Important note: Information in this article was accurate in August 2000. The state of the art may have changed since the publication date. 
Eric Goemaere is a physician from Doctors without Borders who heads an HIV/AIDS clinic for infected mothers and community members in Khayelitsha, South Africa. Speaking in the aftermath of the encouraging reports on preventing mother-to-child transmission at the International AIDS Conference, he observed with satisfaction, "MTCT [programs] will now be seen as very politically correct and beyond that very feasible."
About 1,800 HIV-infected infants are born each day in South Africa. Universal, or even widespread, MTCT coverage would reduce this figure dramatically. Unlike the complicated, costly project of treating infected adults with antiretrovirals, MTCT programs appear to offer a straightforward solution to one of HIV's most devastating routes of transmission. At the most basic level, MTCT programs require little more than HIV testing kits and a small supply of nevirapine or AZT and 3TC. In many instances, the elements of pre- and post-test counseling, formula feeds and antenatal care are also included. Even so, the package of care involves far fewer laboratory and human resources than even the most bare-bones adult HIV clinic would offer.
Cost-effectiveness aside, MTCT programs have their drawbacks. Many parties – women, in particular – are left out of the equation. At Ubumbano IoMama, a women's satellite meeting in Durban, attendees told stories of MTCT interventions that boiled down to receiving a diagnosis and a drug with little or no counseling, support or follow-up care. Such intervention may cut down on perinatal transmission but does nothing for women themselves. At a time when women make up more than half of the world's AIDS cases, this is a dangerous omission. Activists were quick to point out that the Boehringer-Ingelheim offer to developing countries of five years' free nevirapine for MTCT did not include treatment for the mothers. Nor did any of the numerous studies of MTCT in African countries include antiretroviral therapy for women participants.
At the official meeting, many speakers acknowledged the ethically uncomfortable, if not untenable, implications of offering treatment to the women solely to prevent transmission. "Short-course AZT uses women's bodies to deliver benefit to the infant," stated Dr. Allen Rosenfield in a keynote lecture titled "Where is the M in MTCT?". At the same session, South African pediatrician and MTCT advocate Glenda Gray observed that current evaluations of MTCT efficacy take women into account solely as "vectors of viral transmission."
Failure to manage women's disease with whatever treatments are available may well reduce the long-term efficacy of MTCT strategies. Many babies, both infected and uninfected, will die without their mothers. In Durban, Kenyan researcher Ruth Nduati showed data indicating that maternal death causes an eightfold increase in the risk of subsequent infant mortality. As the number of orphans increases, so do the economic and social costs to families and nations. "[The economic studies] have been most discouraging," said Sten Vermund of the University of Alabama at Birmingham, "It highlights the massive loss in productivity and the distortion of the 'dependency ratio' in Africa due to the death of mothers and fathers. Therapy for mothers , whether it's oriented toward opportunistic infections, HIV or both, would be a huge step forward in addressing this crisis."
It is a step that many MTCT advocates are ready and willing to take. Instead of holding back MTCT offerings, they argue, it is time to use them as the cornerstone of a larger strategy for HIV management. "MTCT is the entry point for a broad range of things," said Goemaere. "As soon as you make an offer of MTCT, people go for testing. As soon as they go for testing, they're going to make support groups, which means action groups. You will have to attend these people, make clinics for them – it's a snowball effect."
Many MTCT programs are already being designed with this type of expansion in mind. In the Kenyan model, women will be referred to existing programs at hospitals and community programs for follow-up, counseling and regular management of opportunistic infections. "While the mom is pregnant, you don't hear about her issues," said Dr. Mbori-Ngacha. "If you only see a woman in the antenatal clinic, you don't get a sense of her problems." In South Africa, Doctors Without Borders added an adult HIV clinic to the country's single publicly funded perinatal transmission prevention program. With this in place, infected men, women and children are now cared for using currently available drugs, including basic medications for STDs and opportunistic infections plus cotrimoxizole (Bactrim) prophylaxis for pneumocystis carinii pneumonia (PCP). A similar offering is in place at a University of Alabama-sponsored study site in Zambia. In each case, the results are promising. "While the impact is hard to document due to the lack of a control group [for ethical reasons], nonetheless the data suggest a substantial decline in mortality compared to what might be expected," said Vermund.
The expanded concept of MTCT is a community-based model for HIV care. Like TB programs, MTCT assistance has the potential to identify and treat a large number of individuals already in contact with the health-care system. Defined in this way, the programs become more useful – and more expensive. "I think the resistance to MTCT in this country is partly due to the fact that they know very well when they start by putting their finger in [the AIDS epidemic], they will not be able to stop," said Goemaere.
The specter of the snowball effect may explain why some countries, notably South Africa, have yet to move forward with a national MTCT prevention initiative. In August, South Africa announced that it was holding back an "implementation phase" that would make nevirapine available to all pregnant women. Instead, health minister Manto Tshabalala-Msimang called for "continued research" on the drug in all five South African provinces. At press time, only women participating in approved research projects will be able to access the drug. South Africa's decision came in spite of a favorable cost-effectiveness report on nevirapine sponsored by its own Ministry of Health.
Although South Africa may be dragging its heels, it seems likely that MTCT initiatives will continue to take root around Africa and the developing world. Durban marked a point of no return in global recognition of the importance of access to treatment. MTCT programs have the ability to bridge the gap between prevention and treatment and to mobilize HIV-infected women and their families to demand treatment for themselves. As Zambian researcher Chewe Luo stated in her fiery plenary speech on MTCT, "It is up to women to say what the solution is."
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