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By Ogechukwu Agwu
One of the most common ways through which Human Immuno-deficiency virus (HIV) is spread is the Mother to child transmission. This is the spread of HIV from an HIV infected woman to her child. The ways in which this happens is during pregnancy, childbirth (also called labour and delivery) and breastfeeding.
Mother-to-child transmission (MTCT), which is also referred to as ‘vertical transmission’ or ‘perinatal transmission of HIV’ accounts for the vast majority of new infections in children. Around 1.6 million new HIV infections among children have been prevented since 1995 due to the implementation of prevention from mother –to – child transmission (PMTCT) services. Of these, 1.3 million are estimated to have been averted in five years, between 2010 and 2015. Despite this significant progress, in 2015, 23 per cent of pregnant women living with HIV did not have access to antiretrovirals (ARVs) and 150,000 children (400 children a day) became infected with HIV.
Between 2009 and the end of 2015, there was a 60 per cent decline in new HIV infections among children in the Global Plan priority countries, from 270,000 to 110,000. According to the World Health Organisation (WHO), “this compares to a fall of just 24 per cent between 2000 and 2008, meaning that the rate of the decline in new infections since the launch of the Global Plan nearly tripled. Without Nigeria, the remaining countries reduced new HIV infections by 69.29 per cent.
“While this progress is encouraging, it is significantly below the 90 per cent target. However, some countries got close to this target including Uganda (86%), South Africa and Burundi (both 84%). Botswana, Burundi, Namibia and Swaziland had fewer than 1,000 new infections in 2015. These are small enough numbers that, with determined efforts, could be reduced dramatically.
“At the other end of the scale, Angola and Cote d’Ivoire have experienced less than a 40% decline in new HIV infections among children since 2009. East and Southern Africa is the region to have made the most significant progress on mother-to-child transmission (MTCT). In 2015, 6% of infants born to mothers living with HIV acquired HIV, compared to 18 per cent in 2010, this is a threefold decline.
“Although West and Central Africa has seen a 31% reduction in new child HIV infections between 2010 and 2015 it has made less progress than East and Southern Africa.”
In 2001, the Prevention of Mother-To- Child Transmission of HIV commenced in Nigeria in six tertiary health centres. At the end of 2014, about 6,546 facilities comprising of tertiary, secondary and primary health care centres were providing PMTCT services.
Even though it seems like there has been significant progress in reducing new HIV infections among children, the progress has not been fast enough to meet up with the global targets at eliminating new infections of HIV in children, the effort made has not been enough to prevent and eliminate HIV infections in children.
Nigeria still has the highest number of children acquiring HIV infections, in 2012 the figure was 60,000 and the figure has remained unchanged.This figure contributes about one third of new HIV infections among children in the 21 HIV priority countries in sub Saharan Africa.
WHO stated that, “In Nigeria, new child HIV infections have declined by just 21 per cent between 2009 and 2015. In 2015, an estimated 41,000 children became infected with HIV in the country, the same number as the next eight countries combined.”
PMTCT is the elimination of new infections among children, this intervention to ensure that no child is born with HIV is essential step to ensure an AIDS free generation. The PMTCT initiative provides drugs, counseling and psychological support to mothers to safeguard their infants against the virus.
This is why a great deal of importance is placed on the Prevention of Mother to child transmission (PMTCT) of HIV; this isbecause most of the cases of HIV infection in children come from vertical transmission of the HIV virus from the infected mother to her child.
The infection can occur while the unborn baby is still in the womb (Trans placental route), during child birth process due to the contact with the infected blood and fluids from the mother and finally through breast feeding via the virus in the breast milk.
While referencing Integrated National Guidelines for HIV Prevention, Treatment and Care 2014 DrAkaninyeneUbom, a medical consultant posits that the Prevention of Mother to Child transmission of HIV can be approached in four different ways and they include;
Prevention of HIV in women
The prevention of HIV infection in women of reproductive age and their partners includes a targeted education and information including using the ‘ABC’ approach to enhance safer and responsible sexual behaviour and practices which covers delaying the onset of sexual activity until marriage, practicing abstinence, being faithful to one uninfected partner, consistent and correct use of condoms. Provisions of early diagnosis and treatment of sexually transmitted infections, making HIV counseling and testing widely available and provision of appropriate counseling for HIV negative women.
Prevention of unwanted pregnancies
Prevention of unwanted pregnancies in HIV in infected women include the following : providing good quality, user- friendly and easily assessable family planning services so that HIV positive women can avoid pregnancy if they choose to, promoting condom use (male and female) combined with a more effective method of contraception (dual method) for dual protection from HIV and other STIs and from unplanned pregnancies as an effective strategy to prevent HIV infection. Integrating dual protection messages into family planning counseling services, offering contraception to all HIV positive mothers in the immediate post delivery period to prevent unintended pregnancy because lactation amenorrhea (absence of menses due to breastfeeding) does not guarantee adequate contraception even in women who exclusively breastfeed.
Prevention of mother-to-child transmission of HIV
Prevention of mother-to-child transmission of HIV includes HIV counseling and testing for all pregnant women at booking for antennatal care, administration of antiretroviral treatment for all HIV positive pregnant women who are eligible for such treatment for their own disease, administration of antiretroviral prophylaxis to mother- child pair for women not eligible for antiretroviral treatment for their own diseased, modification of obstetric practices as pertains pregnancy, labour and delivery management, infant feeding counseling for HIV infected mothers. Options include exclusive breastfeeding for 6 months with introduction of complementary feeds thereafter and weaning babies of breast milk at 1 year of age or exclusive use of infant formula. Mixed feeding (i.e. breastfeeding and infant formula) is not encouraged).
Provision of care and support to PLWHA
Provision of appropriate treatment, care and support to HIV infected mothers, their infants and family include : package of services for mothers like antiretroviral treatment for eligible women; cotrimoxazole (septrin) prophylaxis; tuberculosis screening, prophylaxis and treatment, sexual and reproductive health services including family planning, cervical cancer screening (pap smear); partner counseling and testing; psychosocial support amongst others.
Package of services for HIV exposed children, this includes; antiretroviral prophylaxis and treatment, routine immunisation and growth monitoring /support, cotrimaxole prophylaxis beginning at 6 weeks of age, nutritional counseling and support, HIV diagnostic testing, screening and management of TB, prevention of treatment of malaria, psychosocial care and support amongst others.”
In a nutshell, Dr Gabriel Omonaiye agreed that for PMTCT to be successful, the following steps should be taken; “ early diagnosis of the presence of HIV infection in the woman before or early in pregnancy, the infected woman uses the antiretroviral drugs (ARVs), her viral load or burden of the HIV virus in her to be as low as possible, she has a high CD4 count before and after delivery, certain protocols are followed during the delivery process that will minimise the baby’s exposure to the HIV virus, the child is not breastfed and the neonate born to the infected mother is routinely given ARVs for the first six weeks of life.”
Ideally pregnant women with HIV are expected to receive HIV medicines during pregnancy and childbirth to prevent mother-to-child transmission of HIV. In some situations, a woman with HIV may have a scheduled caesarean delivery ( called a caesarian section) to prevent mother-to-child transmission of HIV during delivery. However like most feat there are some factors that may pose as a threat.
Omonaiye listed the factors that favour vertical transmission of HIV from the mother-to-child and they include; the ignorance of the HIV infection and thereby not being treated for it, high viral load, low CD4 count, prolonged labour, early or premature rupture of membranes greater than four hours before the baby is born, chorioamniontis (infection or inflammation of the amnionitic membranes and the placenta), instrumentation during labour like fetal scalp blood sample being taken and if mother also has syphilis.
“As said earlier it is recommended that the pregnant woman who is HIV positive deliver through caesarean section but due to combination of social, cultural, religious and financial reasons, this is almost impossible in our environment.”
“The challenges facing the effective practice of PCMT include non-registration of pregnant women in standard medical facilities where it is being practiced. A large chunk of our pregnant women still patronise and use the traditional birth attendants. Many fail to do the HIV screening tests, more deliver in churches, mosques, at home etc.”
“During labour, certain complications of the partition process can increase the probability of the foetus getting infected. Ante partum and intra partum haemorrhage (bleeding before and during labour respectively) could lead to the maternal blood coming in contact with the fetus which may end up in infection.
“Poverty, poor hygiene and illiteracy conspire to make it difficult for many of the affected women to embark on artificial (formula) feeding and not to breastfeed. The process of breastfeeding will infect some babies that escaped being infected in the intrauterine period and delivery.”
PMTCT is an effective and sustainable intervention with focus on ensuring an HIV- free generation by the strategy of getting no zero and closing the gaps. This strategy seeks to reduce the amount of children being infected with HIV.
In order to ensure that Nigeria achieves the global target for elimination of mother – to – child transmission, government and stakeholders have taken bold steps to develop strategies targeted to ensuring access to prevention and treatment programmes.
These include the adoption of the ‘’Test and Treat all’’ strategy decentralisation task shifting and sharing and scaling up of PMTC services through revitalisation and strengthening of the primary health care systems.
Antenatal services should be available and affordable even to the poor; lectures on PMCT should be given to pregnant women. The antiretroviral treatment should be provided to HIV-positive pregnant women to stop their infants from acquitting the virus.
The antiretroviral treatment should be readily available to all who need them especially the grassroot women. Those on drugs should be motivated to use them religiously and not skip them or stop them on their own as being done by some patients. Empowerment of women is also necessary.
Also, babies born to women with HIV receive HIV medicine for 4 to 6 weeks after birth. The HIV medicine reduces the risk of infection from any HIV that may have entered a baby’s body during childbirth.