An estimated 3.4 million children are living with HIV – 10 percent of the global HIV-infected population although at the same time, the number of children newly infected with HIV has dropped drastically, by 52 percent between 2001 and 2012.
Yet, according to the UNAIDS Global Report 2013, only 34 percent of children under 15 in need of antiretroviral therapy in the world are actually receiving it. This is just half of the ART coverage for adults. The goal of an AIDS-free generation will require a major focus on elimination of HIV in children.
The challenges in reducing and managing of pediatric HIV infections were discussed at the 6th National Conference of AIDS Society of India, currently being held in Mumbai.
Mukesh Agarwal, Head of Pediatrics at GS Seth Medical College in Mumbai, said there are stumbling blocks in the wat of meeting global targets to reduce new pediatric infections by 90 percent; reduce Parent To Child Transmission to less than 5 percent at the age of 18 months in children who are breast-fed; provide anti-retroviral therapy to all HIV infected children; and reduce under-5 mortality due to HIV by 50 percent, 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 newborns stand an estimated 30 percent chance of becoming infected.
It is a scourge that is preventable 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.
Agarwal says the four main pillars/interventions on which effective pediatric HIV management rests are:
Prevention of parent to child transmission of HIV, early infant diagnosis (EID) of infection in HIV exposed infants, prevention and management of HIV-associated opportunistic infections, early initiation of antiretroviral therapy with regular followups.
Preventing Parent-Child transmission:
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. There are an estimated 2.75 million deliveries every year. The National AIDS Control Organization has a target to reach out to 9 million -- less than 33 percent of them -- in 2013. But as of now only 63 percent of the targeted number have been tested in antenatal care,. Of those tested 96 percent got prophylaxis. So though we have achieved a lot, a lot remains to be done still.
Major barriers: The main reasons for missed interventions are the high number of home deliveries, late ANC registrations, non-disclosure of HIV/risk status, voluntary nature of HIV testing in our public health program, limited awareness/testing facilities.
Early Infant Diagnosis:
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. According to the latest UNICEF factsheet only 3-7 percent exposed infants were tested within 2 months of age in 2012.
Major barriers: lack of coordination between various point-of-care agencies like obstetrician, pediatrician and ART centers, 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:
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 opportunistic infections, 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.
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. Under India’s National Pediatric HIV/AIDS Program introduced in 2006, access to treatment of children in need has increased from 6 percent in 2006 to 34 percent in 2011 (same as the global average) and currently 34,000 HIV infected infants are receiving free ART.
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.
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 pediatric HIV transmission to less than 2 percent 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 pediatric HIV is challenging but not unachievable.
(Shobha Shukla is editor of Citizen News Service.)