Indian Journal of Public Health

REVIEW ARTICLE
Year
: 2017  |  Volume : 61  |  Issue : 2  |  Page : 124--130

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

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

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.



How to cite this article:
Nath A. Pediatric HIV in India: Current scenario and the way forward.Indian J Public Health 2017;61:124-130


How to cite this URL:
Nath A. Pediatric HIV in India: Current scenario and the way forward. Indian J Public Health [serial online] 2017 [cited 2020 Oct 21 ];61:124-130
Available from: https://www.ijph.in/text.asp?2017/61/2/124/207411


Full Text

 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}{Table 1}

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}

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 counselingExploring options for providing child-friendly formulationsPromote counseling, emotional support, and skill building for coping mechanisms for mothers living with HIV/AIDSHIV 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 childrenInvolving 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 infectionExploring 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 accountEnsure continued follow-up of exposed babies for their full participation in postnatal carePromote intranatal testing for HIV for patients with no prior record of HIV testingPromote 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 careIntegrating 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 preventionRepeat 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 testStrengthen 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.

References

1Marinda E, Humphrey JH, Iliff PJ, Mutasa K, Nathoo KJ, Piwoz EG, et al. Child mortality according to maternal and infant HIV status in Zimbabwe. Pediatr Infect Dis J 2007;26:519-26.
2Mussi-Pinhata MM, Freimanis L, Yamamoto AY, Korelitz J, Pinto JA, Cruz ML, et al. Infectious disease morbidity among young HIV-1-exposed but uninfected infants in Latin American and Caribbean countries: The National Institute of Child Health and Human Development International Site Development Initiative Perinatal Study. Pediatrics 2007;119:e694-704.
3UNAIDS 2014. Children and HIV: Fact Sheet. Available from: http://www.unaids.org/en/resources/documents/2014/20140508_FactSheet_Children. [Last accessed on 2015 Nov 25].
4NACO Annual Report; 2012-13. Available from: http://www.naco.gov.in/upload/Publication/Annual%20Report/Annual%20report%202012-13_English.pdf. [Last accessed on 2015 Sep 18].
5WHO, UNICEF, UNAIDS. Towards Universal Access. Scaling up Priority HIV/AIDS Interventions in the Health Sector. Progress Report 2011. Geneva: WHO; 2011.
6De Cock KM, Fowler MG, Mercier E, de Vincenzi I, Saba J, Hoff E, et al. Prevention of mother-to-child HIV transmission in resource-poor countries: Translating research into policy and practice. JAMA 2000;283:1175-82.
7Dorenbaum A, Cunningham CK, Gelber RD, Culnane M, Mofenson L, Britto P, et al. Two-dose intrapartum/newborn nevirapine and standard antiretroviral therapy to reduce perinatal HIV transmission: A randomized trial. JAMA 2002;288:189-98.
8Shah NK, Mehta K, Manglani MV. Prevention of mother to child transmission of HIV. Indian J Pract Pediatr 2003;5:337-47.
9National AIDS Control Organization. Annual Report; 2014-15. Available from: http://www.naco.gov.in/NACO/Quick_Links/Publication/Annual_Report/NACO_Annual_Report/Annual_Report_NACO_2014-15_English/. [Last accessed on 2015 Aug 11].
10World Health Organization. Consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection. Geneva: WHO; 2013.
11Sagili H, Kumar S, Lakshminarayanan S, Papa D, Abi C. Knowledge of HIV/AIDS and attitude toward voluntary counselling and testing among antenatal clinic attendees at a tertiary care hospital in India. J Obstet Gynaecol India 2015;65:104-10.
12Rogers A, Meundi A, Amma A, Rao A, Shetty P, Antony J, et al. HIV-related knowledge, attitudes, perceived benefits, and risks of HIV testing among pregnant women in rural Southern India. AIDS Patient Care STDS 2006;20:803-11.
13Bhardwaj A, Gupta B, Ahluwalia SK, Pathak R, Mittal A, Singh M. Women and AIDS: Awareness and attitudes in a peri-urban setting in Punjab. J Commun Dis 2011;43:61-8.
14Bachani D, Garg R, Rewari BB, Hegg L, Rajasekaran S, Deshpande A, et al. Two-year treatment outcomes of patients enrolled in India's national first-line antiretroviral therapy programme. Natl Med J India 2010;23:7-12.
15Nyamathi AM, Sinha S, Ganguly KK, William RR, Heravian A, Ramakrishnan P, et al. Challenges experienced by rural women in India living with AIDS and implications for the delivery of HIV/AIDS care. Health Care Women Int 2011;32:300-13.
16Henry K. The case for more cautious, patient-focused antiretroviral therapy. Ann Intern Med 2000;132:306-11.
17De AK, Dalui A. Assessment of factors influencing adherence to anti-retroviral therapy for human immunodeficiency virus positive mothers and their infected children. Indian J Med Sci 2012;66:247-59.
18Subramaniyan A, Sarkar S, Roy G, Lakshminarayanan S. Status of prevention of parent to child transmission services among HIV-positive mothers from rural South India. Indian J Sex Transm Dis 2014;35:104-8.
19Tadios Y, Davey G. Antiretroviral treatment adherence and its correlates in Addis Ababa, Ethiopia. Ethiop Med J 2006;44:237-44.
20McDonald K, Kirkman M. HIV-positive women in Australia explain their use and non-use of antiretroviral therapy in preventing mother-to-child transmission. AIDS Care 2011;23:578-84.
21Chesney MA. Factors affecting adherence to antiretroviral therapy. Clin Infect Dis 2000;30 Suppl 2:S171-6.
22Lodha R, Manglani M. Antiretroviral therapy in children: Recent advances. Indian J Pediatr 2012;79:1625-33.
23Seth A, Gupta R, Chandra J, Maheshwari A, Kumar P, Aneja S. Adherence to antiretroviral therapy and its determinants in children with HIV infection-Experience from Paediatric Centre of Excellence in HIV Care in North India. AIDS Care 2014;26:865-71.
24Weigel R, Makwiza I, Nyirenda J, Chiunguzeni D, Phiri S, Theobald S. Supporting children to adhere to anti-retroviral therapy in urban Malawi: Multi method insights. BMC Pediatr 2009;9:45.
25Paranthaman K, Kumarasamy N, Bella D, Webster P. Factors influencing adherence to anti-retroviral treatment in children with human immunodeficiency virus in South India – a qualitative study. AIDS Care 2009;21:1025-31.
26Bhattacharya M, Dubey AP. Adherence to antiretroviral therapy and its correlates among HIV-infected children at an HIV clinic in New Delhi. Ann Trop Paediatr 2011;31:331-7.
27Maman S, Mbwambo JK, Hogan NM, Kilonzo GP, Campbell JC, Weiss E, et al. HIV-positive women report more lifetime partner violence: Findings from a voluntary counseling and testing clinic in Dar es Salaam, Tanzania. Am J Public Health 2002;92:1331-7.
28Black BP, Miles MS. Calculating the risks and benefits of disclosure in African American women who have HIV. J Obstet Gynecol Neonatal Nurs 2002;31:688-97.
29Nguyen TA, Oosterhoff P, Pham YN, Hardon A, Wright P. Health workers' views on quality of prevention of mother-to-child transmission and postnatal care for HIV-infected women and their children. Hum Resour Health 2009;7:39.
30Kinsler JJ, Wong MD, Sayles JN, Davis C, Cunningham WE. The effect of perceived stigma from a health care provider on access to care among a low-income HIV-positive population. AIDS Patient Care STDS 2007;21:584-92.
31Wolfe WR, Weiser SD, Leiter K, Steward WT, Percy-de Korte F, Phaladze N, et al. The impact of universal access to antiretroviral therapy on HIV stigma in Botswana. Am J Public Health 2008;98:1865-71.
32Ma W, Detels R, Feng Y, Wu Z, Shen L, Li Y, et al. Acceptance of and barriers to voluntary HIV counselling and testing among adults in Guizhou province, China. AIDS 2007;21 Suppl 8:S129-35.
33Santamaria EK, Dolezal C, Marhefka SL, Hoffman S, Ahmed Y, Elkington K, et al. Psychosocial implications of HIV serostatus disclosure to youth with perinatally acquired HIV. AIDS Patient Care STDS 2011;25:257-64.
34Arun S, Singh AK, Lodha R, Kabra SK. Disclosure of the HIV infection status in children. Indian J Pediatr 2009;76:805-8.
35Lesch A, Swartz L, Kagee A, Moodley K, Kafaar Z, Myer L, et al. Paediatric HIV/AIDS disclosure: Towards a developmental and process-oriented approach. AIDS Care 2007;19:811-6.
36Vreeman RC, Gramelspacher AM, Gisore PO, Scanlon ML, Nyandiko WM. Disclosure of HIV status to children in resource-limited settings: A systematic review. J Int AIDS Soc 2013;16:18466.
37NACO. Pediatric Antiretroviral Therapy (ART) Guidelines. Available from: http://www.naco.gov.in/upload/2014%20mslns/CST/Pediatric_14-03-2014.pdf. [Last accessed on 2015 Nov 04].
38Behrman R, Kleigman R, Jenson H. Nelson Textbook of Pediatrics. 18th ed. Philadelphia: W.B. Saunders Company; 2007.
39Updated Guidelines on Prevention of Parent to Child Transmission (PPTCT) of HIV Using Multi Drug Anti-Retroviral Regimen in India. Available from: http://www.naco.gov.in/upload/NACP%20-%20IV/18022014%20BSD/National_Guidelines_for_PPTCT.pdf. [Last accessed on 2015 Nov 03].
40Hanna LE, Siromany VA, Annamalai M, Karunaianantham R, Swaminathan S. Challenges in the early diagnosis of HIV infection in infants: Experience from Tamil Nadu, India. Indian Pediatr 2015;52:307-9.
41Gupta A, Singh G, Kaushik P, Joshi B, Kalra K, Chakraborty S. Early diagnosis of HIV in children below 18 months using DNA PCR test – assessment of the effectiveness of PMTCT interventions and challenges in early initiation of ART in a resource-limited setting. J Trop Pediatr 2013;59:120-6.
42Alvarez-Uria G, Naik PK, Midde M, Pakam R. Predictors of delayed entry into medical care of children diagnosed with HIV infection: Data from an HIV cohort study in India. ScientificWorldJournal 2013;2013:737620.
43Subramaniyan A, Sarkar S, Roy G, Lakshminarayanan S. Experiences of HIV positive mothers from rural South India during intra-natal period. J Clin Diagn Res 2013;7:2203-6.
44Thomas B, Nyamathi A, Swaminathan S. Impact of HIV/AIDS on mothers in Southern India: A qualitative study. AIDS Behav 2009;13:989-96.
45Rahangdale L, Banandur P, Sreenivas A, Turan JM, Washington R, Cohen CR. Stigma as experienced by women accessing prevention of parent-to-child transmission of HIV services in Karnataka, India. AIDS Care 2010;22:836-42.
46Kumar A, Singh B, Kusuma YS. Counselling services in prevention of mother-to-child transmission (PMTCT) in Delhi, India: An assessment through a modified version of UNICEF-PPTCT tool. J Epidemiol Glob Health 2015;5:3-13.
47Mandal S, Bhattacharya RN, Chakraborty M, Pal PP, Roy SG, Mukherjee G. Evaluation of the prevention of parent to child transmission program in a rural tertiary care hospital of West Bengal, India. Indian J Community Med 2010;35:491-4.
48Darak S, Hutter I, Kulkarni V, Kulkarni S, Janssen F. High prevalence of unwanted pregnancies and induced abortions among HIV-infected women from Western India: Need to emphasize dual method use? AIDS Care 2016;28:43-51.
49Joshi B, Velhal G, Chauhan S, Kulkarni R, Begum S, Nandanwar YS, et al. Contraceptive use and unintended pregnancies among HIV-infected women in Mumbai. Indian J Community Med 2015;40:168-73.
50Chakrapani V, Kershaw T, Shunmugam M, Newman PA, Cornman DH, Dubrow R. Prevalence of and barriers to dual-contraceptive methods use among married men and women living with HIV in India. Infect Dis Obstet Gynecol 2011;2011:376432.
51Suryavanshi N, Erande A, Pisal H, Shankar AV, Bhosale RA, Bollinger RC, et al. Repeated pregnancy among women with known HIV status in Pune, India. AIDS Care 2008;20:1111-8.
52Ghadrshenas A, Ben Amor Y, Chang J, Dale H, Sherman G, Vojnov L, et al. Improved access to early infant diagnosis is a critical part of a child-centric prevention of mother-to-child transmission agenda. AIDS 2013;27 Suppl 2:S197-205.
53Panditrao M, Darak S, Kulkarni V, Kulkarni S, Parchure R. Socio-demographic factors associated with loss to follow-up of HIV-infected women attending a private sector PMTCT program in Maharashtra, India. AIDS Care 2011;23:593-600.
54Rochat TJ, Arteche AX, Stein A, Mitchell J, Bland RM. Maternal and child psychological outcomes of HIV disclosure to young children in rural South Africa: The Amagugu intervention. AIDS 2015;29 Suppl 1:S67-79.
55Cluver LD, Hodes RJ, Toska E, Kidia KK, Orkin FM, Sherr L, et al. 'HIV is like a tsotsi. ARVs are your guns': Associations between HIV-disclosure and adherence to antiretroviral treatment among adolescents in South Africa. AIDS 2015;29 Suppl 1:S57-65.
56Chandra J, Yadav D. Early infant diagnosis of HIV. Indian Pediatr 2015;52:293-5.
57Madhivanan P, NiranjanKumar B, Shaheen R, Jaykrishna P, Ravi K, Gowda S, et al. Increasing antenatal care and HIV testing among rural pregnant women with conditional cash transfers to self-help groups: An evaluation study in rural Mysore, India. J Sex Transm Dis 2013;2013:971458.
58Towle MS. Scaling up beyond 'pills and skills': Preventing parent-to-child HIV/AIDS transmission and the public/private divide in Southern India. Int J Health Plann Manage 2009;24 Suppl 1:S30-51.
59Bindoria SV, Devkar R, Gupta I, Ranebennur V, Saggurti N, Ramesh S, et al. Development and pilot testing of HIV screening program integration within public/primary health centers providing antenatal care services in Maharashtra, India. BMC Res Notes 2014;7:177.
60National AIDS Control Organisation. Ministry of Health and Family Welfare. Government of India. Antiretroviral Therapy Guidelines for HIV-Infected Adults and Adolescents Including Post-Exposure Prophylaxis; May, 2007. Available from: http://www.naco.gov.in/NACO/About_NACO/Policy__Guidelines/Policies__Guidelines1/. [Last accessed on 2015 Nov 05].
61Joshi S, Kulkarni V, Gangakhedkar R, Mahajan U, Sharma S, Shirole D, et al. Cost-effectiveness of a repeat HIV test in pregnancy in India. BMJ Open 2015;5:e006718.