HIV: Mother-to-child transmission, a public health concern –Experts

The Prevention of Mother To Child Transmission (PMTCT) of HIV, which experts say is key to curbing the virus in children, has become an issue of public health concern. A recent workshop attended by APPOLONIA ADEYEMI on how to ensure sustainable progress in the prevention and management of HIV in children centred mainly on the modalities to reinvigorate and produce a work plan for stakeholders in the health sector

Decades after the first HIV infection was reported in Nigeria, curbing the transmission of the virus, particularly from among pregnant women to their unborn babies and the new born, remains a herculean task. Although global and national efforts to tackle the virus appear to have paid off, the progress nonetheless is slowing down again.

Today, the tragic impact of the coronavirus pandemic has contributed greatly to wane the fight against HIV/ AIDs in the country, leaving deaths and morbidity on its trail. HIV/AIDS also called human immunodeficiency virus causes AIDS and interferes with the body’s ability to fight infections. According to data from the Nigeria HIV/AIDS Indicator and Impact Survey (NAIIS) 2018, 1.9 million people were living with HIV in the country. However, a cursory look at the journey so far shows that Nigeria reported the first case of AIDS in 1986.

In 1991, the national HIV prevalence was 1.8 per cent. By 2001, it rose to 5.8 per cent and dropped to 4.4 per cent in 2005. It dipped further to three per cent in 2014. Furthermore, for individuals aged 15 to 64 years, HIV prevalence in Nigeria was 1.4 per cent, according to NAIIS. Although the above data indicated a drop in the spread of HIV infections, which is encouraging news, HIV experts and other care professionals fear that the impact of COVID-19, which disrupted services leading to lockdown last year, may ultimately erode previous gains in the first against the virus. How to ensure sustainable progress in the prevention and management of HIV was the focus of a three-day media dialogue to reinvigorate and produce a work plan for members of Journalists Alliance for the Prevention of Mother-To-Child Transmission of HIV/AIDS (JAPIN).

The event which took place in Calabar, Cross River State from October 11 to 13, was organised by the Child Rights Information Bureau (CRIB) of the Federal Ministry of Information and Culture in collaboration with UNICEF. The workshop, which brought together Journalists from Abuja, Lagos, and other parts of the country, has funding support from the Rivers State government.

The prevention of mother to child transmission (PMTCT) of HIV services, which is key to curb the virus in children, is domiciled in public health facilities, 59 per cent of pregnant women in the country deliver their babies at home and other unorthodox settings operated by traditional birth attendants (TBAs), a factor which automatically excludes them from the needed HIV preventive services. According to medical experts, while heterosexual sex still accounts for majority of HIV transmission in the country, over 90 per cent of transmission is contracted through unprotected sexual intercourse between heterosexual individuals.

Similarly, while it is estimated that men who have sex with men (MSM) only constitutes one per cent of the Nigerian population yet this group contributes 20 per cent of new HIV infections in Nigeria. However, another mode of contracting HIV which is the focus of this report is the method whereby the virus is transmitted from pregnant mothers to their children in-utero, during delivery or through breastfeeding.

In effect, an HIV-positive mother can transmit HIV to her baby any time during pregnancy, childbirth, or breastfeeding. Consequently, tracking HIV positive women during pregnancy has become a key strategy to prevent the virus from being transmitted to their babies.

In his presentation ‘Overcoming Barriers Towards Elimination of Mother To Child Transmission (MTCT) of HIV,’ an Assistant Director, National Prevention of Mother-To-Child Transmission (PMTCT) Lead at the National AIDs & STIs Control Programme (NASCP), Federal Ministry of Health (FMoH), Dr. Olugbenga Ijaodola, said the Prevention of mother to child transmission of HIV (PMTCT) of HIV is delivered through Maternal Newborn and Child Health (MNCH) services in public health facilities; the MNCH coverage is therefore critical. However, as important as this service is towards the prevention of HIV in children, “two-thirds of expected pregnancies are not captured in the PMTCT reporting system, resulting in over 90 per cent of the pregnant women not showing up at health facilities reporting PMTCT to get tested for HIV, Ijaodola said. According to him, it has therefore become necessary to remove such barriers hindering pregnant women from accessing PMTCT services. Ijaodola explained that HIV positive pregnant women must be placed on HIV treatment and encouraged to deliver in health facilities.

“This will ensure that HIV positive babies are identified on time and treated,” he added. Although the PMTCT services are domiciled in public health facilities, baby delivery for 59 per cent of pregnant women in the country doesn’t take place in health facilities, a factor which automatically excludes them from the needed HIV/AIDs preventive services. Data from the National Demographic Health Survey (NDHS) 2018, shows only 39 per cent delivery occurs in health facilities. Ijaodola said: “HIV intervention cannot stand on its own. It also depends on the health system of any particular country.

What we are planning is that irrespective of any challenge we are facing in any healthcare system we must always ensure that we are able to have access to pregnant women and test every one of them for HIV. “Those we find to be positive are put on treatment and encouraged to deliver in health facilities so that we can have access to their babies for early infant diagnosis services. This is the message we want disseminated to all stakeholders.”

The obstacles preventing operators of HIV preventive services from taking advantage of this strategy is that more pregnant women chose to deliver elsewhere except in health facilities. While highlighting some of the benefits of using TBAs to take delivery, women who have used their services pointed out that they are easily accessible, cheaper than institutional care services, provide efficient and quality care; provide support which includes referrals and transportation to facilities, and treatment adherence support.

For those who deliver at home, poverty is the most frequently cited reason for preferring home delivery. Other major reasons include; traditional views, religious fallacy, poor road conditions, limited access of women to decision making in the family, lack of transportation to reach the nearest health facility, among others.

To corroborate the position that delivery by fewer pregnant women takes place in health facilities, Ijaodola lamented that three in four pregnant women in Nigeria are not captured at antenatal care and 63 per cent of HIV positive women in the country do not access PMTCT services. He however recommended that Nigeria must work towards eliminating user fees in public facilities for pregnant women “by strengthening the National Health Insurance Scheme (NHIS)/State Health Insurance Schemes (SHIS) to include PMTCT/Reproductive Maternal Newborn Child Adolescent Health plus Nutrition (RMNCAH) into the benefit package, using the Basic Health Care Provision Fund (BHCPF).”

Similarly, the assistant director called on various state governments to intervene through the procurement of Rapid Test Kits (RTK) for HIV testing to be used majorly by pregnant women as a strategy to expand this process to include more women in rural areas. Considering that Nigeria contributes 22,000 new HIV infections among children, Ijaodola said it has become necessary to strategise on tracking pregnant women in the country and ensuring that they are assessed while those that test positive for HIV are placed on treatment. He said areas of focus in reversing the trend include: low uptake of ante-natal services by pregnant women; low uptake of early infant diagnosis services; low Anti-Retroviral Therapy (ART) coverage for positive pregnant women; low rates of facility deliveries; and ensuring that operators of HIV care services are getting their numbers right with a view to capturing available data for planning purpose.

To this end, he recommended that another key strategy would be finding pregnant women wherever they may be including public and private facilities that are reporting PMTCT data, facilities that are not providing PMTCT services and facilities providing PMTCT but not reporting them. In addition, Ijaodola stressed that pregnant women must be sought from unskilled service providers and in traditional settings that do not provide ante-natal care (ANC) services but take baby delivery. All these activities are geared towards tracking the pregnant women to avert missing those living with HIV but not on treatment.

On its part, the Federal Ministry of Health has also come up with a specific programme that would pave the way for the success of tracking pregnant women. The ministry has urged states to establish and own state-led PMTCT programmes as a way to reach pregnant women in far-to-reach areas of their states.

He also called on states to be consistent and dogged in implementing state PMTCT programmes so as to ensure that no HIV-positive pregnant or breastfeeding woman is left behind. Speaking on the way forward, Ijaodola said it was important to recognise the importance of working with all actors including MNCH care givers, private providers, TBAs, community leaders and the networks of People Living With HIV (PLHIV).

On her part, a Chief Consultant/Associate Professor in Infectious Disease and Respiratory Diseases, Dr. Etana Ewa, who is also the paediatric focal person ART/PMTCT at the University of Calabar Teaching Hospital (UCTH), lamented that HIV/AIDS is a major cause of infant and childhood mortality and morbidity in Africa.

Globally, out of the estimated 37.9 million persons living with HIV/AIDS, he pointed out, 1.8 million are children under 15 years. She charged media practitioners to intervene promptly in the suspected HIV/AIDS cases involving children in their communities. “I see journalists as advocates and counselors and that means once you see a child losing weight or a child who is too weak, you need to speak lovingly to the parents; and encourage them to access a health facility. Any health facility that sees such a child should do a HIV test and we move from there.

“The good news is that there are drugs to administer after a positive test result; a lot can be done as these drugs improve the survival of the children infected with HIV. All we are targeting now is to reduce the viral load and improve survival for these children until we have a cure for them and be assured that the drugs work. We need to encourage the people we meet in the communities,” he said.

However, viral load gives an idea of how much of HIV virus is in the body; the viral load test measures the number of HIV copies in a milliliter. In effect, a high HIV viral load generally indicates HIV is present and replicating. The higher a person’s viral load the higher their risk of developing health conditions associated with AIDS. According to HIV. gov, viral load is typically undetectable below levels of between 40 and 75 copies/ mL.

In her presentation, ‘Managing Children and Adolescents Living with HIV,’ Ewa said identifying HIV in children requires a high index of suspicion. “Usually the symptoms and signs of HIV infection in childhood are similar to those of other diseases seen in the tropics; but they may be more severe and occur more frequently.”

The common conditions associated with HIV are frequently infectious in nature. And the management of HIV/ AIDS normally includes the use of multiple ART in an attempt to control HIV infection. There are several classes of ART agents that act on different stages of the HIV life-cycle Ewa said HIV infected persons must be administered with ART, adding that the treatment with the drugs inhibits the ability of HIV or other types of retroviruses to multiply in the body.

He said: “The thing is, some people cannot eat, but once they start these ART drugs their appetite improves. So, the problem is, if you’re poor, you won’t have needed funds to purchase the variety of needed foods, but a lot of organisations are around to help and nothing stops those who can afford to give out from helping: sometimes a bag of beans, rice or groundnut oil can help while reaching out to some persons in the HIV community.” She added that there are food supplements that some people give them freely.”

The paediatric focal person on ART/ PMTCT at the UCTH also highlighted that there are many giving charity freely to people in the HIV community; they are helping mothers to start trade. They’re also helping children to pay for the Joint Admissions and Matriculations Board (JAMB) forms. Responding to reports about the possibilities of some ART drugs being harmful to human body organs, Ewa explained: “We don’t joke with those drugs. What we do is that as they come, we do blood tests to monitor the impact of the medicine. When the persons living with HIV come in six months we do blood tests.

So, these tests help us to tell if the kidney or liver is failing. “We just don’t give the drugs and walk away. We monitor them. Anyone that has a problem with the drugs we change his/ her medication. But most people don’t have a problem. It’s just a few that have problems with the ART, but we promptly identify them and change their medicine.” Without the administration of ART on persons living with HIV, it may be difficult for them to live normal lives. ART prevents the virus from multiplying, which reduces the amount of HIV in the body and thereby gives the immune system a chance to produce more CD4 cells.

CD4 counts show the robustness of the immune system. A healthy immune system normally has a CD4 count ranging from 500 to 1,600 cells per cubic. Acceptable levels: 500–1,500 cells/mm3. Speaking further on the role of journalists, Ewa said she perceives Journalists at the JAPiN forum as advocates.

“I see them as counselors. So, that means that once you see the signs, or see a child losing weight, or see a child who is too ill, you need to speak lovingly to the parents and encourage them to assess a health facility. “Any health facilities that see such children will do a HIV test and then we move from there. And the good news is that there are ART drugs to administer on the child after the positive test. A lot can be done. And this drug improves survival.”

Ewa stressed that all HIV care givers “are targeting now to reduce the viral loads and improve survival for the children until we have a cure for them. The drugs work and we need to encourage the people we meet in the community.” Speaking further on the challenges of curtailing the spread of HIV is the level/ rate of secrecy, Ewa called for more sensitisation. “To be honest with you, just keep speaking; then teach people how to disclose their HIV status. Partners should disclose to partners; parents should disclose to children.

“We know that there is a lot of guilt-feelings surrounding HIV. But with speaking out and sensitisation, we’ll know over time that HIV is just another disease.” While highlighting the importance of people living with HIV being administered with ART, he said those who take the ART drugs are healthy. “We monitor them in cases of any opportunistic illness and we’ll treat the conditions.” She urged those who do not disclose their status: “Don’t hide it anymore. People are hiding children because of HIV. Do it no more. Bring them out; many health facilities will do HIV testing and will move from there.

Reacting to why the country still face problems hindering PMTCT of HIV, a Public Health Physician, Dr. Doyin Odubanjo, said: “Simply, we need to fix the primary health care system which is the closest to the people and will be most effective in getting to them and ensuring they are captured by all necessary health programmes.” Odubanjo, who is also the executive secretary, Nigeria Academy of Science, added, “We must cascade downwards the management of all diseases to that level even if all that will be done at the PHC is to identify those needing a particular service and ensuring that they are effectively referred to where they can access the service. Until we do that, we will simply just be talking and will continue to miss out on many patients.” In his own view, a Consultant Paediatric Hematology Oncologist, Prof. Edamisan Temiye, said that the lack of progress in PMTCT of HIV in the country.

“The major issue is that governments at every level are not putting in enough effort to solve the problem. The governments are waiting for donors to come and help them solve the problems. “They are unwilling to put their money where their health is; they want people and International agencies to be donating to them and they are not putting enough money in healthcare delivery.

These are major issues for us,” said Temiye, who manages children living with HIV and cancers at the Lagos University Teaching Hospital (LUTH), Idi-Araba, Lagos. Temiye said that the technology, PMTCT of HIV, has been available since the 1980s, and yet the country is not making progress from using the therapy. According to him, in developed countries today it is like a crime to allow a woman to go through pregnancy without knowing his status and then the baby gets infected. That doctor or that healthcare delivery system that took care of that person will be in trouble because it is possible to completely prevent mother to child transmission of HIV and the means to do it is cheap. Yet the governments are unwilling to drive the system, he said.


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