Ending HIV Transmission to Children

Every child has the right to be born HIV negative, even though one or both of the parents may be living with the virus. According to the UNAIDS 2011 report, there has been a 50 percent decline in the number of new HIV infections in India, falling from 2.4 percent to around 1.21 percent in 2009.

Yet the world is far from achieving the UNAIDS goal of zero new infections, zero deaths and zero discrimination by 2015. These goals have been the center of scientific deliberations at the fourth National Conference of AIDS Society of India, which was held over the weekend at the Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow.

New HIV infections can be controlled to a large extent by preventing parent to child transmission of the virus during pregnancy, delivery or breastfeeding. Nearly 5 percent of infections in India are attributable to parent-to-child transmission. It is estimated that in 2009, fewer than 25 percent of the number of pregnant women living with HIV in India received anti-retroviral treatment to prevent parent-to-child transmission. The National AIDS Control Organisation confirms that 18,000 children were infected with HIV from the vertical route - parent to child transmission -- in 2009, although strategies to prevent them are very much available.

According to Dr. Ishwar S. Gilada, Secretary-General of the AIDS Society of India, "It is a shame for us that we cannot protect the rights and lives of our children. Zero new infections can become possible by preventing parent-to-child transmission, where one can have 100 percent prevention in the child. Each of these survivals would amount to saving 68 years of normal life, whereas by saving one adult we save only 10 to 15 years."

Hoosen Coovadia, Scientific Director of the Doris Duke Research Institute, Durban, also feels that the elimination of parent to child transmission of HIV is a realizable goal in developing countries.

"The effectiveness of parent-to-child interventions against HIV-1 is one of the greatest successes in the basket of prevention strategies used to control the HIV epidemic,” Dr Coovadia said. “The benefits of intervention programs directed at all three routes (in utero, during delivery, and postnatal during breastfeeding) of transmission of HIV-1 are evident in industrialized countries where transmission rates have fallen from about 25 percent to under 2 percent and survival of infants has increased. However in resource poor settings prevention services are often unavailable or inaccessible. The use of artificial milk formulas instead of breast milk to prevent postnatal HIV transmission, especially during the first six months of life is associated with growth failure, high morbidity, malnutrition and even death."

Dr Coovadia emphasized that: "It is not enough just to reduce parent to child HIV transmission rates, but it is equally important to increase the survival rate of infants. Children are not just dying of HIV but also due to malnutrition, diarrhea and pneumonia. Exclusive breastfeeding for the first six months (followed by non-exclusive breastfeed till 18 months) is critical to the issue of survival and health of the infants. One of the major advances made in recent years is in reducing HIV transmission through mother’s milk to very low levels of just 1 percent to 2 percent."

Dr Coovadia recommended a combination of two-drug therapy for preventing HIV transmission and improving survival - the drug Zidovudine, or AZT during pregnancy and Nevirapine during delivery and for about 10 days after. To reduce breastfeeding transmissions either the mother can be given highly active antiretrovirals, or Nevirapine can be given to the baby for about six months. He prefers the second option as it is better and more cost effective.

RR Gangakhedkar, Deputy Director of National AIDS Research Institute (NARI), an Indian Council of Medical Research (ICMR) institute in Pune, and Gilada also plead for a multidrug regimen instead of the outdated single dose nevirapine which is currently used in the Indian government’s parent to child transmission program. Gilada says sycg programmes are not very powerful in India and unless they shift to the two-drug regimen, it would be very difficult to achieve zero new infections. According to him a much better option is Lopanivar plus Ritonavir given in the last trimester for 6 to 8 weeks, which offers 99 percent protection.

Let us hope that the National AIDS Cotnrol Organization (NACO) would bring about a qualitative as well as quantitative change in its intervention programmes targeted at reducing transmission of infections to newborns. Of course, there is no single magic bullet to curb the epidemic at large.

So a cocktail approach will be needed, depending upon the targeted populations which could be as varied as male/female sex workers, innocent housewives, migrant laborers, injecting drug users, men who have sex with men.

But above all, we will have to bring about a social, economic and political improvement in the lives of women, so that they are able to exercise greater control over their sexual and reproductive health rights, and demand an end to the needless spread of this chronic infection.

(Shobha Shukla is the Managing Editor of Citizen News Service. Email: shobha@citizen-news.org, website: http://www.citizen-news.org)