1. ANNALS OF THE ACTM 43
HIV TRANSMISSION THROUGH
BREASTFEEDING IN SUB-
SAHARAN AFRICA: A REVIEW
OF THE CURRENT LITERATURE
K McArthur
MPH Student School Public Health
James Cook University
Townsville Qld Australia
Tel 07 4724 4527
Email Kayeemac@hotmail.com
SUBMITTED REVIEW:
HIV Transmission through breastfeeding in
sub-Saharan Africa: A REVIEW OF CURRENT
LITERATURE
K McArthur, MPH Student School Public Health, James Cook University, Townsville Qld Australia
(Annals of the ACTM, 2007; 8,2:43-49)
Abstract
There has been a substantial amount of research on Human ImmunodeficiencyVirus (HIV) in mother
to child transmission (MTCT) through breastfeeding.While breastfeeding is an important part of a
mother’s womanhood and has contributed significantly to childhood survival in this region, these
gains have been compromised by HIV/AIDS. Factored into this public health dilemma are the
feeding practices, traditional mores and the precarious environments in Africa. MTCT significantly
impacts on women and children in most areas sub-Saharan Africa; causing disease, death, and
orphan-hood. Antivirals (AVR) may only provide a brief opportunity to contain HIV. The increase in
global funding needs to be utilised appropriately to counteract the grim statistics.Reviewed in this
article is HIV epidemiology; the virology, susceptibility of the mother and infants to HIV through
breastfeeding. There are many challenges and research questions in MTCT yet to be answered.
Effective programs have been developed, and exclusive breastfeeding (breast milk only with no
other liquid or solid foods given) for the first six months has evolved as a possible intervention for
HIV infected mothers who breastfeed.
Introduction
In the mid 1980s, it was established that HIV was transmitted to infants through breastfeeding.
Vertical transmission of HIV/AIDS (Acquired Immunodeficiency Syndrome) in infants,can be acquired
by the transplacental,or intrapartum route,or through breastfeeding.In sub-SaharanAfrica,within
a background of escalating poverty, HIV co-exists with a dependence on breastfeeding. Given the
grim statistics in the region and the level of inadequate access to healthcare, MTCT of HIV/AIDS
is a public health dilemma that continues to escalate.
There are many preventive MTCT strategies, and while these can reduce the prenatal risk, the
reduction of transmission in breastfeeding has been less successful. It appears that MTCT in HIV
occurs throughout lactation; yet strangely,the majority of breastfed infants who have daily exposure
to HIV-1 remain uninfected.The viral load in breast milk is a major determinant of infection risk for
the infant.The mechanism of transmission and neonatal susceptibility is not yet clearly understood.
The impact of biologic and sociological complexities associated with MTCT in breastfeeding is
enormous. Recent studies show that variations in breastfeeding patterns are important factors
in safer breastfeeding, as is the health status of both infant and mother and the stages of HIV
infection.A more holistic approach is needed together with an understanding of the determinants
associated for HIV infected mothers in resourced constrained countries.
The purpose of this paper is to review current research in the areas of epidemiology and virology
and to access other determinants such as traditional practices associated with MTCT of HIV
in breastfeeding. Articles for this review were mainly sourced from Pub-med and the WHO
(World Health Organisation) site. The public health issue of whether the extent or the different
developments, overall increase or decrease the infectivity and maternal and child survival rate in
theirAIDS situation is discussed.Considered also is the accessibility,acceptability and sustainability
of the strategies that can be monitored and evaluated is also considered.
Epidemiology and trends
Despite the inadequacy of some surveillance systems, global estimates at the end of 2004 were
that 39.5 million people were living with HIV/AIDS70
. Sub-Saharan Africa is the worst affected as

2. ANNALS OF THE ACTM44
7.4% of the overall population or 25.4 million70
people are affected.In
sub-Saharan Africa, new HIV infections (three million) are matched by
high levels of AIDS mortality 70
. In sub-Saharan Africa, 57% of all people
living with HIV/AIDS are women and it has become a major cause of
death for women of childbearing age57
.
The rates of infections vary considerable within the region total. South
Africa and other southern African countries (such as Botswana, Lesotho,
Namibia and Swaziland) (Figure 1) have the fastest growth rates of
HIV/AIDS in pregnant women70
. In Swaziland, HIV prevalence among
pregnant women was 39% in 2002, up from 24% in 200070
. Elsewhere
in the region, Malawi, Zambia, and Zimbabwe, HIV infections rates in
pregnant women have stabilized at lower levels70
.Some of the EastAfrican
countries, namely Uganda and possibly Kenya, have a downward trend
in HIV prevalence70
. In West Africa, there have been varying degrees of
scale and intensity of HIV infections, the highest being in Burkina Faso,
Côte d’Ivoire, and Nigeria70
. Even when the epidemic is reversed, havoc
wrought by AIDS will shape the future generations70
.
Figure 1: Median HIV prevalence in pregnant women attending
antenatal clinics in sub-Saharan Africa.
In the worse affected areas (South Africa, Zambia and Zimbabwe) young
women aged between 15-24 years are three to six times more likely
to be infected than men, and three quarters of the young people living
with AIDS are women70
. In this region, married women have higher HIV
infection levels (10%) than sexually active unmarried girls70
.
Providing assistance to young people in Botswana
Providing young people with skills, information, tools, and services to protect
themselves against HIV/AIDS is critical in halting the spread in sub-Saharan
Africa. In this region many young girls have either never heard of AIDS, or
have major misconceptions about it75
.Botswana has made significant strides
in this area. Schools have been engaged in the country’s AIDS response, by
initiating a national distance learning television program, targeting teachers
and students75
.
Consequently the number of orphans continues to grow in this region.
There are now more than 12 millionAIDS orphans in sub-SaharanAfrica57
.
Countries with high HIV (40 per 1000) for children under five years of age
are; Botswana (57.7), Zimbabwe (42.2), and Swaziland (40.6) 72
.Vertical
transmission of HIV in sub-Saharan,Africa,is estimated at approximately
35%44
. Breastfeeding is responsible for one third to one half of the total
vertical transmission rate, and the longer the duration of breastfeeding
the greater the risk of an infant contracting HIV/AIDS 42
. Fifty percent
of infants, who contract HIV through vertical transmission, and in the
absence of specific antiretroviral therapy (ART), will die within their first
two years of life34
. Ironically in this region, bottle-fed babies do not have
a higher survival rate than breastfed infants whose mothers are infected
with HIV-139
. This is attributable to poverty and reflects the cyclical and
deadly interplay between these two factors57
.
Diagnosis
Diagnosis of HIV inAfrica is often dependant on clinical judgement and in
some cases is supported by antibody testing12
. Estimation of the timing
of HIV transmission in infants is difficult with ELISA antibody tests, as
HIV maternal antibodies (IgG) are detectable up to 18 months after birth
in infants34
. Selected antenatal health services in sub-Saharan Africa
have become focal points for both diagnosis and screening (sentinel) of
pregnant women,providing proxy estimates of the prevalence of HIV/AIDS
infections in the population 4
.
Table 1: HIV diagnostic tests for infants.
Type of Test Description
HIV ELISA Antibody Test For children after 15 months or older.
Saliva and Urine Testing Measures ELISA antibody IgG in saliva/urine. This test
can be used by untrained personnel.
Polymerase Chain Reaction Can be performed at birth. Breastfed children
require further tests at six weeks after cessation of
breastfeeding.
Filter Paper DNA PCR Blood spots dried and stored on filter paper for
processing.
HIV Viral Culture Sensitivity and specificity similar to PCR, expensive,
results not available for two to four weeks.
P24 Antigen Sensitivity is low especially in the first few weeks of
life but relativity inexpensive.
HIV IgA Used to detect intrauterine exposure of HIV.
In developed countries,three types of virologic tests are used for infants.
This includes molecular technique, polymerase chain reaction (PCR),
which can be used to confirm diagnosis as early as 48 hours of age, but
it is expensive19
. Viral culture and HIV antigen assay can also be used to
test plasma or serum for HIV viral proteins19
.
Virology
HIV is an RNA virus,which is classified as a lentivirus68
.Viruses HIV-1 and
HIV-2 are members of this genus88
. Morphologically similar, HIV-2 has
the same method of transmission but it is significantly less transmissible
and virulent 88
. HIV-1 is divided into several groups of virus known as M,
N, and O and within the M group, there are at least nine sub-types A-D,
F-H, J, and K22, 47
. Three sub-types A, C and D have caused the largest
number of infections in sub-Saharan Africa22, 47
.
After a cell has been infected,production of new virions occurs inside the
host cell,causing the cell to either die or form syncytial masses88
.The HIV
externally studded receptor bind to sites in a lock and key mechanism

3. ANNALS OF THE ACTM 45
docking onto the surface of host cells88
.The transmembrane glycoprotein
molecule (CD4) is the principal surface receptor for HIV88
.HIV exists as
a mixture of active and inactive viruses in different cells throughout the
body88
. This chronic, unrelenting, and ultimately progressive infection is
divided into three distinct stages; primary infection, clinical latency, and
symptomatic diseases88
.
Maternal factors that influence MTCT
The determinants associated with mothers contracting HIV and then
transmitting it through breastfeeding is both dependant on high HIV
prevalence rates and inter-dependant on other factors. In sub-Saharan
Africa, women contract HIV mainly during unprotected sex with an
infected partner. However HIV has a low infectivity rate of 0.3%60
for this
method of transmission. Men are four times more efficient transmitters
of HIV/AIDS than women15
but women are biologically more vulnerable35
.
In some countries within this region, women contract HIV infection from
contaminated blood transfusions.A woman’s age appears to have some
relationship with susceptibility to HIV (young women and those over 45
years, being more susceptible), as does contraceptive practice, and the
presence of systemic disease27
.
High maternal viral load and immune-suppression increases the risk of HIV
transmission23
. Women with an HIV primary infection are twice as likely
to pass on the virus, and those with HIV related illness are three times
more likely to transmit the virus43
.Research has established the presence
of HIV in breast milk and that breast disease increases transmission of
HIV23
. Vitamin A deficiency is associated with elevated levels of HIV DNA
in breast milk59
. Clinical trials however have failed to demonstrate that
vitamin A supplementation reduces MTCT of HIV9, 59
. Breast pathologies
(cracked or bleeding nipples,breast thrush,breast abscesses,sub-clinical
and clinical mastitis) are common (30%) in breastfeeding women, and it
is thought that these conditions double the risk of MTCT of HIV19
.
There is now epidemiological evidence of how other diseases increase
the infectiousness of and susceptibility to HIV transmission.Studies have
suggested that poor maternal health plays a major role in MTCT 18
. Both
ulcerative and inflammatory SexuallyTransmitted Infections (STIs) are co-
factors in HIV transmission27
.Treatment of STIs reduces HIV incidence by
40%27
.Timely diagnosis and treatment are important pillars in preventing
HIV infection; however, only two countries in this region have treatment
coverage of more than 50% for STIs 56
.
Tuberculosis (TB) has emerged as a synergistic twin of HIV/AIDS80
. Latent
TB appears reactive in the presence of HIV; 31% of adult TB cases are
attributable to HIV in the region80
.Outbreaks of multi-drug resistantTB are
associated with HIV infections79
.Other co-factors in HIV transmission are
helminthiasis65
and malaria,which activate a chronic immune response
increasing the risk of HIV transmission 61,64
.
Observational studies have shown a direct relationship between
malnutrition/nutritional status and vertical transmission of HIV. Some
studies suggest that breastfeeding creates a metabolic burden with HIV-1;
causing nutritional impairment that accelerates progression of HIV related
deaths,40
while other studies dispute this hypothosis35
. Vitamin B, C, E,
have been shown to have some protective effects on MTCT of HIV in breast
milk 56
.Early mortality in HIV/AIDS has been associated with low levels of
vitamin A, selenium, and zinc56
. These low levels maybe markers rather
than causal factors for the advance stage of HIV/AIDS disease56
.
In the 1990s, there were major advances in the development of
antiretroviral therapy (ART) that changed the natural history of the
progression of HIV.Research established and endorsed by theWorld Health
Organisation (WHO) recommended that a short course of Zidovudine
(AZT) be administered during the last four weeks of pregnancy50, 51
to
HIV infected women. This measure reduced the overall transmission by
more than half however; HIV transmission during the postnatal period
remained largely unaffected29
. In most resource scarce settings, a single
dose of nevirapine (NVP) is given, one dose to the mother during delivery
and one to the infant within 72 hours of birth38
. NVP has been shown to
be more effective (47%)in reducing transmission of HIV than AZT 38
and
reduces the risk of transmission of HIV associated with breastfeeding for
at least the first year of life49
.
Of increasing concern however is the increase in drug resistance. Up to
40% of women and children develop NVP resistance30
in this region.WHO
recommends theART drug combinations of d4T (stavudine) orAZT + 3TC
(Lamivudine) +NVP for pregnant women 20
.Adding the drug Combivir (AZT
and 3TC) to a single-dose of ART has been found to significantly reduce
drug resistance if the combination is correctly timed 52
.
Infant susceptibility
There is a need to not only protect infants but also to reduce susceptibility
to HIV infection. Providing micronutrient supplements to infants born to
infected mothers irrespective of the infants HIV status may be important
in reducing mortality and morbidity56
. Studies have found that both
zinc and vitamin A supplementation in infants is beneficial in reducing
both transmission and progression of HIV, and significantly reducing
diarrhoea56
. Progression of the disease in infants is much more rapid
than in adults34
. Infectious complications for example Pneumocystis
jiroveci with HIV in infants are preventable by primary prophylaxis with
co-trimoxazole from six weeks of age until their first birthday69
. Risk
factors such as prematurity,(less than 34 weeks of age) low birth weight,
teething lesions, breaches in the oral mucosal and thrush make infants
more susceptible to infective mothers who breastfeed56
.
There is growing evidence of the risks to infants of nosocomial
transmission of HIV. The traditional use of wet nurses is also thought to
be unsafe when HIV status is not known11
. HIV-negative children may
also be inadvertently infected through the common use of expressed
breast milk from HIV-positive women11
. In one milk room in South Africa,
where the milk was being pooled, nearly 25% of women who expressed
milk were HIV-positive11
. It is recommended that in these situations
that breast milk must be pasteurised before use11
. Lack of universal
infectious control measures in maternity, paediatric, and dental facilities
and with traditional healers is thought to be responsible for additional
HIV-positive cases11
.
Breast milk factors
The mechanism of transmission of HIV through breast milk does not
appear to be completely understood. HIV has been identified in both
cell associated and cell free conponents of breast milk5
. The risk of
transmission of HIV through breast milk occurs at any point during
lactation and the longer the duration the greater the risk35
.The cumulative
probability of an infant becoming infected through breast milk is less at
4 weeks (1.6%) than at 18 months of age (9.3%)35
.
Breast milk contains immunologic factors and the maintenance
of mammary epithelial integrity is thought to reduce the risk of

4. ANNALS OF THE ACTM46
transmission31
.Studies have indicated that colostrum protects the infant
from HIV but conversely; high concentrations of virus in colostrum could
put the infant at risk45
.Studies that suggest colostrum may protect against
MTCT found greater concentrations of immune modulating factors such
as IgA, vitamin A and lactoferrin1
, that appear to inhibit binding of HIV to
CD4 molecules10
.Associated with these protective factors, mucins have
been found in infant’s saliva, which are thought to inactivate HIV-128
. In a
study in Rwanda, it was found that the lack of the IgM antibody in breast
milk collected at 18 months postpartum was associated with a high risk
of transmission of HIV in infants of this age1
.
Traditional practices associated with MTCT and breastfeeding
Traditional practices are intertwined with the determinants of MTCT.
Greater attention is needed in understanding these traditions; the control
they have, and how in some cases they can be strengthened when
beneficial. Collaboration between traditional and biomedical healthcare
systems is needed to find new and effective ways to fight and prevent
HIV/AIDS. The WHO advocates the inclusion of traditional healers in
nationalAIDS programs54
.There is a high level of use of traditional health
care by this population (80%)54
; in Uganda traditional and biomedical
healthcare personnel work together in a program to provide sustainable
prevention and care 63
.
Key behaviours have the potential to influence the rates of transmission
of HIV.One study has suggested that more emphasis should be placed on
safe sex practices41
.In high prevalence areas,5% of mothers seroconvert
in the year following a delivery; and given that the primary infection of
HIV is the most virulent, this puts infants significantly at risk during the
breastfeeding period2
.While taboos against postpartum sexual activity are
widespread inAfrica,the duration of abstinence varies greatly within and
amongst different countries78
.This can lead men to seek out extramarital
relations increasing a woman’s risk of infection once a couple resumes
sexual relations15
. Male circumcision is found to be protective against
HIV (twofold)46, 83
; however, female circumcision is thought to be a risk
factor37
. The common use of vaginal desiccating agents has not been
conclusively demonstrated as a risk factor in transmission of HIV; however,
such a relationship is plausible36
.
Intervention study in MTCT of HIV/AIDS in Zambia74
A study was carried out in a southern province of Zambia, in a area of high
rates from HIV/AIDS. Reasons for theses rates were; sexual cleansing of a
widow after her husbands death, women being forced into sexual exchange
because of poverty, inter-generational sex, the sexual freedom of young
people, the lack of prevention efforts, prostitution, migrant workers, and not
using condoms.
Results of this study suggest that to achieve successful preventive MTCT
intervention programs, they should simultaneously include care, support and
the reduction of stigma within the community.The practice of mixed feeding
was reduced before suggesting to HIV infected mothers not to breastfeed.
Feeding supplements were introduced however the cost of alternative feeding
is beyond the reach of most households in this location. Breastfeeding was
widely practised and cherished in this region,and a decision to not breastfeed
often resulted in women being labelled a prostitute.
There appears to be a link between the infant’s gender and the
transmission of HIV-1 in association with traditional breastfeeding
practices. Female infants are 40% less likely than males to become
infected through breastfeeding after four weeks of age43
.While duration
of breastfeeding appears similar for both sexes it is thought that males
are being mixed fed at an earlier age putting them at higher risk43
.
Further research is required to examine the possible traditional beliefs
and mores surrounding male preference and how the different practices
impact on infant feeding.
Exclusive breastfeeding
Recent research has suggested that exclusive breastfeeding is a possible
intervention for HIV infected mothers who breastfeed.African infants are
breastfed for an average of 21 months; however,exclusive breastfeeding
is not widely practiced9, 14
. In the process of mix feeding, the virus may
enter the infant’s mucosa6
either through mucosal breaches or lesions7
.
Mixed feeding is thought to make the infant’s gut more susceptible to
HIV transmission through a mechanical or inflammatory mechanism7
.
The practice of mixed feeding contributes to the incidence of mastitis7
.
The introduction of solids or animal milks before three months of age, to
breastfed infants born to HIV-positive mothers almost doubles the risks of
MTCT of HIV48
.An important study from SouthAfrica found that exclusive
breastfeeding might pose less of a risk of transmission of HIV-1 than mixed
feeding33
. From this study, it was suggested that exclusive breastfeeding
facilitated maturation of the infant’s gut,maintained the mucosal barrier,
and enhanced an infant’s immune response9
. Further studies are now
providing justification for shortening the period of exclusive breastfeeding
to six months followed by, a short weaning period of two weeks48
. This
may prevent about one third of the transmissions35
.
WHO recommends for HIV infected mothers when replacement feeding
is not feasible, acceptable, affordable, or sustainable that infants
should exclusively breastfeed for the first six months 24
. The practice on
exclusive breastfeeding has been endorsed by WHO for women who are
HIV infected, HIV-negative or don’t know their HIV status86
. There are
other variations of exclusive breast milk options such as wet nursing,
heat treatment of breastmilk and breastmilk banks 60
. There is now
evidence that HIV infected infants can transmit HIV to their non-infected
breastfeeding mothers6o
.Where infectious diseases and malnutrition are
primary causes of death during infancy, exclusive breastfeeding will be
the only alternative as many mothers will not be able to provide suitable
replacement foods.
Traditional Birth Attendants (TBAs) involvement in preventive MTCT
service delivery in rural locations in Tanzania73
In high HIV/AIDs burdened rural settings in Tanzania, almost 60% mothers
deliver out side health facilities. In two rural districts in Tanzania, TBAs
were trained to participate in preventive MTCT programs implemented by
the district health authorities, with technical assistance from Axios and
funding from the Elizabeth Glaser Paediatric AIDS Foundation. Antenatally
these programs provided HIV/AIDS education and voluntary counselling and
dispensed Nevirapine under “Directly Observed Therapy” to HIV-positive
mothers in their care. These mothers were also referred to health facilities
for post-natal fellow up,their infants received Nevirapine syrup; and reporting
back to health facilities on a monthly basis.This program found thatTBAs can
be used effectively in program implementation and contribute significantly to
reaching women who deliver outside health facilities.
Reproductive healthcare
HIV interventions pose significant challenges in resource-scarce
countries that want to implementing prevention and treatment of MTCT.
In low-resource settings women generally attend antenatal care only
late in pregnancy, and HIV-positive women often have their infection
diagnosed shortly before childbirth67
. In this region, the training of health

5. ANNALS OF THE ACTM 47
professionals varies, and skilled practitioners attend few deliverers67
.
In many sub-Saharan African countries health services were reduced
to repay national debt, but at the same time these countries are forced
to cope with the burden of HIV, and the loss of essential staff through
sickness and deaths related to AIDS71
.
Prevention of MTCT of HIV has been made a global priority increasing
the focus on reproductive healthcare.The United Nations special session
on HIV in 2001 made a commitment to reduce the proportion of infected
infants by 50% by 201071
. Except for Botswana, Nigeria and Uganda,
ART is not widely available in sub-Saharan Africa71
. Partnerships formed
across a variety of sectors including the Global Fund to Fight AIDS
Tuberculosis and Malaria, the United States President’s Emergency Plan
for AIDS Relief, the World Bank, the Clinton Foundation, Medicines Sans
Frontiers74
in the WH.O, “3 by 5” anti-retroviral strategy, to enable three
million HIV infected persons to receive ART53
.
There is a need not only to strengthen and integrate family planning and
STI services, but also to improve access and acceptability to prevention
and treatment services67,71
. Strategies to reduce MTCT included the
prevention of unintended pregnancies among HIV infected women and
prevention of vertical transmission of HIV67
. In the developed world,
MTCT can be almost preventable by; universal precautions,antiretroviral
prophylaxis, elective caesarean section (before the onset of rupture of
membranes) and refraining from breastfeeding67
. Presently, elective
caesarean section cannot be recommended as a routine intervention for
HIV infected mothers in resource-scarce countries67
.
Increasing voluntary counselling and testing in Zambia
A low rate of HIV serostatus disclosure, among women in antenatal settings, has
implications for prevention of MTCT of HIV77
. In Zambia, expansion of voluntary
counselling (VCT) services has been through collaboration between government,NGOs
and the district health management teams76
.VCT starts before having a HIV test,enabling
an informed choice about being teasted75
. Expectant mothers who discover they are
HIV-positive through the use of VCT are more likely to seek measures to prevent the
transmission75
. Counselling of HIV-positive and HIV-negative people helps to dispel
stigma and discrimination75
. Knowledge of serostatus can be a motiving force for both
HIV-positive and HIV-negative people to practice safer sexual behavior75
.
Keeping HIV infective mothers well is an important prevention in postnatal
MTCT. HIV testing and counselling of pregnant women should become
standard practice71
.Providing mothers with care preserves the family unit,
supports disclosure,and adherence to difficult infant feeding choices and
ART regimens71
.It has been suggested that rapid HIV testing of women in
labour, whose HIV status is unknown would be useful58
.This could allow
the immediate provision of ART prophylaxis to HIV infected women and
their newborns58
. However, a scaling up of treatment may impact on the
importance of preventive behaviours67
. Preventive behaviours such as
safer sex/condom use must not be over looked as these measures are
the most effective in reducing HIV transmission71
.
The process of decision making for HIV-positive mothers to either
exclusively breastfeed or artificially fed, generates a high degree of risk
when the mother only partially adheres to her chosen option13
. These
women have to anticipate their condition for at least six months within
a context of cultural and psychosocial factors, material conditions and
resources of their health care system13
.Providing support for HIV infected
mothers and their families with decisions on whether to breastfeed,
bottle-feed, cease breastfeeding early, and replacement strategies
(such as heat-treatment of breast milk and wet nursing) are important71
.
Other measures such as; availability of lactation counselling,provision of
immediate treatment for mastitis and other infections make breastfeeding
safer71
. Studies have shown that education and counselling were found
to be the strongest predictors of exclusive breastfeeding48
.
The barriers to the provision of breast milk substitutes are enormous13
.
One study investigating pregnant women’s views on infant feeding options
for HIV-infected women, found that most women would choose cows
milk as an option8,17
.Their decisions was based on; what health workers
recommended,that the milk would be distributed free of chargethere was
clean water and structured antenatal care available8,17
.In this same study,
concern was expressed for the social consequences of not breastfeeding8
.
Future research into infant feeding options should include the broader
cultural context, economic barriers and the psychological stress that
HIV-infected women face when choosing infant feeding methods8
.
Future developments
There has been an enormous amount of research on HIV by MTCT;
however, replicated studies are needed to verify recent findings along
with the wider complexities that need to be examined. Transmission of
HIV through breastfeeding during the first four weeks of an infant’s life
needs further investigation, as does the correlation between the risk of
transmission, and the presence of anti-infective substances in breast
milk6
.Micronutrient status and food insecurity has created much interest
and studies continue into nutritional support for breastfeeding women
and their infants56
. Micronutrient supplementation (Vitamin B, C, and E)
may be a cost effective prophylactic and a successful treatment modality
particularly with infants56
.
ART may only provide a brief opportunity to contain HIV. Of concern
is the lack of general laboratory infrastructure in sub-Saharan Africa
needed to monitor drug toxicity and thus prevent multi-drug resistance
in the region21
. The use of NVP for prevention of MTCT of HIV needs to
be restricted to effective combinations25
.The long-term health effects of
drug exposure to ART are unknown and there are increasing reports of
hepatotoxicity73
.With the promise of increased availability ofART therapy,
effective distribution along with cost sustainability is needed20
.There are
important ongoing pharmacokinetic studies in not only the use ofART but
in combining therapies.A recent discovery from the Queensland Institute
of Medical Research in Australia identified a group of HIV drugs that also
protects against the malaria parasite66
.
Many other difficulties and research questions must be overcome. The
use of preventable, efficacious HIV vaccines and microbicides has the
potential to significantly curb the HIV/AIDS pandemic. The search for
vaccines and microbicides faces many obstacles such as scientific
challenges and inadequate funding62
. Vaccine development has been
focused on HIV viruses that are prevalent in the developed world76
.
Studies in the use of vaccines have combined both active and passive
immune strategies,and integrate humoral and cellular immunity32
.Many
candidate HIV vaccines have entered trials but are hindered by a lack of
knowledge about protective immunity62
.Microbicides are currently being
investigated in clinical trials but no product is ready for endorsement62
.
These compounds may offer protection to women who are both vulnerable
and are unable to negotiate safe sex61,71
.
In 2001,the Declaration of Commitment a global consensus set out goals
to reverse this pandemic through a rapid up-scaling up of preventative

6. ANNALS OF THE ACTM48
measures57
. Despite improvements of global funding, (USD2.1 billion in
2001 increased to USD6.1 billion in 2004) coverage of prevention and
care services remains uneven71
. No more than 1% of pregnant women
in heavily infected countries are offered services aimed at prevention of
MTCT70
.Expansion of intervention strategies is needed especially to young
women who are disproportionelly at risk,and affected by HIV/AIDS71
.The
acknowledgement of human rights principles is required to accelerate
this progress.
Issues such as poverty, ignorance and the intersection of the principal
determinant political will are important.This mature pandemic increases
the burden on women and children, reflecting multiple economic,
legal, and social inequities. Social norms can impose a dangerous
ignorance74
; and more research is needed on how gender relations
impact on this epidemic. The affect of the survival strategy; exploitative
or transactional sex,greatly increases the vulnerability of acquiring HIV74
.
Women need greater power and skills to help decide the terms of their
sexual relationships74
.The “rights” of young girls need to be protected71
.
Discrimination and stigmatisation are subtle but very real obstacles in the
battle with AIDS.The gap between awareness and action in the process
of compliance needs further investigation to achieve greater success in
risk reduction strategies.Coherent nationally lead responses are needed
along with multi-sectoral national AIDS strategies that translate into an
efficient and concerted action71
.
A review of policies is needed and dissemination of this information
made readily available. Infectious control polices must be stringently
maintained and include traditional healers. The mother-baby friendly
policy encourages all mothers to breastfeed, which ideally is the most
beneficial for children.However,where the mother is HIV-positive and the
child is HIV-negative, increased flexibility of this policy is required.
Conclusion
The determinants of HIV infection on both the HIV infected mother who
breastfeeds and her infant are multi-factorial. Avoidance of the practice
of breastfeeding by HIV-positive mothers in sub-Saharan Africa is not
generally feasible for this population. There are great opportunities
for the developed nations to minimise vertical transmission of HIV and
maximise child survival, but they are not as available in the developing
nations. Access to prevention and treatment needs to be improved.
Greater collaboration is needed between formal health care system and
traditional healers.While variations of exclusive breastfeeding can reduce
the risk of MTCT, safe replacement feeding programs need to take into
consideration indicators such as poverty and social norms in individual
settings. Increase awareness is needed of the practices associated
with son preference in Africa. Despite the intrinsic merits of antivirals,
development of vaccines, microbicides and treatment of conditions that
are co-factors, are important for future prevention of MTCT.
Paradoxically,the problems and their causes are obvious of this pandemic
of HIV/AIDS in the sub-Saharan Africa but solving them is more difficult.
It is hard to provide counselling on safe sex and milk substitutes if you
know the mother is starving and poverty is rife. With the prediction of
progressive acceleration of new HIV infections, the burden of HIV in
vertical transmission in disease, death, and orphan-hood is significant.
The primary determinants of health including traditional practices and
the precarious individual environments in Africa must be factored into
risk reducing strategies to alleviate this cataclysmic suffering.
References
1. Van de Perre P (1997). Transmission of Human Immunodeficiency Virus Type 1 through Breastfeeding. Infect Dis;
179: S405 S407.
2. Mbizvo, M, J Kasule, K Mahomed and K Nathoo . (2001). HIV-1 Seroconversion Incidence Following Pregnancy and
Delivery among Women. Zimbabwe. Central African Journal of Medicine, 47: 115–118.
3. Dunn T, Newell L,Ades E, Peckham S (1992) Risk of Human Immunodeficiency Virus Type 1 Transmission through
Breastfeeding. Lancet 340:585 588.
4. Chin, J (1990) Public Health Surveillance of AIDS and HIV Infections. Bull World Health Org 68 (5): 529-36.
5. Van de Perre P. Simonon A, Hitimana DG, Dabis F, Msellati P, et al. (1993).Infective and Anti-Infective Properties of
Breastmilk from HIV-1-Infected Women. Lancet; 341:914–918.
6. Featherstone C. M (1997) Cells: Portals to the Mucosal Immune System. Lancet, .350:1230.
7. Rollins N et al.(2001) Feeding Mode,Intestinal Permeability and Neopterin Excretion:A Longitudinal Study in Infants
of HIV-Infected South African Women. J Acquire Immune Def Synd, 28: 132–139.
8. De Paoli1 M, Manongi & R, Klepp K (2004). Are Infant Feeding Options that are Recommended for Mothers With
HIV Acceptable, Feasible,Affordable, Sustainable, and Safe? Pregnant Women’s Perspectives. Pub H Nut, 7 611-
619(9).
9. Coutsoudis A, Pillay K, Spooner E, Kuhn L, Coovadia H (1999) Influence of Infant Feeding Patterns on Early Mother
to Child Transmission of HIV-1 In Durban, South Africa: A Prospective Cohort Study. Lancet; 354:471-476.
10. Newburg,S.Viscidi RP,RuffA,Yolken R (1992)A Human Milk Factor Inhibits Binding of the Human Immunodeficiency
Virus to CD4 Receptor. Paediatr Res; 31: 22-28.
11. Nelson Mandela Foundation (2005) HIV Risk Exposure among Young Children. A Study of 2-9 Year Olds Served
By Public Health Facilities in the Free State, South Africa. Human Science Council. http://www.hsrcpress.ac.za/
Document-243.phtm
12. Nicoll A & Killewo, J (1991) AIDS surveillance in Africa. BMJ, 303(6811):1151-2.
13. DesclauxA (2004).PreventingTransmission of HIV through Breastfeeding: A Review of Knowledge and Experience.
Ester Scientific Council. www.ester.fr/snk_rc/snk_rc.enfiles/Allaitement.pdf. Accessed on 17.07.05.
14. Smith M, Kuhn L (2000) Exclusive Breastfeeding: Does it have the Potential to Reduce Breastfeeding Transmission
of HIV-1. Nutr Rev.; 58 (11): 333-40.
15. UNAIDS (2000) Men and AIDS a Gender Approach. UNAIDS www.UNDP.org/gendr/resources/UNDP_Men_
Masculinities.pdf. Accessed on 17.07.05.
16. Bredberg- Raden U, Urassa E, Grankvist O, et al (1995) Early Diagnosis Of HIV-1 Infection In Infants In Dar-Es-
Salaam, Tanzania. Clin Diagn Virol; 4:163-173.
17. Leroy, V Sakarovitch, C Viho, R Ekouevi, Bequet, L et al (2007) Acceptability of Formula-Feeding to Prevent HIV
Postnatal Transmission, Abidjan, Cote d’Ivoire: ANRS 1201/1202 Ditrame Plus Study. Acquir Immune Defic Sydr
Jan 1:44(1):77-86.
18. PhiriW.Kasonka L,Collin S Makasa M,Sinkala et.al (2006) Factors Influncing Breast Milk HIV RNAViral load among
Zambian Women. AIDS Jul:22 (7)607-14.
19. Sebire, K. McGavin, S. Land, T. Middleton and C Birch, (1998) Stability Of Human Immunodeficiency Virus RNA In
Blood Specimens As Measured By A Commercial PCR-Based Assay. J. Clin. Microbiol. 36:493-498.
20. WHO (2004) Scaling up Retroviral Therapy in Resource Limited Settings. Treatment guidelines for a public health
approach. www.who.int/medicines/organization/par/ed/expertnotes.shtml. Accessed on 17.07.05.
21. Wainberg M, Friedland G (1999) Public Health Implications of Antiviral Therapy and HIV Resistance. JAMA ;
279:1977-1983.
22. Robertson D, Anderson J and Bradac J. (2000) HIV-1 nomenclature proposal. Science; 288 (5463): 55-56.
23. Semba R. Kumwenda N, Hoover D,Taha T,Thomas C. et al. (1999) Human Immunodeficiency Viral Load in Breast
Milk, Mastitis and Mother to Child Transmission of Human Immunodeficiency Virus Type –1. J Infect Dis. 199,180
93-98.
24. WHO (2003) Global strategy for Infant and Young Child Feeding. Geneva, World Health Organization. www.who.
int/puyblications/2003/9241562218.pdf. Accessed on 17.07.05.
25. Clayden P (2004) Single-Dose Jeopardizes Long-Term Therapy. HIV Treatment. Bulletin, Vol 3-5.
26. Kuhn L, Abrams E, Matheson, P (1997) Timing of maternal-infant HIV transmission: associations between intra-
partum factors and early polymeraze chain reaction results. AIDS. 11: 429-435.
27. Grosskurth H, Mosha F, & Todd J (1995) Impact of improved treatment of sexually transmitted diseases on HIV
infection in rural Tanzania: randomized controlled trial. Lancet. 346:530-536.
28. McNeely T, Shugars D, Rosendahl M (1997) Inhabitation human immunodeficiency virus type 1 infectivity by
secretary leukocyte protease inhibitor occurs prior to viral reverse transcription. Blood; 90: 1141-9
29. Newell M (1998) Mechanisms and timing of mother-to-child transmission of HIV-1. AIDs.12:831-837.
30. Gordon M, Graham N, Bland R , Rollins N, DeOliveira T,et al (2004) Surveillance of resistance in KZN South Africa,
including mother-infant pairs six weeks after single dose nevirapine. XIII Intl Drug Resistance Workshop, Antiviral
Therapy; 9:S80.
31. Rousseau C, Nduati R, Richardson B, Steele M, John-Stewart G, et al (2003) Longitudinal analysis of human
immunodeficiency virus type 1 RNA in breast milk and of its relationship to infant infection and maternal disease.
Infect Dis, 187:741-747.
32. Safrit, J Ruprecht, R Ferrantelli, F Xue, W Kitabwalla (2004) Immuno-Prophylaxis to Prevent Mother to Child
Transmission of HIV-1.J Acquir Immune Defic Syndr 35: 169-77.
33. Bobat R, Moodly D, Coutsoudis A (1997) Breastfeeding by HIV-1 Infected women and out-come in their infants: a
cohort study from Durban, South Africa. AIDS; 11:1627-1633.
34. Spira R, Lepage P, Msellati P,Van de Perre P, Leroy V, Simonon A et al (1999) Natural History of HIV Type 1 Infection
in Children: A Five Year Prospective Study in Rwanda. Pediatriecs; 104:e56.
35. The Breastfeeding and International Transmission Study (BHITS) Group (2004) Late Postal Transmission of HIV-1
in Breastfed Children: An Individual Data Meta-Analysis. J Infect Dis; 189:2154-66.
36. Dallabetta G, Moiotti P, Chiphangwi J, et al (1995) Traditional Vaginal Agents Use and Association with HIV Infection
in Malawian Women. AIDS, 9: 2993-297.
37. Odoi A Brodly K & Elkans T (1997) Female Genital Mutilation in Rural Ghana,West Africa. Int J Gynecol Obstretrics,
1997; 56:179-180.
38. Jackson B,Musoke P,FlemingT,Guay L, Bagenda D,A et al.(2003) Intrapartum and Neonatal Single-Dose Nevirapine
Compared with Zidovudine for Prevention of Mother to Child Transmission of HIV-1 In Kampala, Uganda: 18 Month
Follow-Up of The HIVNET 012 Randomised Trial. Lancet. 362: 859-868.
39. Coutsoudis A, Pillay K, Spooner E, Coovadia, Pembrey L, and Newell M (2003) Morbidity in Children Born to HIV
Infected Women in South Africa: does mode of feeding matter? Acta Paediatr Scandinavica, 2003.92(8):890-
895.
40. Nduati R, Richardson A, John G. D. Mbori-Ngacha D,A. Mwatha A, et al. (2001) Effect of Breastfeeding on Mortality
Among HIV-1 Infected Women: A Randomized Trial. Lancet; .357: 1651–1655
41. Travengwa V, Piwoz G Illiff, J, Moulton H Zunguza D et.al (2007) Adoption of Safer Infant Feeding and Postpartum
Sexual-practices and their Relationship to maternal HIV Status and the risk of acquiring HIV in Zimbabwe. Trop
Med INT Health. Jan:12(1):97-106
42. De Cock K, Fowler M, Mercier E, De Vincenzi I, Saba J, et al (2000) Prevention of Mother-To-Child HIV Transmission
in Resource-Poor Countries: Translating Research into Policy and Practice, JAMA. 283(9):1175-82
43. Read S, Newell L, Leroy V, Dabis F (2003).Late Postnatal Transmission of HIV in Breastfed Children: An Individual
Patient Data Meta-Analysis (The Breastfeeding and HIV InternationalTransmission Study). Abstract 97,X Conference
on Retroviruses and Opportunistic Infections, Boston, USA, 10–14
44. WHO (2000) New Data on Prevention of MTCT of HIV andTheir Policy Implications.http://www.who.int/reproductive_
health/publications/new_data_prevention_mtct_hiv/identified_needs.en.html Accessed on 17.07.05.
45. Ruff, A, Coberly J, Halsey A, Boulos R, Desormeaux J, et al, (1994) Prevalence of HIV-1 DNA and P24 Antigen in
Breast Milk. J Acquir Immune Defic Syndr, 7:68–72.
46. Weiss H,Quigley M,Hayes R.(2000) Male Circumcision and Risk of HIV Infection in Sub-SaharanAfrica:A-Systematic

7. ANNALS OF THE ACTM 49
Review and Meta-Analysis. AIDS, 4: 2361-2370.
47. Simon F, Manclere P, Roques P, Loussert-Ajaka I, Michaela C.et al (1998) Identification of New Human
Immunodeficiency Virus Type 1 Distinct From Group M and Group O. Nat Med, 1032-1037.
48. Iliff P, Piwoz E, Tavengwa N, Zunguza C & Marinda E (2005) Early Exclusive Breastfeeding Reduces The Risk Of
Postnatal HIV-1 Transmission And Increases HIV-Free Survival. AIDS; 19(7):699-708.
49. Eshleman S, Becker-Pergola G, Deseyve M, Guay L; Mracna M. et al. (2001) Impact Of HIV-1 Subtype on Women
Receiving Single Dose Nevirapine Prophylaxis to Prevent HIV-1 Vertical Transmission (HIV Network for Prevention
Trials 012 Study). J Infect Dis.184: 914-917.
50. Wiktor,S.Ekpini,E,Karon,J.et al (1999) Short Course Oral Zidovudine for Prevention of Mother to ChildTransmission
Of HIV-1 in Abidjan, Cote D` Ivoire: A Randomized Trial. Lancet, 1999.353:781-785.
51. Gray G. The Petra study (2000) Early and Late Efficacy of Three Short ZDV/3TC Combination Regimens to Prevent
Mother to Child Transmission of HIV-1. X111 International AIDS Conference: 2000, Durban, South Africa.
52. McIntyre J,Martison N,Gray G et al.(2004)Addition of Short Course Combivir (CBV) to Single DoseViramune (Sdnvp)
for Prevention of Mother-To-Child Transmission of HIV-1 Can Significantly Decrease the Subsequent Development
of Maternal NNRTI-Resistant Virus. XV Intl AIDS Conference. Bangkok.
53. WHO (2004)”3 by 5” Progress Report, December. http://www.who.int/3by5/progressreport05/en/ Accessed on
17.07.05.
54. UNAIDS (2000) Collaboration with Traditional Healers in HIV/AIDS Prevention and Care in sub-Saharan Africa - A
literature review. http://www.UNAIDS.Org/WAC/2001/background.html. Accessed on 17.07.05.
55. Filteau,M,Rice J,Ball S,J Chakraborty,R Stoltzfus,et al.(1999) Breast Milk Immune Factors in BangladeshiWomen
Supplemented Postpartum with Retinol or B-carotene. Am. J. Clin.Nutr, 69: 953-958.
56. Fawzi W (2000) Nutritional Factors and Vertical Transmission of HIV-1: Epidemiology and Potential Mechanisms.
Annals New York Academy of Sciences; .918:99-114
57. AIDS (2004) Report on the Global AIDS Epidemic. 2004 http://www.unaids.org/bangkok2004/ Accessed on
17.07.05.
58. Bulterys M,Jamieson D,O’Sullivan M,Cohen M,Maupin R et al.(2004) Mother-Infant Rapid InterventionAt Delivery
(MIRIAD) Study Group. Rapid HIV-1 testing during labour: a multi-centre study. JAMA. ; 292(2):219-23.
59. Nduati R, John C, Richardson A. et al (1995) Human immunodeficiency virus type 1-infected cells in breast milk:
association with immunosuppression and vitamin A deficiency. J Infect Dis, 172: 1461-1468.
60. Rollins N, Meda N, Becquet R, Coutsoudis A, Humphrey J, et al. (2004) Preventing Postnatal Transmission of HIV1
through Breastfeeding: Modifying Infant Feeding Practices. J Acquir Immune Defic Syndr, 35(2): 188-195.
61. Palmer J,Validum L, Loeffke K, et al (2002) HIV Prevalence in a Gold Mining Camp in the Amazon Region, Guyana.
Emerg Infect Dis. (3): 330-1.
62. Alliance for Microbicide Development (2004) Microbicides in Development. Complete.ListingAlliance for Microbicide
Development web site. http://www.ipm-microbicides.org. Accessed on 17.07.05.
63. NADIC (2004)Traditional Healers and modern Practitioners together againstAids (THETA).UgandaAids Commission.
http://www.thetauganda.org. Accessed on 17.07.05.
64. Brahmbhatt R (2004) The Effects of Placental Malaria on Mother to Child HIV Transmission in Rakai, Uganda AIDS,
2003,17:2539-2541.
COMMENTARY:
leishmaniasis: a re-emerging
problem for travellers
Professor Peter A Leggat, MD, PhD, DrPH, FAFPHM, FACTM, FFTM
ACTM, FFTM RCPSG FACRRM, FSIA, FAICD, FACE, ACPHM CMSA
(Annals of the ACTM, 2007; 8,2:49)
Leishmaniasis is caused by a protozoan parasite transmitted by the bite of
infected female phlebotomine sandflies.There are several different forms,
but the most common is cutaneous leishmaniasis (CL). CL is increasing
being reported in travellers as they venture into endemic areas,1
in about
90 countries.2
Adventure travellers, humanitarian aid workers, military
personnel and long term travellers amy be particularly at risk.2
CL presents with skin sores, usually one or more chronic skin lesions
where sandflies have fed.It has been coined the“Baghdad boil”reflecting
the areas of operation where it is currently being encountered, including
southwest and central Asia,3
although the leishmaniasis is widely
distributed in other locations around India, the Mediterranean basin,
central Africa and South America. Skin lesions usually develop within a
few weeks of being bitten and are unresponsive to antibiotics or steroids.
Lesions commence as a papule then often enlarge and then ulcerate.They
can be painless or painful, especially if secondarily infected. The peak
sandfly period is April to November, peaking in September/October.
Diagnosis of CL is normally through a biopsy or skin scrapping.Treatment
is available,including sodium stibogluconate,2,4
but prevention is the best
65. Markus B & Fincham E (2000) Worms and Paediatric Human Immunodeficiency Virus Infection and Tuberculoses.
J Infect Dis. 181(5):1873.
66. Andrews K & Skinner- Adams T (2004) HIV Drugs Known as Protease Inhibitors also Protect Against Malaria. J
Infect Dis QIMR. Vol 190 p 1998–2000
67. WHO (2004) Prevention Research Linking Prevention to Access to Treatment. http://www.who.int/whr/2004/
chapter5/en/index1.html. Accessed on 17.07.05.
68. Kennedy J (2003) HIV in Pregnancy and Childbirth. BFM Pp1-7.
69. CoutsoudisA,Kubenden P,Spooner E,Coovadia H,Pembray L,Newell M (2005) RoutinelyAvailable Co-Trimoxazole
Prophylaxis and Occurrence of Respiratory and Diarrheal Morbidly Infants Born to HIV Infestive Mothers in South
Africa. SA Fr Med J. 95(5): 339-345.
70. UNAIDS, WHO (2004). AIDS Epidemic Update. www.unaids.org/wad2004/EPIupdate2004. Accessed on 17.07.05.
71. FHI UNAIDS (2004) Preventing Mother to ChildTransmission of HIV a Strategic FrameWork.www.fhi.org/en/hivaids/
pub/strat/mtctstrategy.htm. Accessed on 17.07.05.
72. UNICEF WHO (2004) Call for Stronger Support for the Implementation of Joint United Nations HIV Infant Feeding
Framework. New York and Geneva, December 22. Bull World Health Organ.; 68(5):529-36.
73. Sanne I, Mommeja-marin H, Hinkle J, Bartlett J, et al (2005) Severe Hepatotoxicity Associated with Norapine use
in HIV-Infected Subjects. J Infect Disae; 191:825-829.
74. B Bond G, Ndubani P & Nyblade L (2000) Formative Research on Mother to Child Transmission of HIV/AIDS in
Zambia. International Centre for Research on Women (ICRW) www.uncicef.org/evaldatabase/index_14401.html.
Accessed 17.07.05.
75. UNAIDS (2003) Accelerating Action Against AIDS in Africa. http://pdf.usaid.gov/pdf_docs/PNACU032.pdf Accessed
19.07.05.
76. Binswanger H (2000) Scaling Up HIV/AIDS Programs to National Coverage. Science; 288:2173-2176
77. MedleyA,Garcia-Moreno C,McGill S & Maman S (2004) Rates,Barriers and Outcomes of HIV Serostatus Disclosure
amongWomen in Developing Countries:Implications for Prevention of Mother-To- ChildTransmission Programmes.
Bull World.Health.Org; 82 (4): 299-307
78. Glynn J, Buvé A, Caraël M, Macauley I, Kahindo M, et al (2001) Is Long Postpartum Sexual Abstinence a Risk Factor
for HIV? AIDS: 2001.ol (8) 25 p 1059-1061.
79. Ritacco V, Di Lonardo M, Reniero A, et al. (1997) Nosocomial Spread Of Human Immunodeficiency Virus-Related
Multi-Drug-Resistant Tuberculosis in Buenos Aires. J Infect Dis. 176:637-642.
80. Cantwell M,Binkin N (1996)Tuberculosis in sub-SaharanAfrica:A RegionalAssessment of the Impact ofThe Human
Immunodeficiency Virus And National Tuberculosis Control Program Quality. Tuber Lung Dis.; 77:220-225.
81. Tess B, Granato C, Parry V, et al (1996) Salivary Testing for Human Immunodeficiency Virus Type 1 Infection In
Children Born To Infected Mothers In Sao Paulo, Brazil. Pediatr Infect Dis J, 15:787-790.
82. Panteleeff D, John G, Nduati R, et al. (1999) Rapid Method For Screening Dried Blood Samples On Filter Paper For
Human Immunodeficiency Virus Type 1 DNA. J Clin Microiol, 37:350-353.
83. Latif AS. HIV Infection and sexually transmitted infections in southern Africa. Annals of the ACTM 2002;3:4-13.
option.The following preventive measures may be useful and are mostly
directed at reducing contact with sandflies:stay in tight buildings,where
possible; spray out the accommodation area; permethrin impregnated
clothing to cover as much of the body as possible; diethyl methyl-
toluamide (or DEET) repellents; control of vermin and stray animals; and
fine mesh bed net soaked in permethrin. Sandflies are most active from
dusk to dawn.2
Other forms of leishmaniasis include the potentially disfiguring
mucocutaneous or mucosal leishmaniasis and diffuse cutaneous
leishmaniasis,primarily found in tropical SouthAmerica,as well as visceral
leishmaniasis (VL).Leishmaniases are regarded as a fairly heterogenous
collection of clinical diseases caused by many different species of
Leishmania,each with its own unique properties,including a fairly specific
geographical location.1
VL is the most serious form of leishmaniasis and
affects some of the body’s internal organs, most commonly the spleen,
liver and bone marrow. It usually takes several months to years develop
and may present with fever, weight loss hepatomegaly and significant
splenomegaly.2
VL is not common in travellers,2
but it has been reported
amongst soldiers deployed to Iraq and Afghanistan.5
Severe cases of VL
are typically fatal, if untreated.2
Leishmaniasis should be considered in those travelling to and returning
from endemic areas. Further information is available from the Centres
for Disease Control and Prevention.2
References
1. Magill AJ. Cutaneous Leishmaniasis in the returning traveler. Infect Dis Clin N Am 2005; 19: 241-266.
2. Centres for Disease Control and Prevention. Prevention of Specific Diseases (Ch 4): Leishmaniasis. In CDC Health
Information for International Travel 2008. URL: http://wwwn.cdc.gov/travel/yellowBookCh4-Leishmaniasis.aspx
(accessed 4 December 2007)
3. Anonymous. Update: Cutaneous leishmaniasis in U.S. military personnel-Southwest/Central Asia, 2002-2004.
MMWR 2004; 53(12): 264-265.
4. Minodier P, Parola P. Cutaneous leishmaniasis treatment. Travel Med Inf Dis 2007; 5: 150-158.
5. Myles O, Wortmann GW, Cummings JF, Barthel RV, Patel S, Crum-Cianflone NF, Negin NS, Weina PJ, Ockenhouse
CF, Joyce DJ, Magill AJ,Aronson NE, Gasser RA.Visceral leishmaniasis: clinical observations in 4 US army soldiers
deployed to Afghanistan or Iraq, 2002-2004. Arch Intern Med 2007; 167: 1899-1901.