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HIV/AIDS in Babies-Avoidable Deaths By Hadiza Bawa-Garba hadiza1@hotmail.comI chose to do my audit1 on the management of vertical transmission (i.e. mother to child) of Human Immunodeficiency Virus (HIV) in a District General Hospital in the U.K because each year an estimated 590,000 infants acquire HIV infection from their mothers, mostly in developing countries that are unable to implement interventions which are now standard in the industrialized world.2 After completing the audit, I decided to write this article exploring reasons why we in the developing world still have babies born with HIV. The first part of the article is an introduction to HIV/AIDS, second part focuses on vertical transmission of the virus and the last part looks at ways in which we can all raise up to the challenge and make HIV/AIDS in babies extinct. Acquired Immune Deficiency Syndrome (AIDS) was first described in the medical journals in 1981 when a cluster of young homosexual men from San Francisco presented with Pneumocystis Carinii Pneumonia (PCP- a severe infection affecting the lungs) and Kaposi sarcoma (a tumour affecting the skin which has a classical appearance). It soon became evident that the clinical syndrome was associated with immune incompetence but it was not until 1983 that the viral aetiology was established. The virus, then described by Montagnier in France as LAV and Gallo in the USA as HTLVIII is now universally known as the human immunodeficiency virus (HIV).3 Subsequently a new variant has been isolated in patients with West African connections-HIV-2. HIV is the virus that causes AIDS. Once introduced into the bloodstream, HIV attacks certain cells of the immune system called the helper T cells which are responsible for helping the body fight off infection. HIV reproduces in these cells and the immune system responds by producing antibodies to fight the virus but this response is ultimately ineffective.4 In the later stages of the infection, HIV destroys increasing numbers of the T helper cells until the body's capacity to fight other viruses and bacteria gradually begins to decline and eventually the body is defenceless against even simple organisms. The term AIDS applies to the the most advanced stages of HIV infection. . How bad is the problem? It is now a Pandemic. A total of 39.5 million people now live with HIV/AIDS worldwide, 2.2 million of them are under the age of 15. In 2006, an estimated 4.3 million people were infected with HIV,530,000 were under the age of 15.5 As of January 2006, the Joint United Nations Programme on HIV/AIDS(UNAIDS) and the World Health Organization (WHO) estimated that AIDS has killed more than 25 million people since it was first recognized on June 5 1981, making it one of the most destructive epidemics in recorded history. Every day 12,000 people contract HIV – 500 every hour. In 2006 alone, 2.9 million people died from AIDS,380,000 of them were under the age of 15- that is one child dying per minute. 5 15 million children around the world have been orphaned by AIDS, losing one or both parents to the disease. Bringing these figures closer to home, in Africa more than 60% of all people living with HIV, 24.7 million, live in Sub-Saharan Africa.5 In 2006, an estimated 2.8 million people in the region became newly infected. In Nigeria, UNAIDS reports that in 2005 there are 2.6 million people between the ages of 15-49 years who are HIV positive of which 1.6 million are women and 240,000 are children.5 This is retarding economic growth and destroying human capital. Mode of Transmission of HIV: HIV is transmitted through direct contact of a mucous membrane or the bloodstream with a bodily fluid containing HIV, such as blood, semen, vaginal fluid, preseminal fluid and breast milk. This transmission can come in the form of anal, vaginal or oral sex, blood transfusion, contaminated hypodermic needles, exchange between mother and baby during pregnancy, childbirth, or breastfeeding. 5 It is not transmitted through the respiratory or enteric routes or by casual person-to-person contact and there is no evidence of transmission by food, water or insects. HIV/AIDS: Any cure in sight? Although treatments for AIDS and HIV exist to slow the virus’s progression, there is still no known cure.5 As mentioned previously 90% of cases are in the developing countries and this are the same countries where access to antiretrovirals is very limited due to financial constraints. A large-scale clinical trial of a candidate HIV vaccine — which previously showed promise in smaller studies in the United States and elsewhere — has now opened in South Africa.6 The study plans to enrol up to 3,000 HIV-negative men and women, making it the largest African HIV vaccine trial to date. The trial is called Phambili (“moving forward”). Also known as HVTN 503, it is a Phase IIb “test-of-concept” trial, the first such vaccine study in South Africa. This type of trial is designed to provide preliminary information on vaccine efficacy and thus enable researchers to decide whether or not to conduct a larger Phase III efficacy trial that could lead to licensure. Thus, until a vaccine becomes available our best weapon will have to be prevention and also working together to ensure that those that are HIV positive have access to the drugs and HIV positive pregnant women are managed properly to prevent vertical transmission. Furthermore, the government in close liaison with UNAIDS, WHO and UNICEF can negotiate with pharmaceutical companies to provide antiretroviral drugs at greatly reduced, affordable public sector prices.
My audit: Approximately 33% of pregnant women infected with HIV will pass the infection to their babies without any interventions. According to the British HIV association (BHIV) this figure of 33% can be drastically reduced to below 2% if the following recommendations are carried out.7 My audit looked retrospectively at management of HIV positive pregnant women in 2003-2004 to see if these recommendations were followed and the results were very reassuring. None of the babies that I followed had HIV. Clearly, these recommendations are working. The recommendations are:
Routine testing of all pregnant women: All women are routinely offered testing for HIV infection on their first attendance to the antenatal clinic. It was interesting and shocking to note that 30% of women found out about their status for the first time through this route. After knowing that they are HIV positive, the women are then managed jointly by the Genitourinary medicine consultants, Obstetricians and paediatricians. They are counselled about the management of their pregnancy and about interventions available that will reduce the chances of their baby becoming positive. · Taking anti-HIV drugs during pregnancy—either a drug called zidovudine or AZT alone or in combination with other drugs called highly active antiretroviral therapy (HAART)—a mother can significantly reduce the chances that her baby will get infected with HIV because the medicines will reduce the levels of the virus in the bloodstream, hence reducing the chances of it crossing the placenta and infecting the baby. · Delivering the baby by caesarean section, and doing so before the mother’s uterine membranes rupture naturally, reduces transmission that may occur during the birth process. We currently can not force HIV positive women to have a caesarean section against their wishes because they could sue us for assault. Interestingly, we had a case of a woman from Zimbabwe who refused a caesarean section, luckily her viral load was very low and recent studies have shown that women with low viral load can be given the choice between vaginal delivery and caesarean section. This lady insisted on a vaginal delivery and her baby was not infected partly because her viral load was low and also because she did not breast feed. · Avoidance of breastfeeding by a HIV-infected mother. HIV can be spread to babies through the breast milk of mothers infected with the virus. The implications of not breast feeding in the developed and developing countries will be covered later. · Prescription of zidovudine elixir 2mg/kg 6 hourly to the baby to start within 12 hours of birth and to be continue for 6 weeks which is when the results for Polymerase Chain Reaction (PCR) blood sampling taken from baby will be back. We use PCR and not a test for HIV antibodies in babies because the latter is more likely to give a false positive since mother is HIV positive and the baby’s blood will contain maternal antibodies if checked at this stage. PCR on the other hand is more accurate as it relies on the presence of copies of the virus in the baby’s blood as opposed to the presence of antibodies. What are the figures in Nigeria? According to work by Chama et al8 in University of Maiduguri teaching hospital almost 6% of women attending antenatal clinics in Nigeria were HIV positive as of December 2002. They looked at prevention of mother to child transmission of HIV at Maiduguri teaching hospital and and their report was published in the Journal of Obstetrics and Gynaecology 2004 edition. They reported that in June 2003, 201 out of 262 pregnant women agreed to receive voluntary counselling and testing for HIV. 31 of them (= 11.8%) were positive. The majority of the HIV positive mothers received nevirapine in labour while 35% had combination antiretroviral drugs in pregnancy. All the infants received nevirapine within 72 hours of delivery. Unfortunately the number of babies that were actually positive if any were not stated in the abstract but they did conclude by rightly saying that expensive and slow testing facilities, insufficient and inconsistent counsellors, lack of antiretroviral drugs for both mother and baby as well as unaffordable caesarean delivery were some of the constraints being faced at their centre.8 Where do we go from here? What are our problems and how can we tackle them? Education: Although we have come a long way from when folks used to define AIDS as American's Idea to Discourage Sex ( in order to reduce the African population), there is still a lot of ignorance and misconceptions about HIV. I have many of stories to tell that depict this but will limit myself to one. A colleague of mine working in Gombe was shocked at the response she got from a patient who has just been diagnosed with HIV. His main concern was for his pregnant wife not to find out about his status until she delivers the baby because the news will distressing to her!! This story illustrates how much work needs to be done especially in the rural areas in emphasizing the need for spouses to let each other know about their status and for HIV positive pregnant women to know that there are ways of protecting their babies. I was also fortunate enough to address a crowd of Hausa women in HFDN, Kaduna (thanks to Mrs DL Mohammed, principal of Essence International school) and together we were able to explore the myths and facts surrounding the HIV/AIDS issue. This talk highlighted the need for our religious leaders to also advocate the importance of women to know the status of potential suitors before committing to marriage, as the audience are more likely to listen to them (religious leaders) than to doctors. I would also like to applaud a lot of the Non Governmental Organizations that work tirelessly to educate the youth about the ABC of HIV/AIDS i.e. Abstinence, Being faithful to your partner and the last one C which is very controversial and stands for condoms. However, I was told not to mention the latter (C ) when I was speaking to a group of youths in Rimi College in 2004 as it is not culturally acceptable- to say that we are in denial about the true state of affairs is an understatement and this is an area that needs to be addressed. However as Sheikh Hamza Yusuf says, if you look closely at the word ignorance, it also contains ignore9, which means some people may not actually be ignorant but rather chose to ignore the facts and think that HIV can never affect them. Nevertheless, we still need to increase awareness about HIV/AIDS and join hands in knowing our enemy really well. Increase input from the Government: I am not here to eulogize the National Health Service (NHS U.K), but one thing is for certain having access to health care that is free at the point of delivery to all citizens is a great service. We all pay taxes whether you work in Nigeria or U.K and I know that the amount taken off for tax in UK is higher in comparison to Nigeria but I am sure that most tax payers will rather see their money being used for a good cause like health than not to have a clue about what it is being used for. We need to remember that preventing babies from getting HIV is not just a good deed to the family that would have suffered because of a child with AIDS but is also a service to the community as that is one less person with the virus who will now hopefully do something worthwhile to the community, in other words it is service to the public. A lot more of the budget needs to be dedicated to health provision and also to services for HIV positive patients. Nigeria is the 7th largest oil producing country in the world and she is blessed with 150million people, so we are not a poor country in terms of natural resources and manpower. You only need to look at the workforce in developed countries and a good proportion of the foreigners in professional sectors are Nigerians- this is probable not the best forum to have the debate about brain drain but the point I am trying to make is a lot of professionals that are based abroad will agree that there is no place like home and if the government will increase their commitment to improving services and providing facilities that will help us translate our theory into practise many of us will be heading back home. How much of our budget and of the millions of naira that we make daily is committed to health sector? What we forget is that the first point of contact of anyone involved in a road traffic accident regardless of their financial status is a teaching hospital, where they will need to be stabilized before they get flown out of the country in their private jets. The golden hour as we refer to in medicine is the critical time when emergency care need to be given to a trauma patient which will determine their prognosis, if this is lacking then surely everyone including the rich will be affected.
Change of our attitude: People's attitude and commitment towards work: Lets assume that the government has actually listened and have now provided facilities to the major teaching hospitals, how long do you think it will last? I can see some people laughing, because we know the Nigerian factor will also be there. A simple example is that of security, the machines from the TV that needs to be caged and padlocked to the CT machine will have to be monitored closely as majority of the staff and the visitors are all potential thieves. Why is it that we have all forgotten how to do things honestly anymore? We all want to make it work, yet corruption from the top to the bottom runs in our blood. We really need to change our attitude and start from within. If we all instil a form of discipline and actually do our job properly then there will be no need for us to be in the mess that we find ourselves today. Everyone is thinking about what is in it for me, and how much damage will it cause if I am the only one stealing. Little do they know that everyone down to the cleaner really matters in the way they discharge their duties. The government also needs to pay their staff well so they don't have to resort to looking for ways to supplement their salary. We need regular appraisals and reminders that in order to change our condition we must first change ourselves, our attitudes. This positive behaviour will filter through to our children and then the society will be a much nicer place to live in.
People's attitude towards HIV Positive patients: HIV/AIDS stigma is more severe than that associated with other life-threatening conditions and extends beyond the disease itself to providers and even volunteers involved with the care of people living with HIV. One hears of many sad stories of how people have been ostracized because of their status. One of such stories includes that of a tailor whose husband sadly died from the virus and her customers stopped taking their clothes to her for fear of being infected!!!!! Sadly, this stigma is not just in Africa, it is also seen amongst Africans that are living in the U.K. Another friend who is working with HIV positive patients in Leicester narrates a story of a HIV positive woman from Zimbabwe who decided to breast feed her baby despite knowing the risks associated with it because of the fear of being ostracized by her local community where lack of breast feeding automatically links in with the fact that the mother must be HIV positive.
Conclusion : In conclusion, AIDS is not only a deadly disease; it is the greatest scientific, political, and moral challenge of our era. In this time of abundant resources and increased global connectivity, we have the means and knowledge to control the pandemic. Yet to do so will require unparalleled global co-operation and shared recognition that AIDS threatens not only individuals, but entire societies and the very notion of a global order based on respect for human dignity and rights.
This audit has been an eye opener for me. I have learnt that things can work and that HIV in babies can be avoided and I know that this can be done back home when we are ready to make a change. For as long as there are children being born every minute, then we owe it to them to make it happen. I have a dream, that one day there will be no baby born with the deadly virus, but as they say dreamers dream while they are sleeping while those who want to make a change dream while they are awake, I hope we belong to the latter group. *********** References: 1) Bawa-Garba H, (2005) Audit on the management of vertical transmission of HIV/AIDS, presented in Joint obstetric and Paediatric meeting, Peterborough District Hospital, United Kingdom. 2) Cock et al (200)Prevention of mother to child transmission of HIV in resource poor countries, Journal of American Medical Association (JAMA) 283:1175-1182 3) Adler et al (2001) ABC of AIDS BMJ publishing Group, 5th edition pp 1-2 4) Irwin et al (2003) Global AIDS; Myths and facts; tools for fighting the AIDS pandemic South end Press , Cambridge pp10-11 and pp26-27
5) UNAIDS statistics Gateway to AIDS knowledge. cited on www.hivinsife.ucsf.edu 6) First Large-Scale HIV Vaccine Trial in South Africa Opens cited in National Institute of Health News on www.nih.gov/news. 7) Blott et al (2005) Guidelines for the Management of HIV infection in Pregnant Women and the Prevention of Mother-to-Child Transmission of HIV cited in British HIV Association (BHIV) on www.bhiva.org. 8) Chama et al (2004) Prevention of mother to child transmission of HIV at Maiduguri, Nigeria. Journal of obstetrics and Gynaecology 24 (3) pp266-269 9) Hamza Yusuf , Clarity amidst confusion cited in www.zaytuna.org. |