or more opportunistic infections, they are said to have AIDS (Acquired Immunodeficiency Syndrome). Opportunistic infections are those that individuals with HIV are particularly susceptible to because of the damage to their immune system. There are a wide range of opportunistic infections that include, but are not limited to, fungal infections, respiratory infections, and various forms of cancer. These infections are ones that are rare among people with a healthy immune system. AIDS is considered a syndrome or a group of signs, symptoms, illnesses, and infections that are related to the damage done to the immune system due to infection with HIV (UNAIDS, 2008). Prior to the introduction of HAART (Highly Active Anti-Retroviral Therapy) the average life expectancy after HIV diagnosis was around 10.5 years (Harrison et al., 2010). The use of antiretroviral (ARV) therapy or HAART (Highly Active Anti-Retroviral Therapy) can slow down the progression of HIV by decreasing the individual’s viral load or the amount of HIV virus in a person’s blood. As a result, ARV and HAART can allow the immune system to strengthen itself. Since 1996, when the use of HAART was expanded, the average life expectancy increased dramatically, approaching that of the general population (Gulick, 2010). Harrison et al. (2010) looked at all people diagnosed with HIV in 25 U.S. states and found that the average life expectancy had increased to 22.5 years following diagnosis. Another study, looking at only those who were receiving treatment, found that survival for HIV infected patient at 25 years of age was more than 35 years, although those with a co-infection of hepatitis C had a much higher mortality rate (Lohse et al., 2007). Bhaskaran et al., (2008) found that by 2004-2006, excess mortality was 94% lower than pre-1996 levels. Despite this major reduction in excess mortality, a significantly increased risk of death remained among individuals of all ages with HIV in 2004-2006. It was suggested that even with current standards of HIV management, some long-term excess mortality would remain because of problems of toxicity, resistance, and therapy adherence, increasing over time receiving HAART. Those exposed through IDU have a higher excess risk of death overall (Bhaskaran et al.). Factors that may contribute to the increased mortality rates of those exposed through IDU include the risks associated with substance abuse, the increased likelihood of having a mental health issues, and co-infections. As well they found a lower uptake of HAART among those exposed through IDU. 2.1 HIV Transmission
HIV can only be transmitted when there is a direct exchange of specific bodily fluids between two humans. The five fluids capable of transmitting HIV are: 1. blood; 2. semen and pre-cum; 3. vaginal fluid; 4. anal fluid; and 5. breast milk (Positive Women’s Network Society, 2001). Common risky activities include unprotected vaginal and anal sex, sharing needles and other drug equipment, and tattooing with used needles. In Saskatchewan, injection drug use accounted for 77% of new cases of HIV in 2008 (Saskatchewan Ministry of Health, 2009), while the primary mode of transmission in other provinces was unprotected sex. In Canada, 45% of new cases of HIV infection were found in men who have sex with men, and 31% were reported in people engaged in heterosexual sex (Public Health Agency of Canada, 2008). HIV-positive mothers can also pass HIV to their babies through pregnancy, childbirth, and breastfeeding, although the occurrence is currently relatively rare in Saskatchewan, with 8 cases of perinatal transmission being reported since 1997 (Saskatchewan Ministry of Health). Another population gathering attention is immigrants from countries where HIV is considered very prevalent (endemic), or where the predominant means of HIV transmission is heterosexual contact. In Saskatchewan between 2006 and 2008, there were 6 cases of HIV identified in people who emigrated from countries where HIV is considered endemic (Saskatchewan Ministry of Health). Every day, casual contact is not a risk for transmitting HIV, unless people are participating in behaviours that could result in an exchange of bodily fluids. Simply put, HIV is spread when: 1. a body fluid with a high concentration of HIV (blood, semen, vaginal fluid, anal fluid, breast milk); 2. enters the body of someone else through an activity (e.g., intercourse, sharing needles, during labour, delivery, breastfeeding); 3. that provides direct access to the bloodstream (e.g., through breaks in the skin or by passing through a mucous membrane) (Positive Women’s Network Society, 2001; Sheth & Thorndycraft, 2009). In other words, HIV transmission requires a direct exchange of body fluids with high concentrations of HIV. Certain activities, like vaginal and anal sex, are considered higher risk activities because small abrasions can occur during sex resulting in direct routes for HIV transmission. 1 Mucous membranes are tissues that line the surfaces of body cavities such as the nostrils, mouth, throat, vagina, urethra and anus. HIV attacks and destroys the body’s immune system, which is the body’s natural defence system against diseases and infections (Society of Obstetricians and Gynaecologists of Canada; SOGC, 2004). Specifically, HIV destroys the immune system’s CD4 cells. Therefore, HIV makes it difficult for the body to fight off infections, making it more likely that life-threatening infections will set in. 2.2 HIV Testing
Early detection of HIV infection is important for both treatment and for the prevention of HIV transmission (Spielberg et al., 2003). HIV diagnostic tests are used to detect whether HIV antibodies are present in a person’s body. These antibodies are produced by the immune system in response to the HIV infection. This type of test is used because it is easier and cheaper to detect antibodies rather than the virus itself (UNAIDS, 2009). As the test relies on the presence of antibodies, there is a window period between the occurrence of risky activities and when the results of an HIV test will be accurate. For most people, it takes three months for enough HIV antibodies to develop and result in a positive HIV test result. Regular HIV testing is extremely important as it allows people who test positive to access treatment, care and support services as early as possible. As someone can have HIV and not have any symptoms for five or more years, waiting until symptoms occur can be detrimental, as damage to the immune system is still occurring (SOGC, 2004). Receiving care before the immune system is severely impacted and/or opportunistic infections occur can help individuals keep their viral loads down, thereby prolonging the time before they are diagnosed with AIDS. Testing is also crucial because it allows people who test positive to take the necessary precautions to prevent the spread of HIV to others. Frequent testing is particularly important for people who are engaged in high risk activities, as their HIV infection status may change rapidly. Also, as the HIV virus mutates quickly, an HIV positive individual can be re-infected with a different strain of HIV by participating in risky behaviours (Canadian AIDS Treatment Information Exchange; CATIE, 2009). For pregnant women, women contemplating pregnancy, or women having unprotected sex, knowing their HIV status can help them to prevent the spread of HIV to their children, in particular their fetus or newborn child. UNAIDS (2009) views counselling and testing as both primary and secondary prevention strategies. Specifically, counselling can reduce the risk of HIV exposure in people who test negative by providing them with accurate information about HIV transmission (i.e., primary prevention). Counselling and testing can also reduce the risk of transmission of HIV to partners and unborn children in those testing positive for HIV. Testing of pregnant women can also serve as a secondary prevention activity, as knowledge of HIV status can increase the opportunities for interventions to slow the progression of HIV to AIDS. 2.3 Symptoms of HIV
Most people with HIV do not show symptoms for several years after infection. This means that they may not know that they have been infected. Some people do develop acute retroviral syndrome at the time of seroconversion, the time at which the body develops antibodies to HIV. Seroconversion usually takes place between 1 and 6 weeks after HIV infection (UNAIDS, 2008). People experiencing acute retroviral syndrome typically have symptoms similar to glandular fever (e.g., fever, rash, joint pains, and enlarged lymph nodes). Even people with HIV who are not symptomatic are highly infectious, particularly at the time of seroconversion, and can transmit the virus to others. 2.4 HIV Treatment
When the HIV/AIDS epidemic first began in the early 1980s, the virus was considered to be a death sentence, and individuals did not live long post-diagnosis. Currently, although there is still no cure for HIV, there are treatments that can help postpone the development of AIDS (Positive Women’s Network Society, 2001). Anti-retroviral medications, known as ARV therapy or HAART, can stop the virus from replicating in the body which, in turn, stops the virus from rapidly damaging the immune system (UNAIDS, 2009). Combination HAART, the use of three or more anti-HIV drugs, allows CD4 cells to live longer and protect the body from infections. Because this therapy does not eliminate HIV from the body, people with HIV need to take these medications for the rest of their lives. HIV is able to quickly adapt to medications, which makes the use of combination HAART very important. For the same reason, treatment adherence is also important. Because HIV is characterized by high levels of virus production and mutation, the virus can become resistant to medication when treatment regimens are not adhered to (Clavel & Hance, 2004; Deeks, 2006). When HIV becomes resistant to one drug, it may also become resistant to other drugs in the same class, even if the individual has never taken those drugs (CATIE, 2009; Clavel & Hance). As there are only a certain number of drug combinations available, acquiring resistance to a drug class can greatly reduce an individual’s treatment options. Keeping the right levels of medications in the body at all times makes it more difficult for the virus to become resistant to the medication (UNAIDS, 2009). Current World Health Organization recommendations for HIV treatment state that three separate ARV medications need to be taken at all times. Some ARV medications can cause side effects like nausea, vomiting, headaches, and skin rashes. Most of these effects improve over time or can be managed through a change in diet or the use of additional medications (CATIE, 2009). Although these side effects can usually be managed, they can sometimes cause low adherence to HIV treatment (Mehta, Moore, & Graham, 1997). This may be especially true in pregnant women who may already be experiencing some of these effects from pregnancy (e.g., nausea and vomiting). 2.5 Diagnosis of AIDS
As previously stated, AIDS is diagnosed when an HIV positive person has a low CD4 cell count and contracts an opportunistic infection. In other words, when the immune system becomes so weak that certain life-threatening infections set in, the person is said to have AIDS (SOGC, 2004). With proper treatment, CD4 cell counts may increase and the person may begin to feel better. Once a person receives a diagnosis of AIDS however, the diagnosis is not removed regardless of subsequent changes in his/her health status. 3. HIV and Pregnancy
3.1 Modes of Maternal Transmission of HIV
About 0.2% of pregnant women are HIV positive (SOGC, 2004). When an HIV positive woman passes HIV to her fetus or baby, this is called vertical transmission1 (CATIE, 2009; Margolese, 2009; du Prees, du Plessis, & Pienaar, 2006). It is also sometimes called mother-to-child transmission, perinatal transmission, or maternal transmission. Transmission can occur during pregnancy, around the time of delivery or postnatally, through breastfeeding. The timing of transmission is difficult to determine for certain, however, the risk factors for transmission vary between in utero, intrapartum and postnatal, and it is important for preventative interventions to address the major risk factors at the appropriate time (Jourdain et al., 2007; Magder, et al., 2005). Researchers have relied on the assumption that infants who tested positive for HIV DNA during the first days of life have been infected in utero (Bryson et al. 1992; Magder, et al., 2005). Evidence now suggests that although the overall mother to child vertical transmission has decreased over time, there has been an increase in the proportion of infections transmitted in utero, with approximately a third of infections acquired in utero and two thirds during delivery, among non-breastfeeding women (Kourtis, Bulterys, Nesheim & Lee, 2001; Madger et al., 2005). Research indicates that in utero transmission occurs primarily in the weeks or days prior to delivery (Thorne & Newell, 2003; Kourtis et al.). HIV positive women have approximately a 25% chance of transmitting HIV to their newborn in the absence of preventative measures and HIV treatment (Boucher, 2001; Margolese, 2009; SOGC, 2004; Walmsley, 2003). Of the 8 cases of perinatal transmission identified in Saskatchewan since 1997, all 8 of the women did not receive HIV treatment during pregnancy or delivery (Saskatchewan Ministry of Health, 2009). Research has identified a link between vertical transmission and maternal factors like advanced stage of disease, decreased CD4 cell count, and increased viral load (Boyer et al., 1994; Katz, 2003; Krist & Crawford-Faucher, 2002). Because of increases in knowledge about vertical transmission, women receiving proper care have less than a 2% chance of having a baby infected with HIV (Walmsley). The use of double or triple ARV therapies, elective caesarean sections, and formula feeding have been found to produce vertical transmission rates that are less than 1% (Boucher; Coovadia, 2004; Thorne & Newell, 2003). Infants are classified as infected in utero if HIV cultures are positive within 48 hours of birth. They are classified as infected intrapartum (during birth) if cultures were negative at birth and then became positive within 90 days of life (Boyer et al., 1994; Bryson, Luzuriaga, Sullivan, & Wara, 1992; Magder et al., 2005). Infants born to HIV positive mothers may receive false-positive HIV test results if standard HIV tests are used. This is because all babies are born with their mothers’ antibodies, and standard tests look for the presence of these antibodies. Therefore, tests that directly detect the presence of HIV are now being used for infants. Although these tests are very sensitive, they are less accurate in newborns under 28 days old (Krist & Crawford-Faucher, 2002). Therefore, it is currently recommended that infants be tested for HIV before 48 hours old, with the test being repeated at one to two months, and four to six months (American Academy of Pediatrics, 1997; Krist & Crawford-Faucher, 2002; New York State Department of Health, 2005). HIV infection is definitively diagnosed when two HIV tests performed on separate blood samples are returned positive. Intrapartum events are important to consider as possible modes of transmission. Mode of delivery, duration of labour, potential mixing of maternal and fetal blood (e.g., abrupto placenta, invasive procedures like amniocentesis and internal monitoring), and the presence of concurrent maternal infectious diseases (e.g., sexually transmitted infections) have been correlated with transmission rates (Boyer et al., 1994; Burdge et al, 2003; Krist & Crawford-Faucher, 2002; Thorne & Newell, 2003). 3.2 Factors that Increase the Risk of Vertical Transmission
As previously discussed, intrapartum events associated with potential fetal exposure to maternal blood are correlated with a higher incidence of the vertical transmission of HIV. Such intrapartum events include placental abruption, use of fetal scalp electrodes, episiotomy, and lacerations. Other obstetric factors associated with an increased risk of transmission include: longer duration between the rupture of membranes and delivery, presence of a bacterial infection in the membranes around the fetus and the amniotic fluid (chorioamnionitis), the use of forceps, and having a vaginal delivery (Burdge et al., 2003; Madger et al., 2005; Remez, 1997; Thorne & Newell, 2003). In addition to these intrapartum events, maternal factors can increase the risk of HIV transmission to the baby. These include: high maternal viral load prior to birth; lack of antiretroviral treatment during pregnancy; having a genital infection during pregnancy; and using alcohol, drugs or cigarettes during pregnancy (Canadian AIDS Society, 2004; Magder et al., 2005; Positive Women’s Network Society, 2001). The health of the fetus, which is related to maternal nutrition and prenatal care, has also been linked to in utero transmission (Vogler, 2006). Overall, women who are less healthy are more likely to pass HIV to their babies. The use of alcohol and drugs can result in poorer maternal health. Specifically, alcohol and drug use can weaken the immune system, impact nutrition, and increase risk of other pathogens. Therefore, women who are HIV-positive and are using alcohol and drugs may be more likely to get infections or viruses. These women may also be less likely to adhere to their treatment regimens (Mehta et al., 1997). To increase their health and the health of their babies, women should use alcohol and drugs less often, practice safer drug use, and stop using alcohol and drugs if possible (Positive Women’s Network Society). Stopping alcohol and drugs should be done under the care of a medical professional, especially when pregnant. 3.3 Factors that Reduce the Risk of Vertical Transmission
There are numerous factors that are known to decrease the risk of vertical transmission of HIV. First, it is important for pregnant women to find a doctor that they trust and see him or her regularly. Pregnancy and HIV require special medical care, so it is important for women to find a doctor who is knowledgeable about HIV (Margolese, 2009). Women with HIV should take special care to increase behaviours that support a healthy immune system, such as: getting enough sleep and rest, lowering their stress levels, ensuring they are getting proper nutrition, getting social support, maintaining contact with professionals, and decreasing substance use (Positive Women’s Network Society, 2001). 3.3.1 Anti-HIV medications. One of the most important ways to reduce vertical transmission is
for women to receive treatment in order to reduce their viral load (Margolese, 2009). Studies
have shown that when pregnant women receive AZT (zidovudine) during pregnancy, labour and
delivery, the risk of vertical transmission is greatly reduced (SOGC, 2004). This is especially
true for women who have not been diagnosed with AIDS. AVERT (2009) reports that a single
dose of anti-HIV medication given to mother and baby can reduce the risk of vertical
transmission by half. As previously mentioned, the chances of HIV infection in the baby are 25%
when women do not receive treatment. Therefore, the identification and appropriate treatment of
HIV during pregnancy is very important (Health Canada, 2002).
Canadian guidelines recommend that all pregnant HIV positive women take combination ARV therapy. The combination of drugs taken depends on many factors, including the drugs the woman has taken in the past. ARV medications can have side effects for both the mother and her fetus. Some maternal side effects include high blood sugar, low red blood cell count (anemia), and stress on the kidneys and liver (Margolese, 2009). As these side effects can be worse during pregnancy, women should be monitored throughout pregnancy. Some ARV medications may, in some circumstances, cause harm to the fetus. Some of the potential effects of these medications include prematurity, neural tube defects, low birth weight, pre-eclampsia and gestational diabetes mellitus (Thorne & Newell, 2005; Thorne & Newell, 2007). However much of the evidence for potential harm is from animal studies and observational studies of varying strength, and the benefits of these medications in reducing the mother-to-child transmission and delaying maternal HIV disease progression means that research is still needed to clarify the risks and benefits of these medications (Chersich et al, 2006; Thorne & Newell, 2007). Physicians should be aware of the most recent evidence and assist a woman to balance the known risks and benefits. Currently, efavirenz (Sustiva) is the most important ARV contraindicated in pregnancy, particularly in the first trimester (World Health Organization, 2009; Perinatal HIV Guidelines Working Group, 2009). However, a recent review of the research has not found any increase in the overall birth defects for women exposed to efavirenz in the first trimester, compared to the general population (Ford et al., 2010). Scientists do not yet know the long-term effects of many ARV and HAART medications on babies, but they are currently considered to be safe. The Antiretroviral Pregnancy Registry is a program run by the United States health authorities. This registry has been monitoring children born to HIV positive mothers since 1994. They have found no evidence of long-term side effects in children of mothers who took anti-HIV medication during pregnancy (Margolese, 2009). This program has also found that the prevalence of birth defects in children born to women using ARV medication is not different among trimesters of exposure (Volger, 2006). Importantly, it is known that these medications greatly reduce the risk of babies becoming infected with HIV (Thorne & Newell, 2007). If women are already on ARV medications, doctors may decide to switch their medications in order to avoid those with possible harmful effects to the fetus. If women are planning on becoming pregnant, they should switch their medication as soon as possible. Women should not change or stop their medications without first consulting their physician. If a woman suddenly stops her medications her viral load will likely increase, thereby increasing the risk of transmitting HIV to her baby (Margolese, 2009). As well, this can increase the risk of the woman developing drug resistance, which, in turn, can limit her treatment options in the future. If a pregnant woman is not already on ARV medication, doctors generally recommend starting treatment after 12 to 14 weeks of pregnancy, unless there is a medical reason to start earlier (e.g., very high viral load). The main reason for waiting is to avoid any potential negative effects of the drugs on the fetus during the early stages of development. Another reason to wait is to avoid taking pills during the first trimester, when women are most likely to experience morning sickness and may throw up their medications. The current best practices to reduce the risk of vertical transmission include: 1. ARV drugs for the mother during pregnancy and labour; 2. delivery by caesarean section; 3. a short course of ARV drugs for the baby after birth; and 4. no breastfeeding (Margolese, 2009). In addition to taking ARV medications, other things pregnant women can do to reduce vertical transmission include being tested for rubella immunity; and tested and treated for sexually transmitted infections, hepatitis B, and group B streptococcus status. 3.3.2 Methods of delivery. In terms of delivery, in many cases a natural or vaginal delivery is
safe and preferable. If a woman’s viral load is less than 1000 copies/ml (i.e., if there are less than
1000 virus particles in a drop of blood), a caesarean section is not likely to further reduce the
chances of vertical transmission. If a woman’s viral load is over 1000 copies/ml, or if she has not
been on ARV medication at the time of delivery, a caesarean section birth may reduce the risk of
transmission. The SOGC’s Clinical Practice Guidelines (Boucher, 2001) state that “the most
appropriate mode of delivery for individual patients infected by HIV” must take “into account
the medication received and the level of viral suppression” (p. 1). These guidelines suggest that
elective caesarean section should be offered to HIV positive women in the following specific
situations: 1. women who have not received ARV therapy; 2. women receiving ARV
monotherapy; 3. women with a detectable viral load; 4. women in whom the viral load is
unknown; and 5. women with unknown prenatal care. In cases of optimal viral suppression (e.g.,
multiple ARV therapy adjusted with viral load determination), vaginal delivery may be as safe as
a caesarean section delivery (Boucher, 1994; Centers for Disease Control and Prevention, 2001;
Katz, 2003).
Caesarean section births do present less risk of vertical transmission in women who have been circumcised, especially in cases of infibulations where all outer genitals have been removed (Margolese, 2009). In women with risk factors such as a high viral load at delivery or co-infection with Hepatitis C (HCV), the chance of vertical transmission can be further reduced with the following precautions: 1. limiting the use of forceps and vacuum, 2. not using fetal scalp electrodes, and 3. avoiding fetal scalp sampling (Health Canada, 2009). 3.3.3 Other elements of care. As discussed above, the use of combination ARV drug therapy
during pregnancy and delivery reduces the risk of mother-to-child transmission of HIV
(UNAIDS, 2009). Even when drug therapy is available, women with HIV need other elements of
care, such as good nutrition, safe water, basic hygiene, plenty of sleep, strong support networks,
and limited stress. In addition to these elements of care, the Positive Women’s Network Society
(2001) lists numerous complementary and alternative medicines which can be used before
starting treatment, with treatment, or instead of treatment, including, but not limited to: yoga,
exercise, massage, reflexology, acupuncture, traditional Aboriginal healing practices (prayer,
smudge ceremonies, sweat lodges, healing circles), journaling, visualising, and meditation.
Nutrition is especially important for HIV positive pregnant women (Positive Women’s Network Society, 2001). HIV causes the body to burn more calories, so women with HIV need to eat more in order to maintain their weight. In order to avoid and better fight infections, women should eat a variety of nutritious foods and take multivitamins with folic acid. Because HIV can make it difficult for the stomach to digest food, women should try to eat frequent, smaller portions. It is also important that HIV positive pregnant women get enough sleep, wash their hands regularly, and try to avoid stressful situations. 3.4 HIV Testing during Pregnancy
As treatments are available to reduce the risk of vertical transmission of HIV, women who are thinking about becoming pregnant or are already pregnant should strongly consider being tested for HIV (SOGC, 2004). The earlier this testing takes place, the sooner arrangements can be made for treatment of both the mother and fetus. In other words, one of the most basic ways of reducing the risk of maternal transmission of HIV is to screen pregnant women as early in pregnancy as possible. As stated by Obermeyer and Osborn (2007), “testing for HIV is the gateway to treatment, care, and prevention” (p. 1). Burdge et al. (2003), on behalf of the Canadian HIV Trials Network Working Group on Vertical HIV Transmission, recommend that women who test negative early in pregnancy but who continue to engage in high-risk behaviours should be offered repeat testing each trimester and at term. The SOGC (2006) state that it has yet to be determined whether repeat testing of all negative women would be cost-effective. As such, the SOGC currently recommends repeat testing only for women at continued risk for HIV infection. In recognition of the importance of HIV testing in pregnancy, it is now recommended that all pregnant women are offered prenatal screening for HIV, instead of those who present as being high risk for HIV (Murray and Weir, 2005; SOGC, 2004; 2006). Targeted testing of those considered to be high risk fails to identify a substantial proportion of HIV positive pregnant women (Walmsley, 2003). Health Canada (2002) suggests that targeted testing identifies only 8 to 58% of pregnant women who are HIV positive. There is an argument as to whether prenatal HIV testing should be mandatory or voluntary. Walmsley states that mandatory testing is not desirable, or ethical, because it deprives women of their fundamental human rights. Such deprivation could cause women to avoid seeking prenatal care. Voluntary testing strategies include opt-in or opt-out. The opt-in strategy requires formal consent. The opt-out strategy is when HIV testing is part of routine screening, but the physician is required to inform the woman that it is part of routine screening, and that she has the option to opt-out if desired. With the opt-in strategy it has been found that, for a variety of reasons, many women are still not receiving the test. Provinces and territories that have adopted the opt-out strategy have higher rates of testing and it is now the recommended strategy (US Institute of Medicine). Ideally, with the opt-out strategy, physicians should make sure that purpose, risks and benefits of the test are explained to the woman and that she understands her right to refusal. Health Canada (2002) states three main goals of HIV testing during pregnancy: 1. to identify women who are HIV positive so that they can receive optimal care; 2. to decrease the incidence of mother to child transmission of HIV; and 3. to reduce the risk of transmission to sexual partners. These goals highlight the importance of offering HIV testing as a part of routine prenatal care and as a way of reducing vertical transmission of HIV. It is also important, however, that the common principles of voluntarism, confidentiality, and informed consent, conducted in a non-judgemental fashion, are applied to HIV testing in pregnancy (Health Canada). HIV testing usually consists of a blood test. First the enzyme-linked immunosorbent assay (ELISA) test is used to see whether the blood contains HIV antibodies, which develop after a person becomes infected (SOGC, 2004). If the first test is positive, a repeat ELISA is done along with a Western blot test The ELISA test is very sensitive but there may be false positives. The Western blot test is a much more specific test used to confirm diagnoses. It takes about 6-12 weeks after exposure to HIV to develop enough antibodies to measure with the ELISA test (SOGC, 2004). 3.5 After-Care for Babies of HIV Positive Women
Throughout pregnancy, a developing fetus has its own blood supply, meaning that it does not come into contact with its mother’s blood. Fetuses do, however, receive nutrients and immune system antibodies from their mothers. This means that although all babies born to HIV positive mothers are born with their mother’s HIV antibodies, not all babies are born with HIV (Positive Women’s Network Society, 2001). Doctors must test the baby’s blood several times before they know whether the baby has been infected. Many babies infected with HIV die within the first three years of life unless they receive ARV treatment (SOGC, 2004). In an effort to prevent this outcome, babies of mothers with HIV often receive special care for the first few months of their lives. If women have taken ARV medication during pregnancy, AZT will likely be given to the baby 6-12 hours after delivery and be continued for 6 weeks (SOGC). Babies of women who did not receive medication, or whose mothers had a high viral load during delivery, may receive combination ARV therapy (Margolese, 2009). As previously stated, doctors regularly test the HIV status of the baby after birth. Babies will typically receive PCR (polymerase chain reaction) tests at birth, 1 to 2 months, and 2 to 4 months of life. With this test, it is possible to be fairly certain about a baby’s HIV status by the age of 2 to 4 months of life (Margolese, 2009). There is a 25 to 50% chance that a baby can be infected through breast milk. As HIV is found in breast milk, it is recommended that mothers infected with HIV formula feed their babies (Margolese, 2009). Donor breast milk is an alternative to formula feeding, but it is important that this milk is screened for HIV and other illnesses. Although research has shown that the amount of HIV in breast milk can be reduced by heating it or by having the mother stay on ARV medications for 6 months after birth, these methods do not eliminate HIV. Therefore, they are not deemed safe and are not recommended in Canada (Burdge et al., 2003; Canadian AIDS Society, 2004; CATIE, 2009). 3.6 Further Prevention of Maternal Transmission of HIV
For women who do not wish to become pregnant, it is important for them to have information about and access to effective contraception (Vogler, 2006). Condom promotion programs provide access to and education about the prevention of HIV infection and the prevention of unwanted pregnancies. For women who do wish to become pregnant, planning their pregnancies is an important step in preventing transmission of HIV to the baby. By planning for a pregnancy, women with HIV are better able to plan for the additional measures that need to be taken to ensure the best possible outcomes for their babies. For example, women can discuss their ARV medications with their doctors, as some medications are safer during pregnancy than others (Positive Women’s Network Society, 2001). Women can also discuss the safest methods of becoming pregnant with their doctors. Because unprotected sex can result in the transmission of HIV to HIV negative male partner(s), this method of reproduction is not recommended (Margolese, 2009; Semprini, Vucetich, Hollander, 2004; Vogler, 2006). To avoid HIV transmission while trying to become pregnant, some women use artificial insemination (either at home or with medical assistance). At home, sperm is placed into the vagina with a syringe or eye dropper. Medically assisted insemination places sperm directly into the uterus, known as intrauterine insemination. Chances of getting pregnant are usually increased with intrauterine insemination (Volger). Unprotected sex can also result in re-infection, also known as superinfection, if both partners are HIV positive (Smith, Richman, & Little, 2005). Re-infection occurs when one infected partner passes the virus to an already infected partner. Infection with a new strain of HIV can cause more health problems or may result in the development of premature resistance to some ARV medications (Canadian AIDS Society, 2004). When both partners are HIV positive, the doctor may recommend sperm washing. According to Semprini et al. (2004), sperm washing involves separating the sperm from the semen, the latter of which contains a higher concentration of HIV. After the sperm is tested for HIV, it is used to inseminate the woman. This method allows for conception without the risk of re-infection. Sperm washing is also an option for HIV positive men who have HIV negative female partners (AVERT, 2009; Margolese, 2009; Semprini et al., 2004). In these cases, sperm washing allows for conception without risking the infection of the woman and potentially the child. 3.6.1 HIV transmission and sexual assault. Although planned pregnancies may be preferable in
terms of preventing HIV transmission, they are not always possible. This is especially true in
cases of sexual violence and sexual assault. Sexual assault can lead to HIV infection directly,
particularly because violent sex can increase the risk of transmission (Andersson, Cockcroft, &
Shea, 2008). Sexual assault has also been found to increase HIV risk indirectly, as women who
have experienced sexual assault, violence, and abuse have been found to engage in more high
risk behaviours (Andersson et al.; Kalichman & Simbayi, 2004). Through participation in these
high risk behaviours, including unsafe sex and sex with multiple partners, these women may also
be at higher risk for unintended pregnancies. It is important for clinical and social service
providers to be aware of and sensitive to the possibility and prevalence of sexual violence in HIV
positive women’s lives (Kalichman & Simbayi; Zierler, Witbeck, & Mayer, 1996). The National
Conference on Women and HIV/AIDS (2000) recommended that more resources need to be
made available for women who have experienced sexual assault.
4. Barriers to HIV Transmission Prevention and Prenatal Care
4.1 Social Determinants of Health
Researchers working in the areas of HIV prevention and prenatal care for HIV positive pregnant women have identified numerous barriers. Many of the barriers to HIV prevention and prenatal care include social determinants of health: lack of food, clothing, stable housing, adequate finances, and transportation (Bunting & Seaton, 1999; Leenerts, 1998; Wood & Tobias, 2005). When pregnant women are unable to meet their most basic needs, it can be difficult for them to participate in prenatal treatments and care. Refusal to be tested and/or inability to obtain test results have been attributed in part to obstacles with transportation and having to return to health facilities (Obermeyer & Osborn, 2007). Related to issues with transportation, the accessibility of HIV testing and treatment can serve as barriers to maternal HIV transmission prevention. With the introduction of rapid testing in Saskatchewan, which provides a negative or preliminary positive result in minutes, issues related to the inability and/or unwillingness to return for test results may become less problematic. Rapid testing allows for results while the individual remains at the testing facility, meaning that more people actually receive their results. This gives people who test positive the opportunity to make decisions about treatment and to take preventative steps to prevent the transmission of HIV to others. Access to other HIV-related services (e.g., counselling, care and treatment services, infant-feeding guidance) is also influenced by the place in which women live and their access to transportation. Other common reported barriers include: lack of childcare while attending doctor’s appointments, mistrust of nurses and doctors, fear of health and social service organizations, and fear of having the baby removed from their custody (Mill et al., 2007; Streetworks, 2009; Wood & Tobias). In order to receive appropriate treatment and counselling, women need to be able to be honest with medical professionals about their lifestyle (e.g., treatment adherence, food intake, drug use). Another identified barrier to reducing the risk of maternal HIV transmission is a lack of access to appropriate substance abuse treatment programs (Wood & Tobias, 2005). Medical substance abuse treatment programs are necessary, and sorely lacking, for pregnant women who are HIV positive and using drugs and/or alcohol. For women who have other children to care for, attending treatment programs can be impossible if the programs do not allow the women to have their children with them. Lack of childcare while in treatment has been identified as a significant barrier to participating in drug and alcohol treatment programs (Wood & Tobias). Although drug and alcohol use increase the chance of vertical transmission, many substance abuse treatment programs are not designed to deal with the barriers faced by pregnant women with HIV. 4.2 Stigma and Discrimination
Fear of potential judgements and discrimination by staff members, based on a pregnant woman’s HIV status, can also decrease the likelihood that women will seek prenatal care (Spielberg et al., 2003; Streetworks, 2009). Mill et al. (2007), state that the stigma surrounding HIV can influence health and health seeking behaviours. For example, stigma from others can limit the services women receive, and internalised stigma can cause women to avoid seeking treatment and/or avoid disclosing their HIV status. Stigma against HIV is reported to be the main reason for reluctance to be tested, to disclose HIV status, and to take ARV medications (Obermeyer & Osborn, 2007). Fear of potential judgements and internalised stigma may be especially experienced by women who are using drugs and alcohol. Wood and Tobias (2005), state that HIV positive women may be “reluctant to access the health care system due to lack of trust, previous negative experiences, or fear of confidentiality violations” (p. 48). These fears are related to the potential stigma and discrimination surrounding HIV. These stigmas may be especially experienced by pregnant women about their choices for wanting to have children and/or their actions during their pregnancy (Margolese, 2009). Moral judgements about women’s lives and their choice to have children can also prevent women from having the opportunity to learn healthy baby and self-care skills (Margolese). Leenerts (1998) states that self-care is not an option in an environment of rejection. Stigma and discrimination are often based on fear and are often the result of a lack of information, or a wealth of misinformation, about HIV. Health Canada (2002) states that because of the stigma and discrimination faced by persons living with HIV/AIDS, confidentiality in HIV testing is of the utmost importance. Leonard et al. (1998) found that the fear of punitive or discriminatory actions based on HIV status may deter women from coming forward for HIV testing, treatment, and/or other prenatal services. 4.3 HIV Testing and Treatment
Common barriers to HIV prevention and HIV treatment include not getting tested or not returning for test results. Spielberg et al. (2003) report that the main reason people provide for not being tested is that they do not believe they are at risk for HIV. Other reasons given for not being tested include not wanting to think about being tested and fear of getting test results. Of people who do get testing, Spielberg et al. summarize research showing that 25% to 35% of people do not return for their test results. These rates will be reduced with the increased use of rapid testing, which allows for an almost immediate response, thereby reducing the anxiety provoked by having to wait for results. Even for women who do access medical services, there may be a number of reasons why they are unable to take their anti-HIV medications (Ammassari et al., 2002; Positive Women’s Network Society, 2001). In their extensive literature review on HIV and HAART adherence, Ammassari et al. found that the following were consistently associated with non-adherence: symptoms and adverse drug effects, lack of social or family support, complexity of the medication schedule, low patient self-efficacy, and inconvenience of treatment. Other identified factors which can influence treatment adherence include access to ARV medication, alcohol and substance abuse, and worry about HIV disclosure (Positive Women’s Network Society). If women are unable to adhere to treatment, or if they choose not to take treatment, they should be encouraged to take care of themselves in different ways (including those mentioned previously). 5. Public Health Education about HIV and Pregnancy
5.1 Basic Education about HIV, AIDS, and Pregnancy
Primary prevention of HIV infection in women of childbearing age is the most effective way to prevent vertical transmission of HIV (Vogler, 2006). Nyblade (2006) states that there is a “growing recognition of the reduction of HIV stigma as central to effective programs across the HIV/AIDS prevention to care and treatment continuum” (p. 335). Mill et al. (2007) agree, stating that stigma and discrimination are two of the most significant barriers to HIV testing and accessing of treatment by people with HIV. As these barriers have serious consequences, it is important that public education focuses on reducing the stigma surrounding HIV. Providing the basic information and facts about HIV is likely a good starting point, as a lot of stigma is based on misinformation (Mill et al.). As will be discussed further in the next section, health care professionals are likely the best source of education for all women, particularly those seeking prenatal care. Aggleton, Jenkins, and Malcolm (2005) suggest that three factors are necessary for successful HIV prevention: 1. quality information and education, 2. appropriate health services, and 3. a supportive societal environment. These authors state that while interventions that reach the masses are rarely effective in directly affecting specific target populations, they can be effective in raising general awareness and changing knowledge. Therefore, the use of such methods may be beneficial for increasing HIV knowledge and decreasing stigma in the general public. In order to be effective with specific target groups, though, Aggleton et al. suggest that messages specific and relevant to those groups should be used. When people decide to be tested for HIV, pre-test counselling has been found to be an effective way of increasing knowledge of HIV transmission as well as increasing use of condoms and contraceptives (Samson & King, 1998; Wiktor et al., 2004). Health Canada (2002) suggests that this information can come from a variety of sources including: written materials, videotapes, referrals to hotlines and other agencies, and/or one-on-one conversations with health professionals. As with any form of education, “the information should be geared to the audience, taking into account such things as linguistic and cultural barriers, geographic isolation, lack of transportation and child care, and fear of punitive action” (p. 107; Health Canada, 2002). It is also important that education and prevention efforts remain cognizant about prevention fatigues, like condom fatigue (Canadian AIDS Society, 2004). Adherence to prevention efforts is difficult to maintain over longer periods of time (Cohen, 2005). The use of a variety of sources and methods, as suggested by Health Canada, may help reduce the occurrence of this fatigue. 5.2 HIV Education in Schools
Schenker (2001) states that “schools are key contributors to our ability to halt the spread of HIV infection” (p. 416). By their very nature, many schools already have the resources necessary for delivering effective education to youth. Specifically, schools reach most children between the ages of 5 to 18, have skilled teachers, include various learning opportunities over the long-term, and have the potential of good parental involvement (Schenker). Several authors have suggested that HIV education may be most effective when carried out within a comprehensive school health education program (Kerr, Allensworth, & Gayle, 2009; Kirby, 2002; US Centre for Disease Control, 1988). Research has identified the use of multiple media (e.g., stories, role-play, lectures, self-tests) as necessary for effective education on HIV (Health Canada, 2002; Ragon, Kittleson, & St. Pierre, 1995). The use of different methods of learning provides an opportunity for students to become actively engaged in learning. Interactive activities, like role playing and simulations, are designed to help youth personalize and retain the information (Kirby, Laris, & Rolleri, 2007). Effective repetition of HIV messaging requires clarity, consistency, accuracy, and sufficient variety in order to hold students’ interest over time (Kirby, 2002; Ragon et al.). Schools also require access to the most current knowledge about HIV and AIDS, including information about how to avoid HIV infection and transmission (Schenker, 2001). Finally, Schenker suggests that teaching HIV prevention to male and female students together, instead of in separate sex education classes, may encourage them to talk about HIV and sexuality amongst themselves. While some schools and parents are concerned that HIV education may serve to promote sexual intercourse, two large-scale literature reviews suggest that this is not the case (Kirby, 2002; Kirby et al., 2007). Instead, it appears that such education can actually serve to delay the onset of sex, reduce the frequency of sex, and increase condom and contraceptive use. HIV education programs were found to be particularly effective at increasing condom use, over and above classes focused on sexual education alone (Kirby). In addition to the characteristics listed above, Kirby suggests other important considerations for youth education: inclusion of activities that address social pressures that influence high-risk behaviour; provision of modelling and practice of communication, negotiation, and refusal skills; and provision of training to teachers and peers who can then provide the information to others. Taken together, these characteristics are similar to those found to be effective for substance abuse educational programs (Dusenbury & Falco, 1995). 5.3 Education for Vulnerable Women
Particularly in Saskatchewan, women who use intravenous drugs are at a high risk for HIV infection. Aggleton et al. (2005) suggest that “the twin stigmas of drug dependence and injecting, often in association with sex work, can make female intravenous drugs users one of the hardest to reach populations” (p. 26). Successful interventions that have been used to reduce the risk of HIV in this population include needle exchange programs, various forms of outreach, voluntary counselling and testing, peer-led education, treatment programs, and methadone therapy. Aggleton et al. suggest that intravenous drug users need information on how to prevent transmission of HIV, the means to prevent this transmission (e.g., sterile needles, condoms), a supportive peer environment, and access to health and social services. Outreach programs can be especially effective at providing HIV prevention information and establishing links with the necessary services (e.g., drug treatment, HIV counselling and testing, medical care, social services) (Aggleton et al., 2005; Spielberg et al., 2003). Such programs also usually offer specific materials for reducing risk (e.g., new needles, condoms, dental dams). The Center for Disease Control (1993) states that outreach programs are particularly effective in reaching intravenous drug users who have never been in contact with mainstream services and in reducing their HIV risk behaviours. Aggleton et al. (2005) suggest that peer-driven interventions can also be highly successful at sharing HIV-related information and reducing the risk of HIV transmission. Bunting and Seaton (1999) found that many pregnant women with HIV are intensely motivated by concerns about their present and future children’s welfare. These authors suggest that health care providers and educators should consider this factor when designing education and treatment programs. Another particularly vulnerable population in Saskatchewan are Aboriginal women. Of the new cases of HIV in Saskatchewan in 2008, 77% of those diagnosed were Aboriginal (Saskatchewan Ministry of Health, 2009). The Public Health Agency of Canada (2007) suggests that evidence-based, culturally specific responses to HIV education are needed. Such responses should be designed to address the realities that contribute to infection and poor health outcomes for Aboriginal women. In order to be successful, women at risk of infection and those living with HIV should be consulted in order to directly shape policies and programs that affect them. The National Conference on Women and HIV/AIDS (2000) recommended that vulnerable women should be included in the planning, implementation, and evaluation of prevention programs in order to give them a sense of ownership of the programs. 6. Education about HIV and Pregnancy for Health Professionals
Similar to education for the general public, it is important for health professionals to receive and understand the information presented in this literature review (e.g., HIV transmission, transmission prevention, testing for HIV, and these topics in the context of pregnancy). Before more detailed education can be effective, health professionals require the basic information. Next, it is crucial that health professionals understand their own importance in HIV transmission prevention. According to Renggli et al. (2008), “inadequate training of health professionals about HIV leads to compromised patient care and perpetuates the spread of myths and other erroneous information” (p. 341). The National Conference on Women and HIV/AIDS (2000) recommended that educational campaigns should be developed to sensitize social and medical workers to the realities of the lives of HIV positive women. 6.1 Reducing Stigma and Discrimination
Mill et al. (2007) summarize research identifying health practitioners as significant sources of stigma and discrimination for people living with HIV. Although stigma is a recognized barrier to effective education and treatment, very few studies have examined the impact of stigma reduction interventions (Mahajan et al., 2008). Instead, studies typically focus on people’s experiences with stigma. For example, many of the HIV positive women in Leenerts (1998) sample described their relationships with their health care professionals as unhelpful and even hostile. Such experiences can lead to women not seeking follow-up treatment and to avoiding HIV testing in the first place. Leenerts states that health professionals should have the knowledge and abilities to educate women and to refer them to additional resources when needed. This is especially important at the time of diagnosis as women who feel alienated by health professionals at this time are less likely to return for follow-up care. The women in Leenerts’ sample waited approximately 2 years after their diagnosis before seeking follow-up health care. On the opposite end of the care spectrum, the behaviour of health care providers can serve to motivate women to practice good self-care and prenatal care. Bunting and Seaton (1999) found that when professionals exhibited caring behaviours, pregnant women with HIV felt more self-worth and hope. These feelings resulted in these women taking better care of themselves and following through on their providers’ health care recommendations. Specifically, the women did this because they felt their health care providers had a personal as well as a professional investment in them and their health outcomes. Makadon and Silin (1995) support the idea that primary care physicians need to realize their potential to influence the attitudes and behaviours of their patients. These authors believe that physicians’ HIV prevention opportunities are hindered in four ways: 1. by narrow conceptions of medical care and the role of the physician; 2. by physicians’ attitudes toward sexuality, drugs use, and HIV; 3. by constraints on time and resources; and 4. by the ambiguity of HIV prevention messages. Reis et al. (2005) agree and suggest that increasing physicians’ knowledge of their own importance in HIV prevention may change how they view their role. Instead of expecting physicians to become knowledgeable about every aspect of HIV, Makadon and Silin suggest that they become part of the system’s approach. In this way, physicians’ roles could be limited to helping patients assess their own risk, referring patients for testing and counselling, reinforcing good prevention strategies, and offering referrals to patients who want more information. Research has found that mental health professionals, including clinical psychologists and social workers, with HIV education and training were less likely to hold negative attitudes toward persons with HIV (Crawford, Humfleet, Ribordy, Hu, & Vickers, 1991). Proper education in HIV prevention, care, and treatment has also been found to positively shape the attitudes of health care professionals towards people living with HIV/AIDS, reduce misconceptions, and increase access to care (Reis et al., 2005; Renggli et al., 2008; Uwakwe, 2000). In other words, education and training can reduce discrimination towards persons with HIV, resulting in an increased quality of care. This highlights the importance of training programs that address the medical and psychological issues related to HIV infection and treatment. 6.2 Pre-Service, In-Service, and Train-the-Trainer Models
Renggli et al. (2008) highlight the importance of pre-service HIV education for health care professionals. They state that pre-service education is critical for an increase in HIV prevention, care, and treatment services as it boosts the numbers of HIV-trained health care professionals. By including HIV-specific information in training curricula, all new professionals can receive fundamental HIV knowledge before entering the workforce. For practicing health care professionals, Renggli et al. recommend in-service training, and particularly on-site training followed by regular support and clinical mentoring after training. Because this type of training is expensive, pre-service training is recommended as the way of the future. Pre-service and in-service training could be expanded to include a train-the-trainer model of HIV education, where medical professionals are provided with the training to train other medical professionals and perhaps the general community. The use of train-the-trainer workshops has been found to be an effective and inexpensive way to disseminate information about HIV/AIDS and to change attitudes and behaviours (Burr, Storm, & Gross, 2006; Hiner et al., 2009; Wu et al., 2002). Research suggests that in order for a train-the-trainer model to work, it must incorporate both a didactic and an interactive approach (Burr et al.; Rees, Sheard, & McPherson, 2004; Scott, 2003). The didactic approach (usually involving oral presentations/lectures) is recommended for the presentation of technical content and for sharing greater amounts of information in a shorter amount of time. The interactive approach (e.g., role play, case study discussions, learning games, standardized patients) allows participants to apply newly acquired knowledge and skills to mock clinical situations. Burr et al. have developed a train-the-trainer package that includes a PowerPoint presentation, extensive speaker notes, case studies, a patient education booklet, an HIV education monograph for health care providers, and a pocket guide to perinatal guidelines for working with women with HIV. Importantly, the curriculum closely followed national guidelines and was updated regularly to reflect changes in research and practice. Wu et al. (2002) and Bradley-Springer et al. (Bradley-Springer, Everett, Rotach, & Vojir, 2006) found that train-the-trainer workshops resulted in better attitudes toward persons with HIV/AIDS and effective dissemination of training to other health personnel and the general public. Burr et al. (2006) also found an increase in positive care of women with and at risk of HIV following the train-the-trainer workshops. The participants in these workshops “agreed that they were more knowledgeable about HIV testing in pregnant women, more likely to discuss it with pregnant women, had a better understanding of guidelines, and were more familiar with local resources for local HIV care” (p. 188). These authors state that successful implementation of these types of workshops “requires ongoing support of faculty trainers by AIDS educators, involvement of local HIV experts as trainers and resource persons, and the use of standardized curriculum based on national guidelines” (p. 183). 6.3 Designing Training Models
In addition to the acknowledged effectiveness of interactive teaching approaches, Bradley-Springer, Vojir, and Messeri (2003) suggest that training and education events must be targeted at an acknowledged need. Therefore, using needs assessments to design and focus educational programs can be very important. Performing a needs assessment allows you to know what information is known, and what information is most needed. Gallagher (1996) states that HIV education programs that “speak to real-life problems, offer clinical case discussions, and can be immediately applied in practice are most valuable” (p. 13). Because medical professionals have very busy schedules, Bradley-Singer et al. also suggest making the education sessions convenient and comfortable. If medical professionals feel as though they do not need information about HIV (e.g., they do not believe they see enough infected patients, they do not want to treat infected patients), it is possible to combine HIV programming with more highly desired topics (e.g., sexually transmitted infections, tuberculosis, etc.). Margolese (2009) states that the Canadian AIDS Treatment Information Exchange (CATIE) is the source for the most up-to-date guidelines for the care of HIV positive women during pregnancy. It is of the utmost importance for medical professionals to understand the need for HIV testing in pregnancy in order to reduce the incidence of vertical transmission of HIV. There is evidence that almost half of pregnant women are not tested for HIV (Health Canada, 2001). Of those women who are tested, in some cases it is done without their knowledge (Health Canada, 2002). Again, it is important for physicians working with pregnant women to be cognizant of the principles of voluntarism, confidentiality, and informed consent for HIV testing. It is important, also, for physicians to realize that along with voluntary testing comes voluntary treatment. Specifically, the decision to receive ARV treatment during pregnancy is a voluntary one under Canadian law (Burdge et al., 2003; Canadian HIV/AIDS Legal Network & the Canadian AIDS Society, 1998). It is a fundamental principle in Canadian health care that every patient has the right to accept or refuse care (Boucher et al, 2001; Burdge et al., 2003; Canadian Medical Association, 1996). Importantly, voluntary treatment and feelings of self-efficacy have been found to result in higher treatment adherence (Smith et al., 2003). The Canadian Medical Association has found that when physicians present women with the risks and benefits of ARV treatment for preventing vertical transmission, most women accept testing and treatment. Other authors have also found that pre-test counselling of pregnant women leads to higher acceptance of testing, increased knowledge of HIV transmission and increased use of condoms and contraceptives (Obermeyer & Osborn, 2007; Samson and King, 1998). Despite the fact that proper care and treatment can greatly reduce the risk of maternal transmission of HIV, many physicians simply fail to offer the test to pregnant women (Walmsely, 2003). With Canadian medical guidelines now recommending HIV testing for all pregnant women (Health Canada, 2002), this lack of testing should be greatly reduced or eliminated altogether. In order for this to happen, however, physicians need to be aware of the latest medical guidelines. It is also important for medical professionals to be aware of information about the guidelines for the care of HIV-positive women during pregnancy, labour, delivery, and the post-partum care of babies. While this information is highlighted in earlier sections of this literature review, a list of important resources for medical professionals can also be found in Appendix A. 7. Conclusions
As there is yet no cure for HIV infection, prevention is currently the only way to stop the epidemic. Effective prevention of mother-to-child transmission of HIV requires the following combination strategy: 1. preventing HIV infection among prospective parents; 2. avoiding unwanted pregnancies among HIV positive women; 3. preventing transmission of HIV from mother to infants during pregnancy, labour, delivery, and feeding; and 4. integration of care, treatment, and support for HIV positive women and their families (AVERT, 2009). Education about HIV and pregnancy is important for the general public, youth, vulnerable women, and health professionals. In addition to increasing knowledge, such education may reduce the stigma and discrimination faced by women with HIV. This, in turn, may increase women’s willingness to seek appropriate care and treatment for their HIV in order to further reduce the risk of vertical transmission of HIV. References
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Barriers to care and unmet needs for HIV-positive women caring for children. Journal of HIV/AIDS and Social Services, 3, 47-65. World Health Organization. (2009). Rapid advice: antiretroviral therapy for HIV infection in adults and adolescents. World Health Organization, Geneva, Switzerland, 2009. Retrieved from Wu, Z., Detels, R., Ji, G., Xu, C., Rou, K., Ding, H., & Li, V. (2002). Diffusion of HIV/AIDS knowledge, positive attitudes, and behaviors through training of health professionals in China. AIDS Education and Prevention, 14, 379-390. Zierler, S., Witbeck, B., & Mayer, K. (1996). Sexual violence against women living with or at risk of HIV infection. American Journal of Preventative Medicine, 12, 304-310. Appendix A. List of Resources for Health Care Professionals
Information about guidelines for HIV screening:

Health Canada (2002). Guiding principles for Human Immunodeficiency virus (HIV) testing of
women during pregnancy - 2002. Canada Communicable Disease Report, 28, 105-108.
Information about guidelines for the care of HIV positive women during pregnancy:

Boucher, M. (2001). SOGC clinical practice guidelines: Mode of delivery for pregnant women
infected by the Human Immunodeficiency Virus. Journal of the Society of Obstetricians and Gynaecologists of Canada, 101, 1-3. Samson, L. M., & Steben, M. (2003). Canadian consensus guidelines for the management of pregnant HIV-positive women and their offspring. Canadian Medical Association Journal, 168, 1683-1688.
CATIE:
CATIE (the Canadian AIDS Treatment Information Exchange) is a source for the most up-to-
date guidelines for the care of HIV positive women during pregnancy. General information about
HIV and information specific to health-care professionals can also be found on CATIE’s website
. Finally, health care professionals can order information (e.g., brochures,
reports, books) for themselves and their patients, free of charge from this website.

HIV/AIDS Epi Updates:
HIV/AIDS Epi Updates can be accessed electronically at

Source: http://www.skprevention.ca/wp-content/uploads/2013/01/7-501-Mother-to-Child-Transmission-of-HIV.pdf