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Preventing mother-to-child transmission of HIV

11 November 2007
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I just wrote a post for this other blog to which I contribute about the ethics of prevention of mother-to-child transmission of HIV. I am curious to hear what others think about PMTCT using Nevirapine. Because Nevirapine can create issues with drug resistance for mothers, does it not pose an ethical dilemma in treating HIV-positive pregnant women in order to decrease the chances of passing the infection to their unborn children?

Many women in resource-poor countries depend on government-run antenatal clinics, which themselves typically provide routine HIV testing (my research says it’s more mandatory than routine). The use of routine antenatal clinic testing is meant to increase opportunities to intervene with PMTCT treatment. However, by prescribing Nevirapine intrapartum and during birth, the patient runs the risk of becoming resistant to other antiretroviral therapy.

Researchers in Zambia have in press an article with the Lancet (gated) detailing their study of using alternative drug treatments for HIV-positive pregnant women. Sounds promising, but I wonder if the concern about drug resistance will be resolved with these different drugs.

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2 Comments leave one →
  1. Audrey permalink
    13 November 2007 12:35 am

    Hmm… so basically we are asking whether it’s okay to improve one patient’s condition at the expense of another patient’s?
    I didn’t really know how I felt about this. I think from a neutral standpoint, this should be ethically wrong. However, I don’t know what mother wouldn’t sacrifice her own health for that of the baby’s well-being.. so who should make that decision– the doctor or the patient? I guess I stand divided. Is there any data on resistance mutations that could show up in the babies of the infected mothers?

  2. 20 November 2007 9:05 pm

    from Emily Churchman via email: The thing about the nevirapine resistance is that nobody knows what the actual treatment outcomes are, particularly since most of the resistance mutations fade after six months. For me, weighing risk of potential detriment to the mother versus risk of fatal illness for the child is clear cut.

    I see the ethical question as why national PMTCT programs are still scaling up single dose nevirapine, which results in an infection rate of about 15%, when there are a large number of relatively simple combination therapy options that get it below 5% (for example, Botswana’s national program). To me, reducing risk of MTCT by half is not enough when there are better options available. Even if we have to roll out single dose nevirapine in hard to reach areas, we should still be making progress on making combination therapy for PMTCT available, and I can’t say that I’ve seen that happening or seen donor commitment. In Africa, pretty much Botswana and Rwanda are the only places that have made that commitment. To me it is more of a public health ethics issue than a medical one.

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