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| REVIEW ARTICLE |
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| Year : 2017 | Volume
: 61
| Issue : 2 | Page : 124-130 |
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Pediatric HIV in India: Current scenario and the way forward
Anita Nath
Associate Professor, Indian Institute of Public Health-Bengaluru Campus, Public Health Foundation of India, SIHFW Campus, Bengaluru, Karnataka, India
| Date of Web Publication | 2-Jun-2017 |
Correspondence Address:
Anita Nath
Indian Institute of Public Health-Bengaluru Campus, Public Health Foundation of India, SIHFW Campus, First Cross, Magadi Road, Bengaluru, Karnataka
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/ijph.IJPH_314_15
 Abstract | | |
In India, the prevention of parent-to-child transmission and antiretroviral therapy services for HIV-infected mothers and children have been rapidly scaled up over the recent years. Despite these advances, a large number of HIV-infected children are born in every year. A thorough literature review has been done by retrieving related studies (published from the year 2000 onward); using a Medline search and by extracting recent findings from the official websites of the National AIDS Control Organization, UNAIDS, UNICEF, and World Health Organization. The efforts that are made to control pediatric HIV are challenged by a large range of factors such as low health service utilization, poor drug adherence, delayed infant diagnosis, discriminatory attitude of health providers, loss to follow-up, and poor coordination in managing continuum of care. These challenges may be addressed by adopting innovative and effective strategies and strengthening the existing health system. This would bring about a significant reduction in pediatric HIV incidence and improve the outcomes in children who are HIV infected.
Keywords: Antiretroviral therapy, National AIDS Control Organization, pediatric HIV, prevention of parent-to-child transmission
How to cite this article:
Nath A. Pediatric HIV in India: Current scenario and the way forward. Indian J Public Health 2017;61:124-30 |
| Introduction | |  |
Pediatric HIV/AIDS is a significant cause of childhood morbidity and mortality.[1],[2] In the year 2013, there were 3.2 million children living with HIV all over the world and 240,000 children became newly infected.[3] India has estimated 145,000 children <15 years of age who are infected by HIV/AIDS, and about 22,000 new infections occur every year. Children account for 7% of all the new HIV infections.[4]
More than 90% of the HIV infections in children are the result of maternal-to-child transmission (MTCT).[5] The MTCT rate ranges from 20% to 45% in the developing world.[6] It ranges from 15% to 30% in nonbreastfeeding populations whereas it is 30%–45% in countries where breastfeeding is a norm.[6] This is because breastfeeding has an additional 5%–20% risk of postpartum transmission. With adequate antiretroviral (ARV) prophylaxis, MTCT risk can be reduced to <2% as is seen in the high-income countries along with other effective measures which include elective cesarean section and avoidance of all breastfeeding.[7] However, these approaches are not always possible in developing countries wherein 95% of vertical transmission occurs.[8]
In India, although the overall HIV prevalence among antenatal care (ANC) clinic attendees continues to be at a low level of 0.35%, there is a rising trend of the infection among monogamous pregnant women.[9] Pediatric HIV is thus poised to become another major public health problem. This is likely to happen in our society where childbearing is considered essential for a woman and is accorded high priority. If not detected early, they may continue to bear children who might be HIV infected. The aim of this review is to provide a comprehensive overview of efforts made and challenges in controlling pediatric HIV and to explore evidence-based recommendations.
| Prevention of Parent-To-Child Transmission Program in India | | |
Over the past few years, India has witnessed a significant scaling up of prevention of parent-to-child transmission (PPTCT) program and antiretroviral therapy (ART) services for pregnant and breastfeeding women and their children. Under the National AIDS Control Programme (NACP), various HIV-related services are provided through public and private health providers. The NACP is implemented by the National AIDS Control Organization (NACO) of the Government of India, in partnership with other partner agencies [Figure 1]. The HIV services which are available at different levels of health care are shown in [Table 1].[9] | Figure 1: The National AIDS Control Organization and partnering agencies.
Click here to view |
The PPTCT of HIV/AIDS program was started in the country in the year 2002 with the aim to offer HIV testing to all pregnant women.[4] During the initial years, single-dose nevirapine was the drug of choice for ARV prophylaxis to prevent MTCT and was offered to the HIV-infected pregnant woman during labor and also to her new born infant. This has now been replaced with the World Health Organization's (WHO) recommended “Öption-B+.”[10] In this regimen, lifelong ART (using the triple-drug regimen) is offered for all pregnant and breastfeeding women living with HIV, regardless of CD4 count or the WHO clinical stage, both for their own health and to prevent vertical HIV transmission and for additional HIV prevention benefits. This has been initiated in the three southern high HIV prevalence states of Andhra Pradesh, Karnataka, and Tamil Nadu in 2012 and is now being implemented all over the country in a phased manner.
Recent data report that at an all-India level, 97.52 (74%) lakh pregnant women were tested for HIV during 2013–2014, against a target of 131.58 lakh.[4] Out of 12,008 pregnant women who were found to be HIV infected, 10,085 (84%) mother–baby pairs were provided ARV. Of the 112,385 children registered in the HIV national program, only 34,367 (30.6%) had started ART by December 2012.[4] While progress is being made in reducing HIV transmission and promoting ART coverage, more efforts are needed to reduce new infections and mortality in children. One of the ways this may be done is by identifying challenges in service utilization and delivery.
| Methodology | | |
An initial framework for this review paper was conceptualized with broad topic outlines. Data pertaining to the implementation of PPTCT and ART and current recommendations in India were accessed from the official websites of the NACO, UNAIDS, UNICEF, and WHO. Literature review was done using Medline search. The links to full-text papers were accessed wherever applicable. The inclusion criteria for selecting articles included both observational and experimental epidemiological studies done in India in relation to the following themes: (i) challenges and barriers in PPTCT implementation, (ii) ART adherence in mothers and children, (iii) disclosure of HIV status, and (iv) quality of care among HIV-infected women. The recommendations are based on the challenges that were identified in the above-mentioned studies. For the purpose of exploring evidence-based recommendations, study findings from even those which were done outside India were considered. The initial keywords that were used for Medline search included “Pediatric HIV, India.” A refined search was done based on the themes in the study framework.
| Challenges in the Control of Pediatric Hiv Infection | | |
The control of pediatric HIV infection in India is challenged by a plethora of factors. These could be at the individual, social, or programmatic level.
Individual level
Lack of awareness about prevention of parent-to-child transmission services
High rates of HIV transmission could be attributed to low awareness about MTCT preventive strategies. The awareness levels are shown to be as low as 37.6% among antenatal women attending a tertiary hospital and 48% among those attending a rural antenatal clinic in South India.[11],[12] Likewise, in a periurban area of Punjab, only 28.5% of women knew about the availability of HIV testing facility.[13]
Utilization of antiretroviral therapy services
Most of the free ART centers are located in urban settings and this requires long distance travel to avail of these services.[14] An analysis of routinely collected program data showed that as many as 63% of patients receiving ART were living outside the treatment district.[14] Women quote multiple reasons for not visiting the ART center on time; these include nonavailability of childcare, sickness, financial crisis, distance, and lack of transport.[15]
Maternal antiretroviral therapy/antiretroviral adherence
Adherence to ART/ARV by the mother is crucial for the successful prevention of mother-to-child transmission of HIV. The treatment is considered to be successful if adherence is more than 95%. Poor adherence results in emergence of drug-resistant viral strains.[16] The proportion of mothers who have reported good adherence rates is fairly low, reported to be 39% and 56.4% from different studies.[17],[18] Nonadherence is shown to be associated with side effects, illiteracy, burden to taking too many medications, and depression.[17],[19],[20],[21]
Antiretroviral therapy adherence among children
It is currently recommended that all HIV-infected children <2 years of age should receive ART, while in older children, the indications are based on clinical and/or immunological criteria.[22] Data from studies done in the Indian pediatric population report low adherence rates. A tertiary care clinic in West Bengal reported adherence rates in the range of 36.2%–63%.[17] Even if the desired adherence level of more than 95% is reached, caregivers could experience multiple problems while administering drugs as reported from a study done in south India.[23] Factors shown to influence adherence include side effects, palatability, formulation, regime, poor access, cost of transport, and time spent in traveling.[17],[24],[25],[26] Some caregivers have even expressed doubt over the quality of drugs that are being freely distributed at ART centers.[25]
Societal level
Maternal nondisclosure of HIV status
Women are fearful to disclose their HIV status which could lead to stigmatization and social ostracism.[27],[28] Stigma acts as a barrier toward accessing PPTCT services [29],[30] as it interferes with HIV counseling and testing.[31],[32] Some mothers tend to hide their HIV serostatus at the time of delivery for fear of discrimination, abuse, and denial of services.[18]
Disclosure of HIV diagnosis to children
The proportion of children who are not aware about their HIV status is fairly high, being reported as 59.6% and 86% in different study settings.[33],[34] Most parents and caregivers feel compelled not to disclose their child's HIV status for fear of stigma, discrimination, and mental trauma. However, research studies demonstrate that the disclosure of HIV status to infected children influences their compliance with ART and initiative to take responsibility of one's own health.[33],[35],[36]
Programmatic level
Delayed infant diagnosis
About half of HIV-infected children are reported to die undiagnosed before their second birthday.[37] Early diagnosis and initiation of ART in children <2 years of age is of paramount significance since failure to do so may result in rapid progression and early mortality.[38] According to the national protocol, for children <18 months, a DNA polymerase chain reaction (PCR) testing using dried blood spots which detects viral DNA is recommended, while for children >18 months, diagnosis is to be done by means of ELISA test [Figure 2].[39] If positive, then a confirmatory test is done on whole blood sample DNA PCR before initiating ART. A study from South India observes the existence of huge gaps in diagnosis, confirmation, and initiation of ART in HIV-exposed infants.[40] | Figure 2: Testing algorithms for early infant diagnosis. (a) For infants less than 6 months of age. (b) For infants and children 6 to 18 months.
Click here to view |
Delayed entry into HIV care
Initiation of ART therapy is reported to be delayed in 55.6% of HIV-infected infants in a study done in Delhi.[41] A study from Andhra Pradesh reports that delayed entry into care was associated with belonging to scheduled caste, age <18 months, female gender, and living >90 min from the HIV center.[42]
Quality of health care
Stigma among health-care providers toward HIV-positive pregnant women poses as a challenge in accessing PPTCT services. In Tamil Nadu, majority of the HIV-infected mothers have been victims of ill behavior from the health staff.[43] In another such study, as many as 97% of such women reported stigmatization while 50% expressed that they would never like to avail of maternity care at a government hospital.[44] Stigmatization included avoidance of physical examination, derogatory comments, unnecessary referrals, and even refusal to provide intrapartum care. Similarly, HIV-positive women in rural North Karnataka have consistently expressed that discrimination and negative attitude of the staff forms an important barrier for access to health care in the medical facility.[45] Furthermore, counseling aspects such as lack of privacy, confidentiality of HIV status of the client, a “hurried” attitude of the counselor, and inappropriate communication skills remain as challenges.[46]
Lack of intranatal testing for HIV infection
Majority of the women without any prior HIV testing who present to the labor room are not investigated for HIV infection.[47] Furthermore, fear of ill treatment by the health-care staff causes many HIV-infected women not to disclose their HIV status.[43]
High unmet need for contraception
Despite the availability of effective ART, there remains a high unmet need for contraception.[48] The evidence for this was seen in a study among pregnant HIV-infected women attending a care facility in Pune, 51% stated that the pregnancy was unwanted while 50% of the pregnancies ended in voluntary termination.[48] In Mumbai, about 69% of HIV-infected women expressed their wish to use dual contraceptive methods for effective protection.[49] Barriers to usage of dual contraceptives include a lack of discussion about the method by health personnel, lack of acceptability of such methods among PLHIV, and lack of involvement of husbands in family planning counseling.[50] Furthermore, women who are unwilling to disclose their HIV status to their spouse are more likely to have repeat pregnancies.[51]
Loss to follow-up
The loss to follow-up (LTF) of mothers and their children challenges the potential effectiveness of the PPTCT program. Even though PPTCT programs report reduced rates of infection among infants tested at 2 months of age, there is limited priority on retention of HIV-exposed infants in care.[52] A study from Maharashtra reports that 10.9% and 19.6% of women were LTF before and after delivery.[53] Significant factors associated with LTF included poor education, low economic status, and registration beyond 20 weeks of pregnancy. Furthermore, women who are less likely to utilize HIV-related care after exiting the PPTCT program were those whose partners had never utilized HIV-related care and were unable to afford travel to the HIV-related facility.
| Future Recommendations | | |
There is an urgent need to address the above challenges by designing interventions and strengthening the preexisting health system. Some of the recommendations are based on the multifactorial challenges that have been observed in various studies as discussed above while some are stated based on strategies that were explored in certain studies.
Promoting antiretroviral therapy adherence in mothers and children
- Parental and caregiver counseling
- Exploring options for providing child-friendly formulations
- Promote counseling, emotional support, and skill building for coping mechanisms for mothers living with HIV/AIDS
- HIV disclosure should be done as a planned intervention and not as an abrupt process. A timely, sensitive, and well-managed disclosure is shown to significantly improve ART adherence and reduce psychological stress in the parents and children
- Involving community level workers: The “Asha-Life intervention” has shown a significant effect in improving ART adherence and decreasing barriers among rural women living with AIDS in India.[54],[55] In this program, the “Accredited Health Social Activist” worker provides basic education and counseling, promotes healthy lifestyle choices, and links women living with AIDS to community resources to match health needs.
Improved case detection
- Scaling up of infant diagnostic services and strengthening programs to retain HIV-exposed children in care and ensure timely testing for HIV infection
- Exploring feasibility for virological testing at birth: About 30%–40% of HIV-infected infants can be identified by 48 h of age.[56] Factors such as the institutional delivery rate, time taken to deliver the test report, and dosing data need to be taken into account
- Ensure continued follow-up of exposed babies for their full participation in postnatal care
- Promote intranatal testing for HIV for patients with no prior record of HIV testing
- Promote antenatal HIV testing: Provision of conditional cash transfer schemes to women's microeconomic self-help groups appears to significantly increase uptake of ANC/HIV testing services in rural Mysore villages.[57]
Strengthening of health systems
- Strengthen mechanisms for integrating PPTCT across private sector by means of promoting public–private partnership. This is attributed to the increase in preference for private antenatal health care, even by women from poor and tribal communities [58]
- Ensure retention of HIV-infected women in the health-care system smooth transmission from PPTCT program to long-term HIV care
- Integrating HIV-screening program at primary health: An initiation to provide facility-based integrated counseling and testing centers at all round-the-clock primary health centers resulted in an additional 27% of HIV-infected women getting detected.[59] This involves capacity building and sensitization of community level workers on HIV prevention
- Repeat testing of HIV infection during pregnancy: At present, women are tested for HIV only once during pregnancy according to the NACO recommendations.[60] A repeat HIV test could be done for those pregnant women who are in the window period at the time of the first HIV test or who acquire HIV after the first test. A study was done in Pune among pregnant HIV-uninfected women to determine the cost-effectiveness of repeat testing of HIV infection.[61] It was found that a single HIV test is 8.2 times costlier for less quality-adjusted life years gained in contrast to a proposed repeat HIV testing of pregnant women who tested negative in the initial test
- Strengthen the provision of comprehensive family planning services to HIV-infected women.
| Conclusion | | |
The PPTCT and free ART programs have made a laudable effort in reaching out to a large number of HIV-infected women and their children. The programs' success to reduce maternal-to-fetal transmission and HIV-related morbidity and mortality is challenged by a host of multiple factors. These challenges may be addressed by adopting innovative and effective strategies and reinforcing the existing health systems. This would bring about a significant reduction in pediatric HIV incidence and improve the outcomes among children who are HIV infected.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]
[Table 1]
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