Agnes Asiimwe
23 October 2008
analysis
Pregnant women are required to undergo an HIV test which is one of the ways to safeguard the unborn child from infection, but in Uganda, a lot has to be done given the low turn out at ante natal centres.
In developed countries, mother to child HIV transmission has been nearly eliminated through successful prevention measures, with the transmission rates reduced to one per cent.
In developing countries like Uganda, not only is mother to child transmission very high, but many of the infected children die of Aids because they don't have medicine. The latest statistics indicate that there are 55,000 children with advanced Aids in Uganda who will soon die due to lack of medical care.
In 2005, a number of non governmental organisations formed a global coalition, the Unite for Children, Unite against Aids to ensure that the next generation are born Aids free. The coalition has four goals known as the "Four Ps"; to prevent Mother-to-Child Transmission, provide paediatric treatment, prevent infection among adolescents and young people and protect and support young children affected by HIV and Aids.
Three years on, the coalition is nowhere near a breakthrough. Thousands of children are still being born infected with HIV. The anguish of some of those born in poor countries like Uganda is that they have to die after a short, painful decline.
Early infant diagnosis is a challenge because the majority of children under two years remains undiagnosed and they are not on treatment. Yet, without treatment, approximately half of the children born with HIV infection die by the age of two.
Medical experts say treating HIV infected children is more challenging because the disease is more aggressive in children than in adults. Although there is increasing availability of drugs for children, available antiretroviral medicines were initially developed for adults and most standard fixed dose combinations are inappropriate for children.
In some cases, children are often treated like small adults or excluded entirely. Doctors Without Borders (MSF) says that of the ARVs available in paediatric formulations, most are not suitable for use in poor settings. The drugs exist either as powders needing to be mixed with water, or as syrups often requiring refrigeration and have a bitter taste.
However, Dr Saul Onyango, the former national coordinator of the PMTCT programme at the Ministry of Health said medicine that required refrigeration has since been replaced with easier formulations.
The increasing availability of children's drugs has dramatically improved the children's life span. Thanks to breakthrough medicine, children (who are lucky to access medication) can live well into their adulthood as long as they properly take their prescription.
But scientists have now concluded that the end of the epidemic will not come through treatment but through the control of new infections. "We seem to be chasing a mirage, we need to stop new infections, not look for more drugs," said Dr Kihumuro Apuuli, the Director General of the Uganda Aids Commission.
Prevention of Mother To Child Transmission (PMTCT) is the key to stopping new infections in children. Positive children largely become infected from their mothers either during pregnancy, delivery or the breast feeding period. There are several reasons why African mothers pass on the virus to their unborn children more than their counterparts in the developed world.
Large numbers of women get pregnant when they do not know their HIV status. Very few pregnant women are being reached through antenatal because either the women prefer to visit traditional birth attendants or they cannot afford transport fare to the nearest health centre for antenatal care.
Its only at antenatal clinics that mothers can be informed of the need for HIV testing and thereafter get interventions for preventing transmission to their children. MSF estimates that only about 20 per cent of HIV-positive pregnant women are receiving ARVs for PMTCT in Africa.
Dr Onyango says 98 per cent of all mothers in Uganda attend antenatal at least once during their pregnancy. "Because it could be the last opportunity, women are immediately tested for HIV on their fist visit." The Ministry of Health policy is that every HIV positive woman gets enrolled for PMTCT. "But they come late, in the middle or last trimester of pregnancy."
A development expert from Harvard University told The Daily Monitor that abject poverty is blocking the progress of PMTCT in developing countries. Dr Jim Yong Kim, the director of Centre for Health and Human Rights at Harvard University and former director, HIV/Aids department, World Health Organisation said that by giving bus fare to mothers in Rwanda, PMTCT intervention actually went up.
"Every place we have looked where people are really poor, even if you say, here is a PMTCT centre, come and get the services, the poor woman who can't afford bus fare, who may have other children and can't afford child care for these children will not access these services," said Dr Kim.
"A lot of attention is being paid to changing the way pregnant women think so that they can change their mind and come to the services," he said. That kind of psychological model, Dr Kim says, of how things work is completely against what actually is the situation.
"Its not a matter of psychology, it's a matter of social structure and poverty that limits the women from being able to go, so we are arguing that you remove those structural processes, remove that poverty, even just a little bit and the women are much better to access services."
Dr Onyango said that in some districts like Kumi, 85 per cent of the population lives within five kilometres of a health centre. However, the more accessible Health Centre II, lack PMTCT services. Because the formulations are complicated, they can only be administered at the bigger Health Centre IV.
After a mother is identified, say at 28 weeks of pregnancy, she is given single-dose nevirapine or AZT. Methods applied in developed countries differ from those used in poor countries. In developed countries any pregnant woman who is HIV positive can receive full antiretroviral therapy throughout pregnancy, followed by formula feeding for the infant. The women in developed countries get three-drug combinations that usually include the more expensive protease inhibitors, instead of nevirapine.
The women in poor countries receive single-dose nevirapine which is less effective as a combination regimen. Onyango said single-dose nevirapine is easy to use and is better than nothing. "It's the drug that is more available, and one in which health workers are trained in administering. It's the most affordable and is able to stop the risk of transmission by half."
In one study in Mulago and Nsambya hospitals, after following up mothers between six weeks and six months, only 15 per cent of the mothers had infected children out of all that had been exposed. Previous studies have indicated, however, that the single-dose nevirapine could make the virus resistant to the drug.
If a mother successfully delivers a healthy baby, there is still the challenge of breast feeding. In Botswana, the government gives free formula to all positive mothers. In Uganda, where the government cannot afford to buy free formula, most mothers cannot afford replacement feeding and have no choice but to breastfeed or the child may still die of other infections. Mothers are advised to keep it short, at most not breast feed for more than six months.
Marion Natukunda, a programme officer with Mamas Club says a poor mother's biggest challenge is accessing the nearest health clinic "They prefer traditional birth attendants because they are nearer to them and that's what they can afford."
Mamas' Club is a group of HIV positive mothers who are expecting, breast feeding and have infants of up to three years. The club helps mothers to access medical care on time. "We have young mothers aged between 15 to 25 years and older mothers of 25 and above," said Natukunda. There are in the four districts of Masindi, Jinja, Mukono and Gulu and hope to expand to Mbale and Soroti soon.
The club, which takes on 50 mothers at a time, trains them in disclosure of their HIV status because the club is aware that fear of stigma keeps some mothers away from accessing treatment yet, for PMTCT to work, a mother must know that she is infected and not fear to seek treatment.
The club makes certain that mothers attend antenatal care that is well integrated with PMTCT and refers some of them to specialist organisations like Makerere University John Hopkins University and Paediatric Infections Disease clinic, both in Mulago, or attach them to a health clinic and may identify a health worker to attend to them.
Many of the mothers in the club have had children who are free of HIV. Mama's Club is a 2008 Red Ribbon Award winner for their work with positive mothers. All mothers need such practical interventions if an Aids free generation is to be a reality.
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