As we mark World Aids Day today, the HIV epidemic remains a serious health problem. The most vulnerable victims are children and the number of HIV-positive children is increasing. As long as they continue to get the virus from their HIV-positive mothers, the battle against HIV/Aids can’t be won. Therefore, the World Health Organisation (WHO) and other UN agencies have called for the elimination of paediatric HIV by 2015.
The threat of infection among infants in the Southeast Asia region highlights the need to strengthen primary healthcare services and address the issue of gender and stigma. The number of HIV-positive children has increased considerably over the past eight years — from 89,000 in 2001 to 130,000 in 2009. The nations in the region have also made progress in providing care: almost half of HIV-positive children have access to treatment, as compared to about a quarter globally. Why, then, has there been an increase in the number? The main reason is that the coverage of the prevention-of-mother-to-child transmission programme (PMTCT) for HIV is low. In the region, women constitute 37% of people living with HIV/Aids. Without any intervention, about a third of infants born to infected mothers may acquire HIV. The virus can be transmitted during pregnancy, delivery or breastfeeding.
There are several measures to reduce the transmission: HIV testing and counselling for pregnant women, antiretroviral (ARV) therapy for women and ARV prophylaxis during pregnancy, delivery and the post-partum period (including during breastfeeding), as well as safer delivery and infant-feeding practices. The key to ensuring that children don’t get infected is to offer pregnant women an HIV test so that if they are found to be HIV-positive, they can be provided care, PMTCT and treatment services. Strengthening primary healthcare services is a critical goal.
The PMTCT programme was started in India in 2001 following a feasibility study in six high-prevalence states. Between January and December 2009, 5.53 million pregnant women were tested, of whom 19,357 were found to be HIV-positive. Almost two-thirds of them received prophylactic treatment to prevent mother-to-child transmission. Yet, only a fifth of the estimated 27 million annual pregnant women in India were counselled and tested for HIV in 2009. WHO is providing technical support to the National Aids Control Organisation to increase access to such services. The national strategies to achieve this include a recent policy change so that HIV testing is routinely offered as part of the basic antenatal screening blood tests, and community-based HIV screening by auxiliary nurses and midwives to identify HIV-positive women among those who are pregnant but don’t visit health facilities.
HIV counselling and testing in primary healthcare centres is being undertaken in conjunction with the National Rural Health Mission to reach populations in individual districts. Greater involvement of accredited social health activists (ASHAs) is also being encouraged. Further plans include round-the-clock counselling and testing services in high-prevalence districts. Another strategy is to offer HIV screening to all direct walk-in emergency labour room patients with a user-friendly whole blood finger-prick HIV test.
The experience of Thailand, which has achieved universal access to an effective PMTCT programme, shows that this can be done with political commitment and leadership, a strategy based on scientific evidence and strong health systems. Thailand is the first nation in the region to integrate interventions to prevent mother-to-child HIV into its existing infrastructure of antenatal services in the early 2000s.
In 2010, WHO revised its guidelines for prevention of mother-to-child transmission. Studies in the past year suggest that antiretroviral therapy (ART) should start early in the course of disease in all patients, including infants under two years of age, for the greatest impact. Until recently, there were no strategies to prevent transmission of the HIV virus through breastfeeding, which accounts for almost half of all transmissions. But evidence shows that it can be prevented by providing either the mother or child with ARV drugs throughout the period of breastfeeding.
Ultimately, the epidemic of HIV/Aids can’t be dealt with in isolation. Experience from countries that have had the greatest success in controlling the epidemic, like India and Thailand, suggests that measures have to be an intrinsic part of primary healthcare services. Removing stigma and building stronger health systems and human resources are crucial to ensuring that HIV/Aids doesn’t destroy the lives of children even before they have begun.
(Samlee Plianbangchang is Regional Director, World Health Organisation, South-East Asia region)
*The views expressed by the author are personal