analysisBy Kemi Yesufu
Abuja — The sight of Aisha Adamu (not real names), a woman living with HIV, breastfeeding her four-month old son in her office is probably one of the most gratifying moments for stakeholders in the national response to AIDS. Adamu's son is her second child after testing positive to HIV in 2005. Incidentally, the little boy like his two-year-old sister was born HIV negative.
Their mother is one of the beneficiaries of Prevention of Mother To Child (PMTCT) services provided at the Al Naori Specialist Hospital, Kano. PMTCT, which aims at curtailing pediatric AIDS, is done by eliminating the transmission of HIV from mother to child during pregnancy, labour and breast-feeding. PMTCT services commenced in Nigeria in 2001 in six tertiary health facilities. PMTCT service outlets have increased to 677 in 2010 across the country, with services in tertiary, secondary and a few primary health care facilities.
Adamu's story is a testament to the fact that with knowledge Nigeria can have generations that are HIV-free. The young mother in her 20s first heard of HIV/AIDS in her Islamic school. She told Daily Independent that she realised from the explanation of the team that visited her class that she had some of the symptoms of a person living with HIV. She had suffered months of coughing accompanied by fever and skin rashes. So she made her way to Al Naori Specialist Hospital where she was counselled and tested. Though her test came out positive, Adamu took the advice of her counsellors to live positively with the disease. She called her then boyfriend to come for a test. He did, but it turned out negative. Adamu repeated the advice of her counsellors to her boyfriend to let go of their relationship that she would look for another partner in her newly joined support group. But love won the day and this couple wedded and they have two children. As at the last time Adamu's husband carried out a test he remained negative.
Model clients like Adamu have in pursuance of the guidelines of the national response been integrated into the system with her employment as an adherence counsellor at Al Naori Specialist Hospital. Two other clients like Adamu earn a living at this PMTCT centre. As an adherence counsellor the young mother of two ensures that the 31 clients currently being treated in her Anti-Retroviral treatment centre adhere to all the instructions given them by medical personnel. Not just in Al Naori but also in other Kano PMTCT the success rates are high, thanks to mothers being adherent. Out of the 768 women that have benefited from services provided at Al Naori Specialist centre none had gotten her baby infected. Daily Independent also gathered that at Muritala Mohammed Hospital where PMTCT service was pioneered in Kano in the last one-year only one child out of the 66 babies born to women living with the virus tested positive. In the recently published national sentinel survey Kano State has a 3.4 prevalence rate that places it on the 22nd position out of the 36 states and the Federal Capital Territory (FCT).
Undoubtedly, the best part of the news about the battle against pediatric AIDs is that mothers can now breast-feed their babies without passing on the virus. Before now mothers who failed to breastfeed their babies were ridiculed and stigmatised in their communities. Some were forced by the mockery of others to breastfeed their babies with dire consequences. Development partners concerned about child survival such as UNICEF have never failed on calling on health professionals to encourage new mothers to breastfeed their babies exclusively for the first six months.
Despite the hesitation from mothers living with HIV, UNICEF has promoted breastfeeding as the best form of nutrition for the newborn. During the 2010 World Breast Feeding Day, UNICEF Country Representative, Dr Suomi Sakai, reiterated the stand of her agency. "Breast milk completely meets an infant's nutritional requirements, and protects babies from dangerous illnesses. Nothing protects a newborn's life better than exclusive breastfeeding for the first six months of life. Nothing protects a newborn's life better than exclusive breastfeeding for the first six months of life," she said.
WHO and UNICEF had in 1989 introduced the ten steps for breastfeeding adopted by more than 1,100 maternities in Nigeria, just as they called on every facility providing healthcare for pregnant women, new mothers, and newborns to, "Have a written breastfeeding policy that is routinely communicated to all health care staff. Train all health care staff in skills necessary to implement this policy. Inform all pregnant women about the benefits and management of breastfeeding. Help mothers initiate breastfeeding within 30 minutes of birth." They also counselled that medical workers should "Show mothers how to breastfeed, and how to maintain lactation even if they should be separated from their infants; give newborn infants no food or drink other than breast milk unless medically indicated; practice rooming in-allow mothers and infants to remain together 24 hours a day; encourage breastfeeding on demand; give no artificial teats or pacifiers (also called dummies or soothers) to breastfeeding infants; foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic.
UNICEF equally stated that the ten steps apply to mothers who are HIV-positive. UNICEF has supported the government of Nigeria, to pursue WHO guidelines, which seeks the exclusive breastfeeding among new mothers who are HIV-positive while providing them with antiretroviral drug therapy to reduce the risk of transmitting HIV through breast milk. Adamu in her work ensures that the WHO guidelines one in 2006 and another in 2010 which proposed starting ARV prophylaxis in the third trimester (28 weeks) of pregnancy, recommended regimen of twice daily zidovudine (AZT), single-dose nevirapine at onset of labour, a combination of AZT+3TC during delivery and one week postpartum, as well as infant prophylaxis for six weeks after birth is adhered to by mothers.
The 2010 guidelines include two options, both of which should start earlier in pregnancy, at 14 weeks or as soon as possible thereafter. The two options provide significant reduction in MTCT with equal efficacy in this group of women who are not eligible for ART. The first option is twice daily AZT for the mother and infant prophylaxis with either AZT or NVP for six weeks after birth if the infant is not breastfeeding. If the infant is breastfeeding, daily NVP infant prophylaxis should be continued for one week after the end of the breastfeeding period. The second is a three-drug prophylactic regimen for the mother taken during pregnancy and throughout the breastfeeding period, as well as infant prophylaxis for six weeks after birth, whether or not the infant is breastfeeding.
But with no less than 56,000 babies in Nigeria born with HIV and an estimated 360,000 children living with HIV in the country, most of whom became infected from their mothers, government must move fast to replicate the Al Naori success story. Aside from challenges, which include a weak health structure, majority of the PMTCT centres in the country are donor driven. In 2010 National Agency for the Control of AIDS (NACA) launched its comprehensive National Strategic Framework to cover 2010 to 2015, which requires an estimated N756 billion (around $5billion) to implement. Some of the aims included in the framework were to reach 80 percent of sexually active adults and 80 percent of most at-risk populations with HIV counselling and testing by 2015; ensure 80 percent of eligible adults and 100 percent of eligible children are receiving ART by 2015; and to improve access to quality care and support services to at least 50 percent of people living with HIV by 2015.
When Daily Independent spoke the National Secretary of the Association of Women Living With AIDS in Nigeria (ASWAN) Ester James on the way forward, she opined that government is doing its best in catering for needs of women living with the disease as well as reducing the number of females infected by HIV in the last two years. However, James who spoke on behalf of the association established in 2004 with over 180 support groups of women living with HIV across the country stressed that there was room for improvement still. She said, "So far so good, when it comes to PMTCT services. It will not be fair for me to condemn what government is doing. But what we are asking for is comprehensive PMTCT services. Recently, a colleague of mine was called up by the hospital where she accesses care and was told that she will pay for some services she joined others in fighting the levies because we all know that PMCT services are totally free in the country. Here in Abuja, from Asokoro (General Hospital) to Maitama (General Hospital) or National Hospital, not a single kobo is paid by pregnant women living with HIV. The only payment made by pregnant mothers living with AIDS is when they come down with opportunistic infections and this is what we want government to stop. If you say PMTCT services are free, why then should a mother pay to treat malaria?"
A large number of experts believe that an HIV free generation is integral for a developing country like Nigeria to make progress. The control of the spread of HIV is without a doubt important to achieving the Millennium Development Goals (MDGs). It is no gainsaying that government will be held accountable for its promise made by the Director General of NACA, Professor John Idoko, that it will take HIV care to the grass root. He said, "When I assumed office, the PMTCT coverage was 7 percent. It is now 23 percent after 18 months. The coming year it will be ramped up because we have more resources coming from the Global Fund, PEPFAR and the government of Nigeria. We hope to reach 30 percent at the PLWHAs this year and 50 percent end of next year. I am confident we will reach these targets as work of upgrading Primary Healthcare Centres and building the capacity of health care workers in various states have started by all the partners mentioned above. This will shift services to rural communities where 70 percent of Nigerians live." For many experts until the rural dwellers are fully catered for government will only be scratching the surface as it concerns the control of AIDS especially with regards to PMTCT service.