• The vulnerability
• Mother to child
transmission of HIV
• Antenatal care
of voluntary testing and counselling
• Infant feeding
non breastfed infant
• Post natal care
of HIV infected mother her infant
• Questions for
reflection and discussion
|In a Tanzanian hospital, a woman cares for her husband who
has AIDS. The pandemic imposes a double burden on women. Already
more vulnerable to HIV infection because of their subordinate
status, they are also affected by the AIDS epidemic in their
role as providers of care in the family and the community.
(Credit: WHO, Gubb)
Over 12.2 million
women world wide have been infected with HIV since the start of
the epidemic and women account for 42% of the 30.6 million adults
now living with HIV. Because of the particular vulnerability of
women, the risk of women contracting HIV is rising worldwide. Although
these figures are increasing in industrialized and developing countries,
in sub Saharan Africa there are already 6 women with HIV for every
5 men, with close to four-fifths of all infected women being African.
In African countries, where young people (age 15-24) account for
60% of all new infections, HIV infection in young women outnumbers
infection in young men by 2 to 1. More than four-fifths of all infected
women get the virus from their male sex partner, often by their
one partner (their husband). The remainder become infected from
blood transfusions or from injecting drugs with a contaminated needle.
Women with sexually transmitted diseases (STD) such as gonorrhoea
are often unaware of the disease because the infection is silent.
Conclusive proof now exists that STDs facilitate the spread of HIV.
An untreated STD in either partner increases the risk of HIV transmission
during unprotected intercourse (without a condom) ten-fold. AIDS
prevention campaigns often fail women by assuming that they are
at low risk, or by urging prevention methods that women have little
or no power to enforce, such as condom use, abstinence and mutual
faithfulness within a relationship (Fact Sheet 12).
Women continue to make strides towards equality with men. However,
for millions of women, this is far from reality. These women are
the most vulnerable to HIV infection. In many parts of the world,
nurses and midwives suffer the same vulnerabilities as women in
the general population.
• The vulnerability
Research shows that the risk of becoming infected with HIV during
unprotected vaginal intercourse is as much as 2-4 times higher for
women than men. Women are also more vulnerable to other STDs (multiplying
the risk of contracting HIV tenfold). One major reason for this
is that women have a larger surface area of mucosa (the thin lining
of the vagina and cervix) exposed to their partner's secretions
during sexual intercourse. Additionally, semen infected with HIV
typically contains a higher concentration of virus than a woman's
sexual secretions. Younger women are even more at risk because their
immature cervix and scant vaginal secretions put up less of a barrier
to HIV., and they are prone to vaginal mucosa lacerations. There
is also evidence that women again become more vulnerable to HIV
infection after menopause. In addition, tearing and bleeding during
intercourse, whether from rough sex, rape, or prior genital mutilation
(female circumcision), multiply the risk of HIV infection, as does
anal intercourse, which is sometimes preferred to vaginal intercourse
because it is thought to preserve virginity and avoid the risk of
pregnancy. Anal intercourse often tears the delicate anal tissues
and provides easy access to the virus.
Social and economic vulnerability
Prevention messages urging abstinence, fidelity (faithfulness to
one partner), condom use, needle exchange programs (for intravenous
drug users) and encouraging and enabling people to get prompt STD
treatments have all helped avoid HIV (Fact Sheet 12). However, for
millions of women, their ability to make these decisions and to
act upon them is crippled by their socio-economic circumstances.
The majority of women in the world lack economic resources, and
are fearful of abandonment or of violence from their male partner.
Thus they have little or no control over how and when they have
sex, and hence have little or no control over their risk of becoming
infected with HIV.
This vulnerability is compounded by:
|REMEMBER! The Fact Sheets can be adapted for primary
and secondary schools.
Millions of young girls are brought up with little knowledge of
their reproductive system or how HIV and STDs are transmitted and
Sexual customs and norms
Typically, women are expected to leave the initiative and decision-making
in sex to males whose needs and demands are expected to dominate.
There is often a tolerance of predatory, violent sex, as well as
a double standard where women are blamed or thrown out for infidelity
(real or suspected), while men are expected or allowed to have multiple
Lack of economic opportunities
There is a failure to respect women's right to equal access to education
and employment opportunities, thus reinforcing their dependence
upon men. Their reliance may be on a "sugar daddy," that is, a partner
who may give gifts to pay for sex, a husband or stable partner,
a few steady male partners who have fathered their children, or,
for prostitutes, a succession of clients. In fact, in many cultures,
sex is seen as a "currency."
Lack of control in relationships
Even when a woman suspects her partner has HIV, she often cannot
risk losing his support by refusing sex, or insisting on condom
use. She would be breaking the "conspiracy of silence" that surrounds
extramarital sex by either partner. Although some men agree to use
condoms, many react with anger, violence and abandonment.
Condom use and pregnancy
Couples wanting children need to know their HIV status. However,
couples are often unwilling to openly discuss issues of sexuality,
and voluntary HIV testing and counselling services are not always
available (Fact Sheet 7).
STDs and HIV
Because STDs carry an especially heavy social stigma for women,
they tend to avoid STD clinics and treatment. In addition, health
care workers are often unsympathetic, judgemental, and unprepared
to diagnose and treat STDs (Fact Sheet 6). Women are often socialized
to accept ill health and women's troubles as their lot in life.
HIV and prostitution
Prostitutes have little power to protect themselves from HIV. In
some countries, girls are forced into sex work, even before puberty.
Such young girls are generally unaware of the AIDS risk and they
are unable to take protective action, or run away. Women also turn
to prostitution as an alternative to poverty, or because their lives
have been disrupted by war, divorce or widowhood where, because
of inequitable laws and customs, they have lost their property and
their husband's earnings. Many sex workers risk violence or loss
of income if they request the use of condoms. However, in some brothels,
sex workers have banded together to insist on condom use.
|REMEMBER! The Fact Sheets can be adapted for teaching
• Fostering empowerment
comes from lack of power and control over their risk of HIV. One
important remedy is to create opportunities to foster empowerment:
Improve education for women, including education about their bodies,
STDs and AIDS, and the skills to say no to unwanted or unsafe sex.
See fact sheet on prevention (Fact Sheet 12) and education (Fact
Provide women-friendly services
Ensure that girls and women have access to appropriate health and
HIV/STD prevention and care services at places and times that are
convenient and acceptable to them. Expand voluntary testing and
counselling (Fact Sheet 7) and teach about condom use and make condoms
easily available without embarrassment.
Develop female-controlled prevention methods
Barrier methods that prevent HIV infection without the knowledge
and cooperation of the male partner are urgently needed. Such methods
might include the female condom and vaginal microbicides (a virus-killing
cream or foam) that women can insert vaginally before intercourse.
UNAIDS is facilitating the development of and access to these and
Build safer norms
Support women's groups and community organizations in questioning
behavioural traditions such as child abuse, rape, sexual domination,
and mutilation. Educate boys and men (Fact Sheet 9) to respect girls
and women, and to engage in responsible sexual behaviour (Fact Sheet
Reinforce women's economic independence
Encourage and strengthen existing training opportunities for women,
credit programmes, saving schemes, and women's cooperatives, and
link these to AIDS prevention activities.
Reduce women's vulnerability through policy change
At community and national levels (as well as through international
initiatives), the rights and freedoms of women must be respected
and protected. This will only be achieved when women have a greater
• Mother to child transmission
to child transmission (MTCT) of HIV is the major means of HIV infection
An estimated 600,000 children are infected in this way each year,
accounting for 90% of HIV infection in children (Fact Sheets 2 &
5). Without preventive treatment, up to 40% of children born to
HIV-positive women will be infected. Of those who are infected through
MTCT, it is believed that about 2/3 are infected during pregnancy
and around the time of delivery , and about 1/3 are infected through
breast feeding. Most of the transmission in pregnancy occurs at
the time of labour and delivery (more than 60%). Using the most
widely available tests (see Fact Sheet 1), it is not possible to
tell whether a newborn infant has already been infected with HIV.
The child of an infected mother may have maternal antibodies in
his/her blood until 18 months of age (Fact Sheet 5). Therefore,
testing cannot be used to help make decisions about whether or not
to breast feed.
• Antenatal care
testing and counselling (VCT) (Fact Sheet 7) should be available
in antenatal clinics. Many HIV-positive women will be diagnosed
for the first time during pregnancy, therefore, this service is
critical to the ongoing treatment, care and support for the mother,
her family and new born child. The benefits of VCT in antenatal
of a negative result can reinforce safer sex practices.
diagnosed with HIV can encourage their partners to be counselled
their HIV status enables women and their partners to make
more informed choices related to breast feeding and future
(and her family) who knows she is HIV infected can be encouraged
to enter into the continuum of care in order to seek early
medical treatment and care of opportunistic infections for
herself and her child (Fact Sheet 4 & 5), as well as be
linked to other health and social services and resources (see
Fact Sheet 3).
access to VCT can help normalize the perception of HIV in
of their HIV-positive status can enable women to access peer
Access to VCT is
important in antenatal clinics because there are ways to prevent transmission,
termination of pregnancy,
of MTCT is dependent upon the identification of the HIV-positive woman.
· antiretroviral therapy (ARV),
· modifying midwifery and obstetrical practices, and
· modifying infant feeding.
Termination of pregnancy
Where termination of pregnancy is both legal and acceptable, the
HIV-positive woman can be offered this option. However, many women
learn of their HIV status during pregnancy, and will not be diagnosed
in time to be offered termination. If termination is an option,
the woman, or preferably the couple, should be provided with the
information to make an informed decision without undue influence
from health care workers and counsellors.
Antiretroviral therapy (ARV)
A recent study showed that the administration of zidovudine (AZT)
during pregnancy, labour, delivery and to the new born reduced the
risk of MTCT by 67%. This regimen has become standard practice for
HIV-positive women in most industrialized countries and many women
are receiving a combination of ARV treatments. This long-course
regimen is often not available for women in developing countries
because of cost and lack of adequate infrastructure. However, there
is a concerted effort to provide short term AZT to all HIV-positive
pregnant women. Short course AZT is taken orally from 36 weeks of
pregnancy through labour and delivery. This treatment does not prolong
the life of the mother, but has been found to be effective in reducing
transmission of HIV to the infant.
Nevirapine is a much cheaper antiviral drug than AZT, costing
about $4 per mother and baby treated. Recent studies have shown
it to be effective in reducing MTCT if a single dose is given to
mothers just prior to delivery and to newborns immediately afterwards.
In terms of both cost and infrastructure requirements Nevirapine
offers a more optimistic and realistic alternative for ARV for developing
countries. Many countries are in the process of developing guidelines
and an effective infrastructure to support ARV. Because ARV treatments
vary considerably throughout the world and are still in the experimental
stages, nurses/midwives are encouraged to learn more about the ARV
treatments and protocols available within their community and country.
• Labour and delivery
About 60% of HIV
transmission from mother to child is thought to occur around the
time of labour and delivery. Several factors have been associated
with an increased risk of MTCT at the time of labour and delivery.
The mode of delivery
Vaginal deliveries are more likely to increase the risk of MTCT
while elective Caesarian sections have been shown to reduce MTCT.
However, the potential benefits have to be balanced against the
risk to the mother. Higher rates of post operative death in HIV
positive women have been reported, especially from infective complications.
In addition, elective Caesarian sections are not available to the
vast majority of women worldwide.
Prolonged rupture of membranes
Rupture of membranes for longer than 4 hours has been associated
with an increased risk of transmission. Artificial rupture of membranes
is practiced routinely in many countries. Membranes should not be
ruptured artificially unless there is fetal distress, or abnormal
progress in labour.
Routine episiotomy is not recommended. This procedure should only
be used where there are specific obstetric indications. Forceps
deliveries and vacuum extractions do not necessarily require an
This has been associated with increased MTCT transmission in some
studies. Should a blood transfusion be required, there is the added
risk of receiving HIV contaminated blood (Fact Sheet 1).
Invasive fetal monitoring
Penetrating scalp electrodes may be associated with increased risk
The first baby delivered of a multiple pregnancy has a higher rate
of HIV infection than the subsequent births.
Other areas for consideration during labour and delivery include:
Fact Sheet 11 provides a detailed overview of Universal Precautions
that should be followed by nurses/midwives in all aspects of care
regardless of the HIV status of the woman or the nurse/midwife at
the time of labour delivery. Frequent hand washing and glove use
(whenever possible) are critical practices in precaution.
The use of chlorhexidine 0.25% to cleanse the birth canal after
each vaginal examination and during labour and delivery has been
shown to be effective in reducing MTCT transmission.
Education of traditional birth attendants
Traditional birth attendants (TBAs) play an important role in the
labour and delivery of many women worldwide. Educating the TBA about
HIV prevention (Fact Sheet 12) and care and the use of universal
precautions (Fact Sheet 11) is often the responsibility of nurses/midwives.
This education should include the use of ARV and STD treatments.
They should also be encouraged to avoid traditional practices that
may increase the risk of HIV transmission such as the use of vaginal
herbal potions and scarification.
• Infant feeding
one third of infants who are infected through MTCT are infected
through breast milk. Where alternatives such as replacement feeding
exist, HIV positive mothers should avoid or limit breastfeeding
their infants. For HIV-negative mothers, breastfeeding still remains
the best option.
Where resources are limited, the option of using replacement feeding
may be unavailable. Many communities do not have a safe water supply,
have limited resources to provide sterile feeding equipment, and
have no methods of refrigeration. Replacement feeding is also expensive
and many families cannot afford this added expense. In addition,
where breast feeding is the cultural norm, seeing a mother artificially
feed her infant can lead people to suspect she has AIDS. One must
also consider additional problems associated with gastro-intestinal
infections, malnutrition, stigma and discrimination (Fact Sheet
6). Decisions about whether to breast feed or to provide replacement
feeding must be made in light of the above considerations. If replacement
feeding is an option, breast milk substitutes include: commercial
infant formula, or home-prepared formulas which are made from animal
milk, dried milk or evaporated milk with additional ingredients.
Once the decision has been made about whether or not to breast feed,
then other considerations must be taken into account:
|For the non breastfed infant:
access to an adequate supply of replacement milk substitutes,
with adequate funds to pay for them, adequate utensils for
feeding, and fuel for sterilizing equipment and heating the
• Educate the mother about safe preparation of replacement
feeds, correct cleaning of utensils, and methods of sterilization.
• Monitor the growth and development of the child to ensure
adequate infant feeding and nutrition.
• Monitor the safe preparation of replacement feeds.
• Appropriate care of the mother's breasts to prevent engorgement.
|For the breastfed infant:
the mother to inspect her child's mouth for thrush and breakages
in the mucous membrane (an added risk for HIV transmission
(see Fact Sheet 5).
• Teach the mother about the increased risk of HIV transmission
should she suffer from mastitis, breast abscesses, and bleeding
or cracked nipples.
• Discuss replacement feeding after three months (to reduce
some risk of transmission).
• Stop breastfeeding after 6 months when the baby can be safely
• Use expressed milk that is boiled and then cooled. (Boiling
kills the virus.)
• Use the breastmilk of other women who are HIV-negative (wet-nursing).
• Post-natal care of
the HIV-infected mother and her infant
In many instances,
the basic post natal care of the HIV-infected woman and her infant
will be no different from routine postnatal care. However, the mother
(and possibly partner/family) might need additional counselling
and support (see Fact Sheet 7). Such counselling might include decisions
on infant feeding (although this decision should have been made
in the antenatal period), and advice on birth control. It is important
that the woman and her family are involved in a continuum of care
(Fact Sheet 3), so that comprehensive linking of resources and services
can be provided where and when they are most necessary and effective.
HIV-infected women are more prone to medical complications such
as urinary tract infections, chest infections, episiotomy sepsis,
and uterine and Caesarian section wound sepsis. Nurses/midwives
should be alert for signs of infection such as fever, rapid pulse,
episiotomy or lower abdominal pain, and foul smelling lochia (vaginal
discharge). HIV infected women should be taught about perineal care
and safe handling of blood and lochia.
|Don't forget that the women's family -- close and extended
-- and her community must be educated so that they support the
women in their choices.
for the HIV-infected mother might include:
advice. The only contraceptive methods that will prevent the spread
of HIV are barrier methods such as the male and female condom
(Fact Sheet 12).
· Support for her infant feeding choice and further education
· Information about the possibility of infection in the child
and details of how and where the child can be checked and treated
(Fact Sheet 5).
· Discussion about disclosure of her HIV status to her partner,
family, and trusted friends.
· Exploration of feelings, particularly guilt, grief, fear, and
denial. It is also important to address the possibility of her
having infected her infant (Fact Sheet 7).
· Encouragement to access peer support.
· Discussion on how to cope with possible stigmatization, particularly
if not breast feeding (Fact Sheet 6).