An end to parent-to-child transmission of HIV in Asia Pacific?

Eliminating new HIV infections in children and congenital syphilis is now a real possibility in Asia-Pacific. This is an exciting prospect that I would not have thought possible even five years ago. Advances in treatment and testing technologies, and above all, political commitment to scaling up the prevention of parent-to-child transmission (PPTCT) services, are bolstering the hope that an HIV and AIDS-free generation is within reach.

Last week, I attended the 9th Asia-Pacific UN PPTCT Task Force meeting in Kathmandu, Nepal. We heard remarkable national progress to battle new HIV and syphilis transmission in newborns, with Malaysia and Thailand leading the way. Parent-to-child transmission rate has been brought down dramatically to nearly 2 per cent in these two countries.

In addition, six countries in Asia-Pacific – Cambodia, China, Fiji, Malaysia, Sri Lanka and Thailand – have committed to eliminate both HIV and syphilis in newborns altogether. This new generation of children will have the chance to live lives free from HIV and syphilis.

Impact on lives

I have seen for myself the devastating impact of HIV and AIDS on children’s lives. Through my work for UNICEF, I have met many children infected with HIV or affected by AIDS. They start their life at a substantial disadvantage. In Thailand, I met 12-year-old Sombat (not his real name) who had to follow a regimen of multiple antiretroviral drugs every day, to control HIV in his body and fight emerging tuberculosis.

In China, I met a six-year-old boy who was rejected by his classmates because he was living with HIV, and was forced to attend class alone. When the school principal and teachers intervened, parents of other children threatened to withdraw their kids from the school.

I also came across many children who had lost both parents to AIDS. Jin-jin (not her real name), a 15-year-old in Guizhou, China, shouldered the care of her parents, who eventually died of AIDS from injecting drug use. She was attending to household chores in a dilapidated, mud-brick and almost barren home when I visited, her 11-year-old brother by her side.

The two children had no caregivers, only a distant uncle who came by once in a while. They were given some vital subsidies and money for school by the county government. These children are extremely vulnerable to abuse, exploitation, and emotional and physical injury.

 

A health worker speaks with two pregnant women about HIV/AIDS
as part of a UNICEF-supported programme in Papua New Guinea
© UNICEF/NYHQ2004-1228/GIACOMO PIROZZI

 

Big leap forward

Having co-managed the previous Task Force meeting in Laos with other UN partners in 2010, the commitment I witnessed in this meeting represented a big leap forward. At that time, we were merely exploring the possibility of eliminating new infections in newborns by introducing a conceptual framework. Nearly all countries in the region have now adopted national targets recommended in the framework.

Elimination of PPTCT, by definition, means a reduction of transmission rate to 2 per cent for infants who are not breastfed, or 5 per cent for babies who are exclusively breastfed for six months. Another way to measure this is to bring down incidence to 50 cases per 100,000 live births.

About 21,000 newborns in the region are infected with HIV each year. Another 25,000 are infected with syphilis transmitted from their mothers or die in the form of still birth. Without interventions, more than one-thirds of HIV infected babies die before their first birthday, and more than 50 per cent do not survive beyond two years old.

To reach the elimination target, a country has to treat at least 90 per cent of pregnant women tested positive. Because HIV does not affect the majority of people in each country, the challenge lies in finding the pregnant women who are infected. And the common public health approach is to test every pregnant woman.

For cost considerations, many nations in Asia-Pacific have chosen to combine HIV with syphilis test at antenatal clinics. Some have also included screening of maternal anemia and Hepatitis B. I was told by a number of participants at the meeting that the offer of a package of tests has not only helped detect more HIV positive cases among women, it has also reduced women’s fear of HIV-exclusive stigma.

For Cambodia, Fiji, Malaysia and Thailand, HIV and syphilis rapid tests are universally available – in nearly all antenatal clinics. China, after adding HIV to its on-going syphilis and Hepatitis B tests, has scaled up coverage to 75 per cent within a short time. The government has also substantially increased the budget for PPTCT in China.

With strategic expansion of testing comes the most crucial step – of treating pregnant women detected HIV-positive to prevent transmission to their child. Only 39 per cent of HIV-positive pregnant women in the Western Pacific and 16 per cent in Southeast Asia are receiving the most effective anti-retroviral (ARV) for PPTCT. Other challenges include dropouts, distance to hospitals and inadequate follow up.

PPTCT cuts across a wide range of services – from testing and counseling at antenatal clinics to initiation of antiretroviral therapy at the fourteenth week of pregnancy, to delivering the baby at designated sites. It also requires the mother to bring the child back for tests, including a virological test after six to eight weeks, with nutrition, infant feeding counseling and care. Human resources for these kind of activities are already overstretched and thinly spread.

 

In Papua New Guinea, a health worker discusses the advantages and risks
of breastfeeding with Tina, an HIV-positive new mother
© UNICEF/NYHQ2004-1229/GIACOMO PIROZZI

 

Towards global goals

With two more years to the end point of the Millennium Development Goals in 2015, the world community and the PPTCT Task Force, set up by UNAIDS in 2000 with UNICEF and WHO as joint secretariat, are tracking progress rigorously. The pace of decline is, however, slowest in Asia – at 12 per cent – compared to a 24 per cent global reduction.

“Improved coverage of HIV testing, availability of ARVs, and change in ARV guidelines to start treatment earlier in pregnancy are quickening the pace of decline in new infections in newborns globally,” said Craig McClure, UNICEF’s Chief of HIV and AIDS, at the meeting.

Countries with the political will and resources in Asia-Pacific are demonstrating that the target is achievable, whether by 2015 or 2020 or beyond. There is no question that PPTCT is a moral imperative that save lives and comes with long-term cost benefits. For me personally, it it is exciting to witness how elimination, which started out as a concept three years ago, is now actually happening on the ground in countries of this region.

The author
Wing-Sie Cheng is Regional Adviser, HIV and AIDS, for UNICEF East Asia and the Pacific

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