15 Month follow up of African children following vaginal cleansing with benzalkonium chloride of their HIV infected mothers during late pregnancy and delivery

OBJECTIVES

To study mother to child HIV-1 transmission (MTCT) and infant mortality following benzalkonium chloride (BC) disinfection.

METHODS

A randomised, double blind phase II placebo controlled trial. Women testing positive for HIV-1 infection in prenatal care units in Abidjan, Côte d'Ivoire, and Bobo-Dioulasso, Burkina Faso, from November 1996 to April 1997 were eligible, with their informed consent. Women self administered daily a vaginal suppository of 1% BC (53) or matched placebo (54) from 36 weeks of pregnancy, plus a single dose during labour. The neonate was bathed with 1% BC solution or placebo within 30 minutes after birth. MTCT rate was assessed based on repeated polymerase chain reaction (PCR) and serology results. For the present analysis, children were followed up to 15 months.

RESULTS

A total of 107 women were enrolled. Of 103 eligible liveborn children, 23 were HIV infected, 75 uninfected, and five of indeterminate status. MTCT transmission rate was 24.2% overall (95% confidence interval (CI): 14.3% to 30.4%). On an intent to treat basis, the transmission rate did not differ between the two groups (23.5%, CI 13.8 to 38.5, in the BC group and 24.8%, CI 15.0 to 39.6, in the placebo group at 15 months). Similarly, there was no difference in mortality at 15 months (22.9%, CI 13.7 to 36.9, in the BC group and 16.5%, CI 9.0 to 29.4, in the placebo group).

CONCLUSION

This analysis failed to suggest any benefit of BC disinfection on mother to child HIV transmission or perinatal and infant mortality.

[Cell culture for active Chlamydia trachomatis infection in a population of symptomatic women in Abidjan]

The object of our study has been to assess Chlamydia trachomatis prevalence among symptomatic women in Abidjan and to identify issues related to the use of cell culture methods in a tropical laboratory. 1522 women with vaginal discharge were enrolled in a cross sectional study. One endocervical swab was taken per woman and inoculated into cycloheximide treated Mac Coy cells. Elementary bodies were detected by direct fluorescent antibody (DFA). The isolate rate of Chlamydia trachomatis by cell culture was estimated to 86%. The prevalence of chlamydial infection among symptomatic women was 10.8%. Culture was influenced by presence of blood or cervical mucus in the sample. 206 samples gave no results because of blood or cervical mucus. During this study repeated contaminations of cells with facultative bacteria were noted and disposing of a sufficient number of cells was not easy.

Operational issues in preventing mother-to-child transmission of HIV-1 in Abidjan, Côte d'Ivoire, 1998-99

OBJECTIVE

To demonstrate the feasibility, from the public health standpoint, of preventing mother-to-child transmission of human immunodeficiency virus type 1 (HIV-1) in Africa.

METHODS

Voluntary counselling and HIV serotesting were routinely provided in four health centres in Abidjan, Côte d'Ivoire, for six months in 1998-99. Peripartum treatment with zidovudine and alternatives to breastfeeding were provided free to HIV-infected women.

FINDINGS

Of the 4309 pregnant women in the study who attended their first antenatal care visit, 3756 benefited from individual counselling and pretesting (87.2%), and 3452 (80.1%) agreed to undergo HIV serotesting. Overall HIV prevalence was (12.89%) and 5% for women aged under 18 years. Among the 2998 HIV-negative women, 71% returned for their test result, whereas only 60% of the 445 HIV-positive women did so. A total of 124 HIV-positive women were informed of their serostatus and the possibility of preventing mother-to-child transmission of HIV; 100 started treatment and 80 completed zidovudine prophylaxis. At 6 weeks of age, 36 of the 78 liveborn children were being breastfed (46%), two were being mixed-fed and 41 (52%) were being artificially fed.

CONCLUSIONS

In Abidjan, voluntary counselling and HIV testing with a view to preventing mother-to-child transmission was feasible in antenatal care units and was well accepted by pregnant women. An insufficient proportion of women returned to obtain their test results. This was especially so among HIV-positive women, the target group for preventing mother-to-child transmission of HIV. Additional staff were required in order to offer voluntary counselling and HIV testing to the study women. Close supervision and strong commitment of health workers were essential. Alternatives to breastfeeding were effectively proposed to HIV-positive women, with active follow-up of children and clinical, nutritional and social support.

Genital mycoplasmas among pregnant women in Cóte d'Ivoire, West Africa: prevalence and risk factors

A cross-sectional study was conducted among pregnant women in Côte d'Ivoire to assess the prevalence and the factors associated with mycoplasma colonization. A positive culture was found in 400 of 551 women (73%); Ureaplasma urealyticum was identified in 22%, Mycoplasma hominis in 20% and both microorganisms in 31%. Mycoplasma colonization was not associated with genital symptoms or signs. Young age, low educational level, antimicrobial chemotherapy before consultation and presence of bacterial vaginosis were factors independently associated with M. hominis colonization. Among women colonized with M. hominis, HIV seroprevalence was 21% in women with high amounts of M. hominis (> or = 10(4) colour-changing units per ml) versus 7% in women with lower amounts (P=0.01). U. urealyticum was found more often in unmarried women and when pregnancy was less than 20 weeks. Mycoplasma colonization is frequent among pregnant women in Abidjan, but their pathogenicity requires further study.

Safety and acceptability of vaginal disinfection with benzalkonium chloride in HIV infected pregnant women in west Africa: ANRS 049b phase II randomized, double blinded placebo controlled trial. DITRAME Study Group

OBJECTIVES

To study the tolerance and acceptability in Africa of a perinatal intervention to prevent vertical HIV transmission using benzalkonium chloride disinfection.

DESIGN

A randomized, double blinded phase II trial.

SETTING

Prenatal care units in Abidjan (Côte d'Ivoire) and Bobo-Dioulasso (Burkina Faso).

PATIENTS

Women accepting testing and counselling who were seropositive for HIV-1 and under 37 weeks of pregnancy were eligible. A total of 108 women (54 in each group) enrolled from November 1996 to April 1997, with their informed consent.

INTERVENTION

Women self administered daily a vaginal suppository of 1% benzalkonium chloride or matched placebo from 36 weeks of pregnancy, and a single intrapartum dose. The neonate was bathed with 1% benzalkonium chloride solution or placebo within 30 minutes after birth.

MAIN OUTCOME MEASURES

Adverse events were recorded weekly, with a questionnaire and speculum examination in women through delivery, and examination of the neonate through day 30. The incidence of genital signs and symptoms in the women and cutaneous or ophthalmological events in newborns were compared between groups on an intent to treat basis.

RESULTS

The median duration of prepartum treatment was 21 days (range 0-87 days). Compliance was 87% for prepartum and 69% for intrapartum treatment, and 88% for the neonatal bath, without differences between the two groups. In women, the most frequent event was leucorrhoea; the incidence of adverse events did not differ between treatment groups. In children, the incidence of dermatitis and conjunctivitis did not differ between the benzalkonium chloride and placebo groups (p = 0.16 and p = 0.29, respectively).

CONCLUSION

Vaginal disinfection with benzalkonium chloride is a feasible and well tolerated intervention in west Africa. Its efficacy in preventing vertical HIV transmission remains to be demonstrated.

Cervical screening in Africa: discordant diagnosis in a double independent reading. DYSCER-CI Group

Interobserver variation in the cytological diagnosis of cervical lesions poses a problem for public health screening programs. This study assessed the frequency of discordant diagnoses between two independent cytopathologists in the screening of African women. In Abidjan, Côte d'Ivoire, 2157 women were recruited from three outpatient gynecology clinics and screened for cervical abnormalities and genital and human immunodeficiency virus (HIV) infections. The degree of agreement between the cytopathologists was assessed by kappa statistics. The overall agreement was poor (kappa = 0.33); however, the degree of agreement increased with the severity of the lesions and was fairly good (kappa = 0.53) for high-grade and invasive lesions requiring curative treatment. Discordance was associated with HIV infection but not with genital infections. For a prevention program of cervical cancer in this African context, strategies must be developed to minimize errors in cervical screening. Particularly, HIV-infected women require a systematic rereading to reduce false-negative results.

[The costs of treating HIV-infected children in Abidjan, Ivory Coast, 1996-1997]

Little is known about the costs of treating HIV-infected children in Africa. However, this is one of the factors that must be taken into account when assessing the cost-effectiveness of strategies aimed at reducing the transmission of HIV from mother to child. The aim of this study was to estimate the direct costs of the treatment of African children born to HIV-infected mothers and the additional costs of treating those children who are themselves infected with the virus. We assessed the direct costs of care for a sample of children born in 1996 to HIV-positive mothers participating in a clinical trial to evaluate the efficacy of administering a short course of zidovudine to the mother in the peri-partum period, in Abidjan, Ivory Coast (DITRAME ANRS 049a). We systematically reviewed the medical records of these children and recorded drug prescriptions, clinical investigations, consultations with medical specialists, hospital admissions and transportation costs during their first year of life. This study included 78 children, 15 of whom were HIV-positive. The mean cost of treatment was 1,671 FF (254 Euros) per child-year for infected children, 709 FF (108 Euros) more than the mean cost of treatment for HIV-negative children born to HIV-positive mothers. Thus, HIV infection resulted in a 74% increase in treatment costs. The mean cost of a drug prescription was 50 FF (7.6 Euros), and could have been halved if only generic drugs had been prescribed. This study was limited to the direct costs of pediatric HIV infection and did not take into account the cost of health service provision in Ivory Coast or the indirect costs for the family. These results were obtained in the context of a prospective clinical trial within a system providing free and unlimited access to health care. In a city where the mean salary of a civil servant is 900 FF (137 Euros) per month, the expenditure necessary to pay for the basic care of one HIV-infected child is high. Health-care services in sub-Saharan Africa should make more use of generic drugs and pediatric HIV infection provides a clear example of the benefits to be obtained by such a rational strategy for the use of scarce health resources.

Abortion complications in Abidjan (Ivory Coast)

The aim of this study was to describe the various methods of abortion used by women admitted to an obstetrics department in Abidjan (Ivory Coast) for abortion complications. The study was retrospective, and was based on the medical files of all 472 women admitted for abortion complications during a 3-year period (1993-1995). The introduction of plant stems into the uterus, the use of certain instruments, use of vaginal preparations, and ingestion of plants were the most common abortion methods. Seventeen maternal deaths were registered, giving a maternal mortality rate of 3.6%. A high number of previous pregnancies and the ingestion of plants to provoke abortion were factors associated with the highest risk for maternal death. Complications of "local" abortion methods accounted for a high proportion of maternal deaths.

Vaginal douching: association with lower genital tract infections in African pregnant women

BACKGROUND AND OBJECTIVES

Douching, a common practice, could further increase the risk of genital infections.

GOAL OF THIS STUDY

To describe douching practices in pregnant women and to evaluate associations with lower genital tract infections.

STUDY DESIGN

Cross-sectional study in Abidjan, Côte d'Ivoire.

RESULTS

Among 552 women included, douching before consultation was reported by 97% and was common practice for 98%. Intravaginal drying agents were used by 10%. Genital warts were less frequent for women who usually douched (p = 0.015). U. urealyticum infection was associated with douching and with the use of intravaginal agents. Diagnosis of genital infections was independent of douching with water or soap, but chlamydial infection was associated with douching with antiseptics, used by 14% of the women (p = 0.036). HIV infection was two times more frequent in women using antiseptics (p = 0.17).

CONCLUSION

The study confirms the widespread practice of douching in African pregnant women. The harmful effects of antiseptics need to be substantiated.

Impaired fertility in HIV-1-infected pregnant women: a clinic-based survey in Abidjan, Côte d'Ivoire, 1997

OBJECTIVE

Differences in fertility among HIV-1-positive and HIV-negative women tested in prenatal clinics were suspected by routine data collection in Abidjan, Côte d'Ivoire. This study was conducted on detailed fertility patterns among women at the same antenatal care centres, in order to assess these differences.

METHOD

The survey was carried out on 1201 consecutive women who agreed to be tested for HIV. Data collected included a detailed account of pregnancies, the time interval between the last two pregnancies, and the health status at the time of the survey. Blood samples were tested for HIV and syphilis with informed consent.

RESULTS

Despite an earlier exposure to pregnancy risk, HIV-1-infected women aged 25 years and above, had, on the average, fewer pregnancies than uninfected women. An analysis of the interval between the last two pregnancies among multigravidae showed that, all things being equal, being HIV-1 positive decreased the risk of being pregnant by 17% (Cox regression, hazard ratio = 0.83, 95% confidence interval (CI): 0.69-0.99). This shift in the occurrence of the last pregnancy was more profound among HIV-1-positive women already at the symptomatic or AIDS stage, than among asymptomatic women.

CONCLUSION

These data confirm that women infected by HIV-1 would become pregnant less often than uninfected women, for an equal exposure to the risk of pregnancy. Therefore HIV-1-positive women could be under-represented at antenatal centres. Programmes involving such settings both for epidemiological surveillance and the reduction of mother-to-child transmission should take this observation into account.

6-month efficacy, tolerance, and acceptability of a short regimen of oral zidovudine to reduce vertical transmission of HIV in breastfed children in Côte d'Ivoire and Burkina Faso: a double-blind placebo-controlled multicentre trial. DITRAME Study Group. DIminution de la Transmission Mère-Enfant

BACKGROUND

Zidovudine reduces the rate of vertical transmission of HIV in non-breastfed populations. We assessed the acceptability, tolerance, and 6-month efficacy of a short regimen of oral zidovudine in African populations practising breastfeeding.

METHODS

A randomised double-blind placebo-controlled trial was carried out in public clinics of Abidjan, Côte d'Ivoire, and Bobo-Dioulasso, Burkina Faso. Eligible participants were women aged 18 years or older, who had confirmed HIV-1 infection and pregnancy of 36-38 weeks duration, and who gave written informed consent. Exclusion criteria were severe anaemia, neutropenia, abnormal liver function, and sickle-cell disease. Women were randomly assigned zidovudine (n=214; 300 mg twice daily until labour, 600 mg at beginning of labour, and 300 mg twice daily for 7 days post partum) or matching placebo (n=217). The primary outcome was the diagnosis of HIV-1 infection in the infant on the basis of sequential DNA PCR tests at days 1-8, 45, 90, and 180. We compared the probability of infection at a given age in the two groups. Analyses were by intention to treat.

FINDINGS

Women were enrolled between September, 1995, and February, 1998, when enrolment to the placebo group was stopped. Analysis was based on 421 women and 400 lifeborn infants. Baseline demographic, clinical, and laboratory characteristics were similar in the two groups. The Kaplan-Meier probability of HIV infection in the infant at 6 months was 18.0% in the zidovudine group (n=192) and 27.5% in the placebo group (n=197; relative efficacy 0.38 [95% CI 0.05-0.60]; p=0.027). Adjustment for centre, period of recruitment, mode of delivery, maternal CD4-cell count, duration of labour, prolonged rupture of membranes, and duration of breastfeeding did not change the treatment effect. The proportions of women taking more than 80% of the planned maximum dose were 75% before delivery, 81% during labour, and 83% post partum, without statistical difference between the groups. No major adverse biological or clinical event was reported in excess among women and children of the zidovudine group.

INTERPRETATION

A short course of oral zidovudine given during the peripartum period is well accepted and well tolerated, and provides a 38% reduction in early vertical transmission of HIV-1 infection despite breastfeeding.

HIV-1 infection and reproductive history: a retrospective study among pregnant women, Abidjan, Côte d'Ivoire, 1995-1996. Ditrame Project

The aim of this paper is to determine the differences of fertility between HIV-1 infected and uninfected women in Abidjan, Côte d'Ivoire, using data available in an observational study conducted in 1995 and 1996 in 2 antenatal care centres in the district of Yopougon, Abidjan, within an intervention programme to reduce mother-to-child HIV-1 transmission (DITRAME project, ANRS 049). Fertility indicators have been constructed from retrospective data on pregnancies and births, and univariate and multivariate analyses have been performed on these indicators and stratified by age groups to compare HIV-1 positive and HIV-negative populations. The main outcome measures were the number of pregnancies, the number of miscarriages, the risk of miscarriage and the proportion of primigravida. Four thousand, three hundred and ninety-six women agreed to HIV testing: 12.1% were found to be HIV-1 infected. HIV-1 positive women had significantly fewer pregnancies than HIV-negatives in age-groups 25-29 (P = 0.05) and 30-34 (P = 0.008). The risk of having had at least one abortion or stillbirth was significantly higher for HIV-1 infected women than for HIV-negatives (OR = 1.28, 95% CI: 1.02-1.60), when controlling for social and demographic factors. This study suggests that HIV-1 infection has deleterious consequences on female fertility, with lower fertility rates and more frequent adverse pregnancy outcomes. Family planning and antenatal care services should consider antenatal HIV counselling and testing in women in areas of high HIV prevalence.

Squamous intraepithelial lesions of the cervix, invasive cervical carcinoma, and immunosuppression induced by human immunodeficiency virus in Africa. Dyscer-CI Group

BACKGROUND

Squamous intraepithelial lesions (SILs) of the cervix are associated with human immunodeficiency virus (HIV) infection, but multiple risk factors must be considered in this context. The authors performed a cross-sectional study to assess the prevalence of and the factors associated with SILs and invasive cervical carcinoma (ICC).

METHODS

In Abidjan, Côte d'Ivoire, women were recruited from three outpatient gynecology clinics and screened for both cervical disease and HIV infection. A CD4 cell count was performed for HIV-infected women.

RESULTS

A total of 2198 women were included in the study. The prevalence of HIV infection was 21.7%. Of the 2170 women who underwent a cervical screening, 254 (11.7%) presented with a dysplasia or neoplasia: 7.6% had low grade SILs (LSILs), 3.3% had high grade SILs (HSILs), and 0.8% had ICCs. In multivariate analyses, factors associated with these lesions were as follows: for LSILs, HIV-1 seropositivity, age <24 years, parity >1, consultation for genital infection, and no use of oral contraception in the past; for HSILs, HIV-1 seropositivity, chewing tobacco use, low educational level, and parity >1; and for ICCs, age >33 years, parity >3, and illiteracy. In women infected with HIV-1, the prevalence of LSILs increased with a decrease in CD4 cell count, whereas this relation was not found among patients with HSILs. ICCs were linked to HIV-2 infection, but not to HIV-1 infection, in univariate analysis.

CONCLUSIONS

In Africa, the prevalence of SILs is high. The factors associated with precancerous and cancerous lesions are different. Cancers in women infected with HIV-1 often may not reach the invasive stage. These findings could have implications for cervical screening programs in the future.

Human papillomavirus and human immunodeficiency virus infections: relation with cervical dysplasia-neoplasia in African women

Our study assessed the factors associated with cervical squamous intra-epithelial lesions (SILs) and invasive cervical cancer, with special attention to human immunodeficiency virus (HIV) and human papillomavirus (HPV) infections. Women from 3 outpatient gynecology clinics of Abidjan, Côte d'Ivoire, were screened for cervical abnormalities: 151 women with low-grade SILs and 151 controls, 60 with high-grade SILs and 240 controls, and 13 with invasive cancer and 65 controls were enrolled in 3 case-control studies. Controls were chosen at random among the women without lesions, with a frequency matching for age and center. We used the PCR method for the detection of cervical HPV DNA and the restriction fragment length polymorphism analysis for HPV typing. HIV antibody testing and CD4 cell count were performed. In multivariate analyses, factors associated with cervical lesions were: for low-grade SILs, HPV positivity, HIV-1 seropositivity and parity >3; for high-grade SILs, HPV positivity, chewing tobacco, HIV-1 seropositivity and illiteracy, and for invasive cancer, HPV positivity only. We found a diversity of HPV types associated with SILs. In HIV-1-infected women, SILs occurred at an early stage of HIV disease. Women infected with both HIV-1 and HPV were at much higher risk of SILs than women infected with each of these 2 viruses separately. Invasive cancer was linked to HIV-2 infection in univariate analysis only. Our results suggest that the relation of SILs with HIV-1 infection is mainly explained by HPV infection and that HIV-1-infected African women may not often reach the invasive stage of cervical cancer.

[Attitudes and behavior of pregnant women towards HIV screening in Abidjan (Ivory Coast) in 1995 and 1996]

A research program into ways of reducing the maternal transmission of HIV (Project DITRAME, trial ANRS 049) was started in December 1994 in the maternity and child health clinics of the University Hospital and a community health center (Formation Sanitaire de Yopougon, FSU) in Abidjan. The first stage of this program was the introduction of voluntary HIV testing for pregnant women. During their first visit to the maternity clinic, all women were asked their age, how long they had been pregnant and where they were planning to give birth. Women over the age of 18, less than 32 weeks into gestation, who were planning to give birth in Abidjan were routinely offered an HIV test. Women who gave written consent to the test then gave a blood sample for HIV testing. Those testing positive for HIV were given posttest counseling and were invited to participate in a clinical trial of AZT. There were high rates of refusal to be tested and failure to return for posttest counseling during the first year of voluntary HIV testing. We therefore carried out a qualitative study of the reasons for refusal and failing to return. The study involved in-depth interviews with 50 pregnant women who refused to be tested and 50 others who missed the posttest appointment. Most of the women who refused to be tested thought they were probably HIV-positive. The main reason for refusing the test was the fear that the disease process would accelerate once they were informed of their HIV infection. Many women were also afraid of the reactions of their relatives, and particularly of their husband or partner, to a positive test result. There was also concern about possible breaches of confidentiality. Some women felt that pregnancy was not the best time to find out that they were HIV-positive. The reasons for not returning after testing were essentially the same, although some women were confused about the date of the appointment or did not understand the difference between standard prenatal blood test and HIV testing. Our study shows that even when most pregnant women accept the test, there are persistent problems. Some relate to the perception of HIV infection in Africa as "the disease" that cannot be cured, resulting in the view that there is no point in knowing that you are infected. Refusal to be tested is also associated with the socioeconomic vulnerability of women and their fear of exclusion. Means of reducing the maternal transmission of HIV will shortly become available in developing countries. Therefore, we need to address this problem and make voluntary HIV testing for pregnant women as widely available as possible.

HIV counseling and testing: behavior and practices of women of childbearing age in Abidjan, Côte d'Ivoire. DYSCER-CI Group

We assessed factors associated with women's attitudes toward HIV test results in gynecology clinics in Abidjan, Côte d'Ivoire. HIV testing was systematically offered to nonpregnant women attending two gynecology clinics in Abidjan. Individual pretest counseling was performed by trained midwives. Posttest counseling was given 2 weeks later to women who wished to know their HIV test results. HIV testing was offered to a total of 1482 women, of whom 1401 (94.5%) agreed to be screened. The prevalence of HIV infection was 21.3%. Of the women who participated, 10% failed to return. Youth, low educational level, and absence of genital infection were findings individually associated with failure by participants to return for their test results. Among the 1242 women who returned, 13.7% did not wish to know the results of their HIV test. A positive HIV test result, being native to Côte d'Ivoire, a high educational level, and knowing the existence of the asymptomatic stage of HIV infection were factors independently associated with declining to know the HIV test result. In conclusion, women who declined to know their HIV test results presented a specific profile at the time of HIV testing. This information can be used to improve pretest counseling and the efficacy of future HIV screening programs.

[The reduction of mother-child transmission of HIV infection in developing countries: potential intervention strategies, obstacles to implementation and perspectives. The Reduction of Mother-Child Transmission of HIV Infection in Africa Group]

Mother to child transmission (MCT) of Human Immunodeficiency Virus (HIV) is the main cause of the spread of the HIV epidemic in the pediatric population. It is estimated that to date, three million children worldwide have been infected by HIV. The epidemic burden in developing countries is dramatic. Ninety-five percent of the world's HIV-infected women are living in developing countries. In industrialized countries, antiretroviral treatment of pregnant women and newborns with azidothymidine (AZT, ACTG 076 regimen) and discouraging breast feeding by HIV-infected mothers are effectively reducing MCT of HIV. However, there are three major obstacles to the systematic application of these strategies in developing countries: (a) difficulties in implementing the complex AZT administration and its corollary the avoidance of breast feeding; (b) the complexity of the logistics of the ACTG 076 regimen; (c) cost. Indeed, in developing countries the socioeconomic situation of the populations are precarious and health structures and services are underdeveloped. In addition, the anxiety and the reluctance of general population in the face of the HIV problem and the high prevalence of maternal anemia reduce the acceptability and safety of AZT treatment for pregnant women in developing regions. Only interventions that are applicable, acceptable, safe, affordable, of low cost and integrated into health system will be able to reduce HIV MCT. We now know that MCT occurs mostly during the perinatal period and the maternal viral load in blood, in cervical secretions and in breast milk appears to be the main determinant of transmission. Maternal vitamin A deficiency may also favor MCT of HIV. It is however possible that this association is confounded by the relationship between advanced maternal HIV disease (a known risk factor for transmission) and vitamin A deficiency. In spite of these uncertainties concerning determinants of MCT of HIV, several interventions have been designed. The first involves treating the mother with antiretroviral drugs for the perinatal period. The second is vaginal disinfection by application of virucidal antiseptics during the perinatal period. The third is to give vitamin A supplements to pregnant women and children. Finally, passive immunotherapy with anti-HIV antibodies applied to pregnant women and/or new born, may be beneficial. The feasibility, safety and efficacy of these potential interventions have not yet been demonstrated in developing countries. In view of the dramatic spread of HIV infection in these countries, the evaluation of these interventions is of utmost priority. These trials are necessary because of the public health emergency but should be performed in strict respect of human rights and medical ethics.