By Usman Waheed, Technical Advisor-SBT Project, Ministry of Health, Islamabad
We are living in an “international” society, and AIDS has become the first truly “international” epidemic, easily crossing oceans and borders. AIDS is one of the most devastating entities that medical science has ever had to tackle. AIDS has become a pandemic now and was first reported in June, 1981. The causative agent HIV was recognized in 1983 by Luc Montagnier (won the 2008 Nobel Prize in Physiology or Medicine for this discovery). Different names were given to the disease initially such as lymphadenopathy, Kaposi’s sarcoma and opportunistic infections, GRID (Gay-related immune deficiency), and the 4H disease (haitians, homosexuals, hemophiliacs, and heroin users), But finally the name AIDS was introduced in July 1982. The HIV attacks the body’s immune system and leaves individuals susceptible to opportunistic infections and tumors.
More than 25 million people have died of AIDS since 1981. Globally, an estimated 33.4 million (range 31.1-35.8 million) people lived with HIV at the end of 2008, including 31.3 million adults and 2.1 million children under 15 years. The 2008 year also saw two million deaths from AIDS of which an estimated 280,000 were children under 15 years. More than 1,000 children are newly infected with HIV every day, and of these more than two thirds will die as a result of AIDS because of a lack of access to HIV treatment. Every hour, around 31 children die as a result of AIDS. About 9 out of 10 HIV positive children live in Sub Saharan Africa and globally most children (90%) get the infection during pregnancy, labour and delivery or breastfeeding from mothers with HIV. Almost all of these infections occur in low and middle income countries. It is crucial that safe infant feeding practices are established, that protect the infant against mortality and morbidity, and decrease mother-to-child transmission of HIV. Apart from inadequate funding, major obstacles in tackling the global AIDS epidemic include weak infrastructure of health services in most developing countries. Another hurdle is the stigma associated with AIDS which exists around the world in a variety of ways, including ostracism, rejection, discrimination and avoidance of HIV infected people. This sort of prejudice discourages people from seeking HIV testing, treatment and care.
Antiretroviral therapy (ARV) works very well for children. An estimated 200,000 children are on antiretroviral (ARV) therapy. Typically when three or four ARV drugs, are taken in combination, the approach is known as Highly Active Antiretroviral Therapy, or HAART. The death rate of children with AIDS has dropped after the HAART. Children immune systems are still developing, so they might have a better chance of fully recovering from damage caused by HIV. One of the greatest challenges when it comes to treating children with AIDS is loss to follow up. This is when a patient tests HIV positive but does not return to a health facility to receive treatment. Vitamin or mineral supplementation has shown benefit in some studies. Selenium can be used as an adjunct therapy to standard antiviral treatments, but cannot itself reduce mortality and morbidity. There is some evidence that vitamin A supplementation in children reduces mortality and improves growth also.
The ARVs are also given to mothers during pregnancy to eliminate the risk of transmission from mother-to-child. There are different classes of antiretroviral drugs that act at different stages of the HIV life-cycle and have led to dramatic advancements in life expectancy and quality of life for people living with HIV/AIDS. Where ARVs and good medical care for pregnant women are available, new infections of children are rare. The women in developing countries have certain responsibilities in addition to taking care of their children and had to travel from long distances for antenatal clinics, so most of the pregnant women don’t attend the clinics. Without treatment, around 15-30% of babies born to HIV positive women will become infected with HIV during pregnancy and delivery. A further 5-20% will become infected through breastfeeding. The prevention of mother-to-child transmission (PMTCT) services helps the mothers to safeguard their infants against HIV. The PMTCT services have scaled up and the proportion of women visiting PMTCT has increased from 15% in 2005 to 53 % in 2009. Women who are HIV positive should be encouraged to give birth at a clinic. The services should further be scaled up so that all pregnant women across the developing world must be tested for HIV. Under the July 2010 WHO guidelines on PMTCT, all HIV positive mothers, identified during pregnancy, should receive a course of antiretroviral drugs to prevent mother to child transmission. Effective communication about the PMTCT programme to potential beneficiaries, their communities, service providers, managers and policy makers is an essential element of the programme because the success of the program relies heavily on community support and mobilization.
It is very important that HIV infected children are tested at the earliest, so they can be provided with appropriate medication and care. The testing for HIV antibodies has been performed since 1985 and is useful in rapid field testing and also in antenatal clinics because they are easy to perform, and do not require expensive laboratory infrastructure, and obviate the need to process and store specimens and transport them from the field. Unprecedented number of kits is available for testing HIV antibodies. However, testing children for HIV can be complicated as antibody tests are ineffective in children below the age of 18 months. Instead, children below this age are usually diagnosed through polymerase chain reaction (PCR) testing and other advanced molecular techniques.
Although some tentative steps have been taken in the right direction, much needs to change in order to achieve parity in the standard of care for HIV-infected children. The effects of the HIV/AIDS epidemic on children are manifold. The prevention of HIV infection and relieving the impact of HIV and AIDS for children and their families and communities is possible through greater access to the drugs that can prevent mother to child transmission, appropriate testing and support for the families. There is also a need to assess the operational challenges inherent in the introduction of anti-retroviral regimen for the reduction of transmission in rural and urban settings. This is due in part because the introduction of ARV interventions needs to be accompanied by a series of other interventions such as the delivery of voluntary and confidential counseling and HIV testing, and revised obstetric practices and infant feeding practices. These require extensive capacity building, infrastructure development, improved management and community mobilization efforts. However, lack of resources for adequate testing, antiretroviral drugs, and prevention programmes, as well as stigma and discrimination, mean children continue to suffer the consequences of the epidemic.
References:
1. UNAIDS (2008) ‘Report on the global AIDS epidemic’.
2. UNAIDS (2009) ‘AIDS Epidemic Update’
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