Viewpoint

Prevention of mother-to-child transmission of HIV and the health-related Millennium Development Goals: time for a public health approach

La revue de littérature internationale met en évidence une morbimortalité néonatale plus importantes chez les patientes migrantes et leurs bébés. Un suivi tardif de grossesse avec une difficulté d’accès aux soins, des barrières linguistiques, et une représentation culturelle différente de l’accompagnement de la grossesse font partie des hypothèses explicatives. Nous proposons d’une part d’expliciter les facteurs culturels qui peuvent impacter la relation de soin en période périnatale. D’autre part, nous transmettons des outils de compréhension anthropologiques et psychologiques pour favoriser un partage des représentations culturelles autour du suivi de grossesse, des besoins d’un bébé, et des complications obstétricales ou postnatales. La demande d’un avis spécialisé transculturel n’est pas systématique, la posture transculturelle est adaptable à chacun des professionnels de soin. Cela nécessite pour le professionnel d’aborder de manière explicite l’impact de la culture dans les soins et de prendre en compte sa propre distance culturelle. L’avis spécialisé est recommandé dans certaines situations de cumuls de vulnérabilités (trauma complexe, dépression périnatale avec codage culturel des symptômes), de blocage ou refus de soins pour raisons culturelles, et pour éviter les malentendus culturels. Nous en détaillons deux modalités : la médiation, et un groupe de parole autour des questions culturelles mis en place à la maternité. Le travail institutionnel que nous proposons au sein de l’équipe pluriprofessionnelle en maternité permet aussi l’acquisition de compétences transculturelles.

The international literature review highlights higher neonatal morbimortality in migrant patients and their babies. The explanatory hypotheses include late pregnancy follow-up with difficulty accessing care, language barriers, and different cultural representation in pregnancy support. On the one hand, we propose to explain the cultural factors that can impact the caring relationship during the perinatal period. On the other hand, we set out tools for anthropological and psychological understanding to enhance the sharing of cultural representations around pregnancy follow-up, the needs of a baby, and obstetrical or postnatal complications. The request for a specialised transcultural opinion needs to be more systematic; the transcultural posture is adaptable to each care professional. This requires the professional to address explicitly the impact of culture in care and consider their own cultural distance. Specialised advice is recommended in certain situations of cumulative vulnerability (complex trauma, perinatal depression with cultural coding of symptoms), blockage or refusal of care for cultural reasons and to avoid cultural misunderstandings. We detail two modalities: mediation and a discussion group around cultural issues set up in the maternity ward. The institutional work we propose within the multidisciplinary team in the maternity ward also allows the acquisition of transcultural competencies.

Malawi's PMTCT Option B+ program has expanded the reach of ART services among pregnant and breastfeeding women, but retention in lifelong HIV care remains challenging. Given that depression can undermine retention, it is important to understand how depression changes over the perinatal period, varies across treatment and retention groups, and could be buffered by social support.

Data are from an observational study conducted among women enrolled in Malawi's PMTCT Option B+ program. We used multilevel generalized linear models to estimate the odds of probable depression by time, treatment and retention group, and social support. Probable depression was assessed with the Edinburgh Postnatal Depression Scale and Patient Health Questionnaire-9.

Of 468 women, 15% reported probable depression at antenatal enrollment and prevalence differed across newly diagnosed individuals, second line therapy users, and previous defaulters (18%, 21%, 5%, p = 0.001). Odds of probable perinatal depression decreased over time (OR per month: 0.87, 95% CI: 0.82–0.92) but were higher among those newly diagnosed (OR: 3.25, 95% CI: 1.59–6.65) and on second line therapy (OR: 3.39, 95% CI: 1.44–7.99) as compared to previous defaulters. Odds of probable postpartum depression were lower for participants with high social support (OR: 0.19, 95% CI: 0.09–0.39).

Lack of diagnostic psychiatric evaluation precludes actual diagnosis of depression.

Probable depression varied across the perinatal period and across treatment and retention groups. Social support was protective for postpartum depression among all participants. Depression screening and provision of social support should be considered in PMTCT programs.

We estimate that there will be 13·7 million new cases of childhood cancer globally between 2020 and 2050. At current levels of health system performance (including access and referral), 6·1 million (44·9%) of these children will be undiagnosed. Between 2020 and 2050, 11·1 million children will die from cancer if no additional investments are made to improve access to health-care services or childhood cancer treatment. Of this total, 9·3 million children (84·1%) will be in low-income and lower-middle-income countries. This burden could be vastly reduced with new funding to scale up cost-effective interventions. Simultaneous comprehensive scale-up of interventions could avert 6·2 million deaths in children with cancer in this period, more than half (56·1%) of the total number of deaths otherwise projected. Taking excess mortality risk into consideration, this reduction in the number of deaths is projected to produce a gain of 318 million life-years. In addition, the global lifetime productivity gains of US$2580 billion in 2020–50 would be four times greater than the cumulative treatment costs of $594 billion, producing a net benefit of $1986 billion on the global investment: a net return of $3 for every $1 invested. In sum, the burden of childhood cancer, which has been grossly underestimated in the past, can be effectively diminished to realise massive health and economic benefits and to avert millions of needless deaths.

This study aimed to evaluate the effects of in-utero exposure to HIV and ART on pregnancy outcome and early growth of children.

This cohort study enrolled 802 HIV-infected pregnant women between October 2009 and May 2018 in Guangzhou, China. The women were assigned to receive combination ART (cART) or mono/dual ART or no treatment. The primary outcomes were the combined endpoints of any adverse pregnancy outcome [including ectopic pregnancy, spontaneous abortion, stillbirth, preterm birth, small for gestational age (SGA)] and adverse early growth outcome (including infant death, HIV infection of mother-to-child transmission, and underweight, wasting and stunting of infants at 4 weeks of age).

Adverse pregnancy outcomes occurred in 202 (35.1%) of all enrolled HIV-infected women, and 121 (31.3%) of all infants exhibited adverse effects on early growth at 4 weeks of age. The rates of adverse pregnancy outcomes, spontaneous abortion, ectopic pregnancy, stillbirth, infant death and perinatal HIV infection were higher among women not receiving ART, compared to those treated with cART or mono/dual ART (P < 0.05). However, women treated with cART had a higher rate of SGA, compared to untreated women (P < 0.05). No differences in early infant growth were observed among the different treatment regimens.

Our findings underscore the essentiality of prioritizing HIV-positive pregnant women for ART, as even mono/dual ART available in resource-limited countries could improve pregnancy outcomes and infant survival.