HIV in children is predominantly acquired vertically. Without intervention, mother to child transmission (MTCT) has varied from 20%-40%(1). Vertical transmission of HIV can occur in utero through placental transmission, intrapartum through contact with infected birth canal secretions or postpartum through breast feeding. It is estimated that of the 30% of babies who get infected vertically, 2% get infected in early gestation, 3% get infected in late gestation, 15% get infected intrapartum and 10% get infected via breast feeding(2). HIV transmission from infected mother to child is mainly prevented by antiretroviral drug (ARV) prophylaxis to mother and baby, replacement feeding and elective cesarean section. ARV prophylaxis acts by reducing viral load in the mother and as post-exposure prophylaxis to the baby. Cesarean section decreases risk of intrapartum transmission of HIV by decreasing transplacental hemorrhage during labour and reducing the length of exposure of baby to vagino-cervical secretions. Cesarean section decreases transmission by approximately 50 percent as compared to other modes of delivery(3). MTCT rates of less than 2% have been reported from countries where ARV prophylaxis, cesarean section and avoidance of breast feeding is practiced. However, in a setting where ARV prophylaxis as well as replacement feeding is provided, is there really a necessity of elective cesarean section delivery?

Elective cesarean section is associated with post partum morbidity in form of fever, urinary tract infection, endometritis and thromboembolism(3). An Italian registry for HIV infection in children found that MTCT rate was 15.5% in 1985-1995 period and 5.8% in 1996-1999 period. They found only elective cesarean section was associated with lower risk of mother-to-infant transmission before 1995. After 1995, non-breast feeding and receipt of ART were protective whereas elective cesarean section was not significantly protective(4). Similarly, a study by the author in Mumbai in 222 mother-child pair found that vaginal delivery was as effective as cesarean section for prevention of MTCT of HIV when combined with ARV prophylaxis and no breast feeding(5).

Thus, when ARV prophylaxis to mother and child are available and replacement feeding can be issued, the added advantage of cesarean section is not seen and vaginal delivery may be a safe and inexpensive option in this setting. However, in areas where safe replacement feeding may not be available, elective cesarean section may decrease rate of transmission of HIV initially but breast feeding may substantially increase the overall transmission rate nullifying the advantage of cesarean section.

Ira Shah,
Incharge, Pediatric and Perinatal HIV Clinic,
B.J.Wadia Hospital for Children,
Mumbai, India.
E-mail: [email protected]