Ethical, psychosocial and anthropological

1027 December 2013, Vol. 103, No. 12 (Suppl 1) SAMJ Women of advanced maternal age (AMA, >34 years old) are at an increased risk of having an infant with a chromosome abnormality, but only a minority of older South African women have access to genetic counselling and testing for such abnormalities during pregnancy. These women face difficult choices relating to their risks and options. AMA in itself may cause anxiety for women, but the HIV/AIDS pandemic in South Africa complicates their predicament. In the antenatal genetic counselling clinics held at three academic hospitals in Johannesburg, the percentage of pregnant women who are HIV-positive is increasing. For a pregnant HIV-positive woman to make fully informed decisions regarding her pregnancy and her reproductive choices, she needs to have a clear understanding of the impact of her HIV status on her own future health and that of her unborn infant. HIV is a retrovirus that is usually transmitted through sexual contact, but it can also be transmitted vertically from mother to child during pregnancy, at birth and through breastmilk. In developing countries, HIV is most commonly transmitted by heterosexual contact and by mother-to-child transmission (MTCT). The risk of MTCT depends on several factors, including maternal viral load and CD4 count, mode of parturition, and availability of antiretroviral treatment during pregnancy and delivery. The type and regimen of antiretroviral therapy (ART) also influences the transmission rate. South Africa, with only 0.7% of the global population, has 17% of the HIV/AIDS burden. As a result life expectancy has fallen from 62 years in 1992 to 50.5 years in 2007. However, it has been difficult to estimate the number of infected adults accurately. According to data extrapolated from antenatal surveys, the HIV prevalence rate rose from 1% in 1990 to 25% in 2000, and population incidence estimates range between 10.4 and 14.2%. According to Dabis and Ekpini, the MTCT rate in Africa ranges from 25% to 45%, with transmission dependent on maternal viral load and length of breastfeeding. The higher the maternal viral load, the greater the risk of intra-uterine and intrapartum transmission. Worldwide, approximately 600 000 infants are infected with HIV via their mothers each year. The infection accounted for 7.7% of all deaths of under 5-year-olds in sub-Saharan Africa in 1999, compared with 2% in 1990. In Africa there is more rapid progression from HIV to AIDS than in industrialised countries, as a result of poor baseline health, poor nutrition and ill-equipped health services. The World Health Organization has suggested the following strategies to reduce MTCT: prevention of new infections in adults; prevention of unwanted pregnancies; prevention of MTCT; provision of antiretroviral treatment to pregnant women in the peripartum period and to the neonate; and provision of care and support to HIVThe influence of HIV status on prenatal genetic diagnosis choices