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VERTICAL TRANSMISSION: CONTINUING PROBLEMS IN THE 21ST CENTURY

Vertical transmission

Vertical transmission is when a virus can be passed on from a mother to an infant during intrapartum
and postpartum (breastfeeding). A few diseases can be transmitted through vertical transmission,
such as chorioamnionitis, malaria, viral hepatitis B & C and GB-virus C, tuberculosis (TB), and AIDS
(1). Vertical transmission remains a persistent challenge despite the 21st-century biotechnological
and medical advancements. In 2022, it was reported that approximately 1.3 million people were
newly infected with HIV (2). Given the ongoing challenge posed by HIV, I have chosen to focus
primarily on the vertical transmission of this virus.

Intrapartum and postpartum vertical transmission of HIV

Intrapartum transmission (during labour) contributes to 10%-20% of HIV infection in children for
women who didn't receive antiretroviral therapy (ART) (3) and hasn't declined significantly since
2006 (4). A caesarean section could be the alternative as it reduces fetal contact with the birth canal;
however, no statistical differences confirm the effect. There are reported treated cases that vaginal
deliveries are lower than caesarean but did not reach statistical significance (4). Postpartum
transmission (breastfeeding) accounts for 5-15% of the mother-to-child transmission (MTCT) (3)(5).
While avoiding breastfeeding might be a way to reduce the transmission, for women in developing
countries, this might not be the best option since lack of clean water, inadequate healthcare
infrastructure, the potential stigma associated with not breastfeeding, the cost of formula and
competing public health priorities in the face of limited healthcare resources (3)(6). Breastfed
children who also received solids are more susceptible to MTCT of HIV and higher mortality rate
compared to exclusive breastfeeding (7) due to early exposure to pathogens that lead to immune
activation because of the disruption of the infant's gut mucosal lining (3).

Prevention of mother-to-child-transmission (PMTCT)

The rate of MTCT was higher in HIV-infected women who were tested late (shorter therapy time),
had no ART therapy, were breastfed, or had lower CD4 cell counts (8). One of the common ways of
PMTCT is ART and highly active antiretroviral therapy (HAART) using antiretroviral drugs or a
combination of 3 or more to treat HIV, as shown in Figure 1 below. The significant difference of the
PMTCT used in a few papers is the starting and stopping of the therapy. MTCT rates for women on
treatment at least the last two weeks of pregnancy remained low, consistent with reposts elsewhere
in Europe and the United States (5). For pregnant women who begin the ART in the second trimester
or earlier, intrapartum intravenous zidovudine, six weeks of oral ART to the infant and exclusive
formula feeding are proven to reduce the MTCT to less than 2% (4). However, transmission is still
reported despite the HAART or selective caesarean delivery due to failure to reduce viral load,
associated with short duration of treatment (8) or in-utero transmission (5). Due to improved access
to ART among pregnant women, there was a substantial reduction of 52% in new infections between
2001 and 2012 (6). However, only 67% of HIV-infected women in low and middle-income countries
received ART in 2013. In 2015, options B and B+ were compared to see their outcomes and cost-
effectiveness in Ghana (6). Option B+ recommends continuous ART regardless of the CD4 count
(lifelong) beginning at their first pregnancy. The author has proven it to be cost-effective than Option
B (6). However, there is no data considering multiple pregnancies for this paper that might hinder the
benefits of Option B+. The author believes option B+ can potentially reduce MTCT for future
pregnancies and benefit people who opt to have many kids (6). In 2015, there was a paper
investigating the effect of starting ART before conception, which had <50 copies/mL at delivery and
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resulted in no case of MTCT among nearly 2700 women, which is incredibly improved from the 10%-
20% MTCT risk (9). The World Health Organization endorsed the objective of starting as early as
possible (9); however, this will have a limitation for developing countries, as mentioned before.

Figure 1 shows how HIV particles infect a host CD4 cell and a few ways used by antiretroviral therapy (ART) to combat the
infection (10) created with BioRender.com.

References:
1. Ellington, S.R., King, C.C. and Kourtis, A.P. (2011). Host factors that influence mother-to-child transmission of HIV-
1: genetics, coinfections, behaviour and nutrition. Future Virology, 6(12), pp.1451–1469.
2. UNAIDS. "Global HIV & AIDS Statistics — 2020 Fact Sheet." Www.unaids.org, 2023,
www.unaids.org/en/resources/fact-sheet#:~:text=GLOBAL%20HIV%20STATISTICS.
3. Amin, O., Powers, J., Bricker, K.M. and Chahroudi, A. (2021). Understanding Viral and Immune Interplay During
Vertical Transmission of HIV: Implications for Cure. Frontiers in Immunology, 12.
4. Forbes, J.C., Alimenti, A.M., Singer, J., Brophy, J.C., Bitnun, A., Samson, L.M., Money, D.M., Lee, T.C.K., Lapointe,
N.D. and Read, SE (2012). A national review of vertical HIV transmission. AIDS, 26(6), pp.757–763.
5. Townsend, C.L., Cortina-Borja, M., Peckham, C.S., de Ruiter, A., Lyall, H. and Tookey, P.A. (2008). Low rates of
mother-to-child transmission of HIV following effective pregnancy interventions in the United Kingdom and
Ireland, 2000–2006. AIDS, 22(8), pp.973–981.
6. VanDeusen, A., Paintsil, E., Agyarko-Poku, T. and Long, E.F. (2015). Cost effectiveness of option B plus for
prevention of mother-to-child transmission of HIV in resource-limited countries: evidence from Kumasi, Ghana.
BMC Infectious Diseases, 15(1).
7. Horvath, T., Madi, B.C., Iuppa, I.M., Kennedy, G.E., Rutherford, G.W. and Read, JS (2009). Interventions for
preventing late postnatal mother-to-child transmission of HIV. Cochrane Database of Systematic Reviews.
8. Whitmore, S.K., Taylor, A.W., Espinoza, L., Shouse, R.L., Lampe, M.A. and Nesheim, S. (2012). Correlates of
Mother-to-Child Transmission of HIV in the United States and Puerto Rico. Paediatrics, 129(1), pp. e74–e81.
9. Mandelbrot, L., Tubiana, R., Le Chenadec, J., Dollfus, C., Faye, A., Pannier, E., Matheron, S., Khuong, M.-A.,
Garrait, V., Reliquet, V., Devidas, A., Berrebi, A., Allisy, C., Elleau, C., Arvieux, C., Rouzioux, C., Warszawski, J. and
Blanche, S. (2015). No Perinatal HIV-1 Transmission from Women with Effective Antiretroviral Therapy Starting
Before Conception. Clinical Infectious Diseases, p. civ578
10. Khan, Sal. "Treating HIV: Antiretroviral Drugs (Video)." Khan Academy, 26 June 2015,
www.khanacademy.org/science/health-and-medicine/infectious-diseases/hiv-and-aids/v/treating-hiv-
antiretroviral-drugs. Accessed 15 Oct. 2023.