Giving Hope to the Children

Imagine a scenario where for every hundred newborn babies, more than 2 of them are HIV infected. Depending on where you are in the Caribbean, that, in fact, is the reality. It is actually the mother-to-child transmission of HIV statistic for Guyana for 1999.

Incorporated into a bigger picture for the same year profiling additionally three other countries of the English-speaking Caribbean - Trinidad and Tobago, Jamaica, and Belize - the rate of HIV infected babies ranged from five to 21 per 1000 live births.

AIDS IN CARIBBEAN CHILDREN

AIDS in children living in the Caribbean is always a direct consequence of sexual transmission in women and should be seen as a subset of the epidemic in women. Mother-to-child transmission (MTCT) now accounts for 6% of reported AIDS cases (1998), and it is established that MTCT rates are, on average, 28% with a range of 26% to 30% in the Caribbean.

From many studies conducted worldwide, the rate of MTCT of HIV1 ranges from 13 per cent to 48 per cent. Two thirds of this transmission occurs in the pre-natal and intra-partum periods and one third in the post-partum period due to breast-feeding.

Women are more at risk dependent on their degree of maternal immune deficiency and increased maternal plasma viral load, either new infection or late stage of HIV, and incorporating prevalent endemic diseases and mastitis. Other risk factors include low maternal CD4 cell count, low maternal serum Vitamin A concentration, prolonged labour, chorioamnionitis, vaginal or traumatic delivery, presence of other sexually transmitted infections, HIV biological phenotype and sub type, and premature rupture of membranes, prematurity and breast-feeding.

In 1999, with an HIV prevalence among pregnant women of 2% to 3% in the region, the Caribbean Epidemiology Centre (CAREC) estimated that between 2,600 and 3,900 infants were born to HIV infected mothers in this part of the hemisphere. Taking into account a mother-to-child transmission rate of 30%, this means that between 780 and 1,170 infants, or 2 to 3 infants daily, were infected in the region during that year.

TREATMENT: A SUCCESS STORY

But there is a bright side to this grim scenario. Treatments on the basis of international experience are now available. These have been shown to reduce the transmission of HIV from an infected mother to her child by between 51 and 66 per cent. Caribbean countries are being urged to capitalize on these gains that have been realised in several countries, including closer home in the Bahamas.

The requisite action includes the admission of anti-retroviral drugs to women during pregnancy, delivery and in the postnatal period. With studies showing that breast-feeding also accounts for close to one-third of the number of newborns infected by the virus from their mothers, avoidance of breast-feeding is also prescribed as an essential part of the regimen.

In the specific case of the Bahamas, after voluntary counselling and testing, women visiting antenatal clinics and testing HIV positive or found to be already AIDS infected were offered AZT (zidovudine) regardless of their CD4 (T-lymphocytes) count levels. These mothers received AZT treatment from the 14th to the 34th week of their pregnancy. They were also administered AZT during labour, and their newborn given AZT syrup for six weeks. Mothers were also made to avoid breast-feeding, receiving instead infant formula for their babies.

All of this was part of an integrated approach to HIV/AIDS prevention and care, which the Bahamas government adopted during 1994 and 1999. The approach also encompassed a range of mass information, education and communication interventions for behaviour change, including promotion of condom use; voluntary counselling and testing; and a programme for clinical management of all adult AIDS patients.

Now the Bahamians have begun to reap the rewards of their labour:

 the rate of transmission of HIV from mother to child has dropped by more than half, from 28 per cent to 12 per cent;

 the number of reported AIDS cases in children dropped from 20 to 6 over 1997-1998;

 the number of reported HIV cases has been reduced by 48 per cent;

 AIDS cases decreased by 17 per cent between 1995 and 1998;

 AIDS deaths consistently decreased from 221 to 162 over the same period; and

 the child mortality rate dropped from 2.8 in 1994 to 1.1 per 1000 live births in 1996.

The Bahamas’ achievements have been regarded as a major Caribbean success story in the region’s battle against the HIV/AIDS epidemic, and the country’s approach recommended as an international best practice for replication, not only here in the region but in the wider world.

CAREC, which has been in the forefront of recommending guidelines for the implementation of such programmes in the region, estimates that such replication could prevent between 360 and 540 new infections among children annually in the Caribbean.

THE DILEMMAS

The use of anti-retroviral treatment (AZT or Viramune) only during pregnancy has given rise to several questions, including concerns about the safety of the women. CAREC recommends in any case that the treatment should be offered under informed consent, and the minimum package of standard of care should be offered to every pregnant mother who participates in the programmes for reducing mother to child transmission of HIV.

There are no major side effects or physiological anomalies detected among women exposed to anti-retrovirals during their pregnancy, neither has there been any worsening of their prognosis in terms of the natural history of the disease. In countries where anti-retroviral therapy exists, CAREC recommends that pregnant women benefit from that therapy immediately after diagnosis or after delivery depending on the national policy in place.

Another important dilemma surrounds the future of the child, since, in the majority of cases, children born to HIV positive mothers will become orphans. Therefore, CAREC recommends that social structures be put in place to take care of these children. Scientific studies have shown that the absence of these structures can seriously compromise the life expectancy and survival of these orphans. This absence can erode gains realised through the use of anti-retroviral therapy because child mortality among children born to HIV + mothers will remain the same as it was before the introduction of this preventative measure.

CAREC has sent its guidelines for programmes aimed at reducing mother to child transmission of HIV to all of its member countries, and has also begun assisting and even partnering some of them in staging workshops and other activities to point the way forward.

Among reported AIDS cases in children in the region, more than 95% are due to mother to child transmission of HIV, underscoring the importance of instituting these programmes as a major public health priority for the Caribbean.

Dr Bilali Camara is the Head, Special Programme on Sexually Transmitted Infections at CAREC Jones P. Madeira is the Information Adviser, Special Programme on Sexually Transmitted Infections at CAREC