PMTCT: The baby's 'saviour' from HIV

Staff Writer
It 'lives' and lets children live. Prevention of Mother-To-Child-Transmission (PMTCT) is the baby's 'number one' saviour in this era of HIV/AIDS.

As HIV/AIDS remains the leading  social and public health problem in Botswana, as indeed elsewhere in sub-Saharan Africa, the government vigorously used the three-pronged strategies of information, education and communication to help change behaviour and stem the scourge of HIV/AIDS, available government policy documents on HIV/AIDS reveal.

This, the government did, right from the onset of the epidemic in the late 1980s.

With such government efforts however, the number of people living with HIV/AIDS rose.

"Although the provision of ART [antiretroviral therapy] and PMTCT programmes on a national scale has significantly reduced the number of deaths in recent years, this is expected to reverse in the not-so-distant future with the number of deaths again increasing year-on-year," notes Government of Botswana Country Report, United Nations General Assembly Special Session on HIV/AIDS, December 2008.

"As a result of the increase in population and provision of the life-prolonging ART," regrets the report, "the number of HIV infected people in Botswana is expected to continue growing reaching more than 35,000 people by 2021".

It adds that the number of people on ART will also rise over the same period reaching around 124,000 by 2021 from the current 91,780.

"HIV and AIDS has had a significant impact on the population of Botswana, with its 2021 total projected to be nearly 18 percent lower than it would have been in the absence of the epidemic, the number of deaths doubling, and the number of orphans increasing more than four-fold," concludes the report on its demographic impact.

According to the UNAIDS epidemic 2007 update, 33.2 million people worldwide are HIV positive.

This includes an estimated 15.4 million women and 2.5 million children under the age of 15.The update further reveals that about 1,400 children under the age of 15 are infected  by HIV every day.

It says in 2007 alone, 420,000 children were newly infected with HIV and, according to the update; approximately 90 per cent of these infections are in sub-Saharan Africa.

But the Botswana government did not relax, and, has not relaxed to date.

In a bid to save the lives of the always innocent children born to HIV-positive mothers, in 1998, Botswana became the first African country to institute therapeutic PMTCT. The government has found it important to protect children from HIV infection.

Government efforts in saving the lives of children born to HIV positive mothers and/or children born with HIV, are supplemented bynon-governmental organisations  or NGOs.

Monthly, according to Dr Frank Apondi, an HIV/AIDS Specialist in private practice, about 340 children's lives are saved from contracting the virus at birth. This figure implies that in a year, about 4,080 children born to HIV-positive mothers grow up HIV-free.

One such child is the now two-year-old Paul*. He is very energetic.

The boy is a promising academic genius. "I want to take him to school. This could be the future president of Botswana. I like my son. He is naughty but very bright," confides Alice*, who says she was diagnosed with HIV in 2006. Paul was born in November 2007.

Actually, during the time of this interview, the usually amiable and playful Paul was called 'Festus Mogae', Botswana's former president.

"This is Festus Mogae," a man was overheard saying, probably recognising the boy's brilliance.

Paul is the second born. His elder brother was born in 1993 at a time when his mother was still HIV negative.

Alice does not really know when and how she contracted HIV but she believes it was sometime in 2005 when she had unprotected sex.

"I want my sons to grow, go to school and get married at the same time. I am confident I will still live for more than 20 years," she says.

The clinical 'mystery' of Paul's freedom from HIV is better known to HIV/AIDS Specialists like Dr Apondi. "The mother is put on PMTCT immediately she is discovered to be HIV-positive during antenatal treatment," he explains.

"But for the child," he continues, "it starts immediately when the mother goes into labour. It is called an obstetric case during delivery".

The HIV/AIDS specialist also confirms that breastfeeding can transmit HIV to children; partly explaining why most mothers in Botswana put their babies on the bottle feeling
On which birth method is suitable for PMTCT to succeed or for a child to be born

free of HIV, Dr Apondi says they prefer selective caesarian section because vaginal delivery has proved to be riskier than caesarian section.

The caesarian section is preferred to vaginal delivery because the caesarian method avoids rupturing of the membranes and extended labour.  It also avoids cutting of the vagina  and use of sharp instruments which increases the chances of blood-to-blood contact, the likeliest way of HIV transmission.

It is now a government policy in Botswana that all pregnant women not already on Highly Active Retroviral Therapy (HAART) must receive priority scheduling for CD4 screening and clinical evaluation for both HAART and for the need for prophylaxis, a preventative kind of treatment administered by clinicians in the management of HIV. CD4 counts - a person's measure of white blood cells able to fight against HIV - of these patients must have priority status.

"Failure to adequately and promptly screen pregnant women for HAART eligibility is a major violation of national guidelines, risks both maternal and foetal health, and risks HIV transmission to the baby," reads an update of the 2008 Botswana National HIV/AIDS Treatment Guidelines.

On pregnancy, HAART and PMTCT, according to the national guidelines, any pregnant woman presenting for care at 28 weeks of gestation or more must immediately be started on AZT 300mg BD [a variety of ARV] pending urgent screening for HAART eligibility.

And once the baseline evaluation has been completed, the national policy guideline directs, then the AZT should be replaced with full HAART; if the woman is eligible for HAART for her own health.

But even if late in pregnancy, the national guideline demands, HAART should be started if the patient is eligible and is believed ready to start HAART.

Unless active labour has started, the national guideline insists, it is never too late to begin HAART. "Clinics which dispense formula must not turn away a mother who requests additional formula for her baby, and must provide additional formula," reads, in part, the national guideline to clinics in Botswana.

This also forms part of a serious clinician responsibility in administering HAART and PMTCT.

In Botswana, PMTCT is also one among indications for rapid tests in diagnostic HIV infection. Perhaps this explains why, according to Dr Apondi, Botswana is managing to save about 4,080 children yearly from contracting HIV/AIDS from their mothers at birth.

Pregnant women with HIV, writes the United Kingdom-based Medical Education Resource Africa, or Mera, January 2008 issue, are at risk of transmitting HIV to their infants during pregnancy, birth, or breastfeeding, and without any interventions, between 20 percent and 45 per cent of infants may become infected.

"Well over 90 per cent of children under 15 years living with HIV are believed to have been infected through mother-to-child transmission," Mera reports.

"Despite numerous statements of political commitment," regrets the neutral carrier of continuing medical education information for physicians and other health professionals in Africa magazine, "a well-defined set of interventions and the know-how required to implement them, the vast majority of pregnant women in need of PMTCT services do not receive them."

"... The latest data from the end of 2005 estimates that only 11 per cent of infected pregnant women in Africa received antiretroviral prophylaxis for PMTCT."

Intrapartum single-dose nevirapine to mother, and then to infant within 72 hours of birth, according to the Mera report, is the cornerstone of the PMTCT approach in much of Africa, emphasising: it is 40 per cent efficacious in preventing HIV transmission, easy to use, safe, and cheap.

"A randomised trial in Botswana showed that women who started nevirapine-based ART [antiretroviral therapy] regimens 6 months after receiving single-dose nevirapine had no excess risk of virological failure compared with women who received placebo [a substance that has no physical effects, given to patients who do not need medicine but think that they do, or used when testing new drugs]," says Mera, "thus providing some reassurance that future ART is not unduly compromised by this approach."  

Mera recommends the scaling up of the simple intervention of single-dose nevirapine to many more pregnant women "than is currently the situation" [so as to save the children from HIV].

And Botswana has done exactly that: scaled up the intervention of single-dose nevirapine to pregnant women.

*Not their real name



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