No excuse to not end HIV transmission to children

An estimated 3.4 million children are living with HIV, thus accounting for 10% of the total global HIV infected population. At the same time, the number of children newly infected with HIV dropped drastically by 52% between 2001 and 2012. And yet as per the UNAIDS Global Report 2013 currently only 34% of children under 15 years of age in need of antiretroviral therapy (ART) in the world are actually receiving it. This is just half of the ART coverage for adults. To reach the goal of an AIDS-free generation we have to focus on elimination of HIV in children.

The challenges in reducing and managing of paediatric HIV infections were discussed at the 6th National Conference of AIDS Society of India (ASICON 2013), which is currently being held in Mumbai.

Noted paediatrician of Mumbai and Head of Paediatrics Department, GS Seth Medical College Dr Mukesh Agarwal, gave an overview of the current situation in India and the stumbling blocks in meeting the global targets. The global targets are to reduce new paediatric infections by 90%; reduce Parent To Child Transmission (PTCT) to less than 5% at the age of 18 months in children who are breast fed; provide ART to all HIV infected children; and reduce under 5 mortality due to HIV by 50%, by the year 2015.

India has an estimated 220,000 children infected by HIV. Most of them (as elsewhere) acquire the infection from their HIV-infected mothers during pregnancy, birth or breastfeeding. UNICEF estimates that in India 55,000 to 60,000 children are born every year to mothers who are HIV positive.  Without treatment, these new born stand an estimated 30% chance of becoming infected.
We can prevent this by tackling HIV exposure in mothers. We have very good tools to prevent HIV exposure from becoming HIV infection and to prevent infection from progressing to the actual disease.

According to Dr Agarwal the 4 main pillars/interventions on which effective paediatric HIV management rests are:
(i) prevention of parent to child transmission of HIV (PPTCT)
(ii) early infant diagnosis (EID) of infection in HIV exposed infants
(iii) prevention and management of HIV-associated opportunistic infections (OIs)
(iv) early initiation of antiretroviral therapy (ART) with regular follow ups.

The international guidelines say: screen all pregnant women for HIV infection; start ART in infected ones as early as possible; and start ART prophylaxis in the baby.

Current status in India: There are an estimated 2,75,00,000 deliveries every year. The National AIDS Control Organization (NACO) has a target to reach out to 90,00,000 (less than 33% of them) in 2013. But as of now only 63% of the targeted number have been tested in antenatal care (ANC). Out of those tested 96% got prophylaxis. So though we have achieved a lot in PPTCT a lot remains to be done still.

Major barriers: The main reasons for missed PPTCT interventions are high number of home deliveries, late ANC registrations, non-disclosure of HIV/risk status, voluntary nature of HIV testing in our public health programme, limited awareness/testing facilities.

Early Infant Diagnosis (EID):
The international guidelines say: virological tests should be done for all exposed infants at 4-6 weeks, results should be available within 4 weeks, infants of mothers with unknown status should be assessed for exposure at all contact points including when they come for vaccinations, and all seropositive exposed children should be retested at 9 months.

Current status in India: As per the latest UNICEF factsheet only 3-7% exposed infants were tested within 2 months of age in 2012. 

Major barriers: lack of coordination between various point-of-care agencies like obstetrician, paediatrician and ART centres, missed postnatal follow-ups, limited awareness and poor laboratory facilities, screening is limited to high risk children, delay of 2 to 3 months in getting the report.

HIV associated Opportunistic Infections (OIs):
Opportunistic infections are an important cause of morbidity and mortality in HIV infected children. Most of them can be managed by simple prophylactic measures, early suspicion, timely diagnosis and therapeutic treatment. Prophylactic treatment should be started in all children as well as immunizations (including with special vaccines). However delayed diagnosis due to non- specific presentation of OIs, low immunization coverage even for routine vaccinations, poor follow up (especially in cases which are not on ART), and limited diagnostic facilities are major barriers in resource poor settings like India.

Early initiation of ART:
The international guidelines say: all children under 5 years should be immediately put on ART upon diagnosis in order to decrease rates of loss to follow up.

Current status in India: Under India’s National Paediatric HIV/AIDS Programme introduced in 2006, access to treatment of children in need has increased from 6% in 2006 to 34% in 2011 (same as the global average) and currently 34000 HIV infected infants are receiving free ART. Dr BB Rewari from National AIDS Control Organization (NACO) informed the ASICON 2013 delegates that NACO has revised the paediatric ART guidelines in the light of International recommendations of putting all children below under 5 years on ART. Dr Rewari said that paediatric formulation of tenofovir-based ART regimen however will be a challenge.

Major barriers:  availability, affordability, acceptance and palatability of formulations; treatment compliance, adverse effects, drug resistance; other health problems like nutrition.

More challenges ahead:
There are other issues too of social acceptance/care in the absence of parental disease, disclosure of disease, long term effects of the disease/treatment on nutrition, schooling and physical/mental health which will have to be kept in mind while tackling HIV infection in children.

Let us not forget that HIV-positive children born to HIV-positive parents are innocent sufferers of the tragic consequence of the HIV epidemic. We have the tools to bring down paediatric HIV transmission rates to less than 2% even when breastfeeding. Improved surveillance of pregnant women, strengthening of PPTCT and ART services, management of OIs and co-illnesses with adequate follow up to ensure compliance will help us achieve the goal of zero new infections in children at least. This requires combined and dedicated efforts of policy makers, health professionals, care givers, community and other stakeholders. Eliminating paediatric HIV is challenging but not unachievable.

Shobha Shukla, Citizen News Service - CNS
December 2013