Making strides in child HIV prevention

Yesterday, December 1, Malawi joined the rest of the world in commemorating of the World Aids Day. Among other areas that the country has performed well in the fight against Aids is the Prevention of Mother-to-Child Transmission (PMCTC). Our staff reporter AYAMI MKWANDA caught up with Karen Msiska, National Aids Commission (NAC) Corporate Services and Public Relations Officer. EXCERPTS:

What was the situation (number of infections) before the interventions to prevent pregnant and breastfeeding women from infecting their unborn (and newly-born) babies with HIV?

The estimated peak in the mother-to-child transmission (MTCT) of HIV was 1999. At that time the rate of new adult infections was also the highest. Statistics indicate that at that time, as many as 27 000 babies acquired the HIV from their mothers.

Anti-retroviral prophylaxis for HIV-infected mothers, which fosters prevention of MTCT of HIV, was introduced around 2002. However, the regimen given was not very effective and access to such initiatives remained sub-optimal, until 2011, when Malawi invented the Option B+ for PMTCT.

Under Option B+, all HIV-infected pregnant and breastfeeding women are placed on the life-prolonging anti-retroviral therapy (ART) immediately they are diagnosed with the virus. This is done regardless of their CD4 count.

Option B+ has proven very effective in preventing transmission during pregnancy, child birth and throughout the breastfeeding period. For example, in 2012, the estimated number of children that acquired the virus from their mothers had fallen to about 11 000.

What is the situation now?

Since coverage of Option B+ is wide among HIV infected women of reproductive age, there has been an ever-increasing population of women with suppressed viral load by the time they get pregnant for another child. As such, transmission of the virus by mother-to-child is minimized.

For example, this year, fewer than 4 000 babies are estimated to have contracted the HIV from their mothers. We envisage that by 2020, the number will drop to below 2 500.

What have been the efforts or initiatives that NAC has been making that have improved the situation?

NAC realizes that successful implementation of the national response to HIV and Aids hinges on concerted efforts by all players in the response. As such, NAC has been working with government and the civil society on implementation of HIV and Aids prevention, treatment, care and support programmes at national and community levels.

With support from government and the international donor community, NAC established a Grants Facility to engage all players in the response. Through the Grants Facility, the Commission has supported and continues to support various partners to scale up implementation of such programmes and increase coverage.

Apart from coverage, various sectors are also engaged to aim at maximum impact. The Commission supports partners to create demand for services and link such demand to service delivery facilities at every level of care. The supported partners are from across the country.

What are the struggles the country has encountered along the way?

There have been quite a number of challenges. For instance, at the onset of Option B+ for PMTCT, the policy put forward by the Ministry of Health and Population was not recommended by the World Health Organization (WHO) as it was deemed too radical. No other country in Africa had considered that model for PMTCT.

There was also need for more funding to pay for the additional patients on life-prolonging ART. Thankfully, the country re-programmed a grant from the Global Fund to mobilize the needed resources. And a year later, results from implementation of the model convinced WHO that Option B+ was the best for all low-income countries. Thus, WHO endorsed it and the initiative has since been the benchmark for the present universal ART policy, which is to immediately enrol anyone who tests HIV positive on the life-prolonging ART, instead of waiting for their CD4 count to reduce. Malawi started implementing this ‘Test-and-treat’ policy last year.

Which areas are remaining that should be addressed to achieve zero cases MTCT of HIV?

According to the WHO, with PMTCT, the risk of a mother transmitting HIV to a child during pregnancy, child birth and breastfeeding is as low as five percent. As such, dealing with that five percent risk is one of the tasks the country has.

Reducing the rate of new infections among adults is another task for the country, as doing so would contribute massively towards reducing MTCT of HIV. We reckon that if a woman acquires the HIV during pregnancy or breastfeeding, the risk of her transmitting it to the child is high because the tests leading to them being placed on Option B+ are often done on their first antenatal visit. Further, it is difficult to detect and treat early infections among women that are breastfeeding.

It is anticipated that by the end of the year, 75 percent of all HIV infected Malawians will be placed on ART. Therefore, another task is working to place the remaining 25 percent on ART. Research has pointed towards the fact that once a person is on ART and adheres to the treatment, the risk of onward transmission to a sexual partner or from mother to child is almost eliminated. The high-level ART coverage indicated earlier means that the number of HIV-infected people who can infect others has drastically reduced. Luckily, an estimated 90 percent of patients on ART are well adherent to treatment and have their viral load suppressed.

Where does Malawi rank in southern Africa and in the world in terms of PMTCT?

As indicated earlier, Malawi’s Option B+ model informed the current global HIV treatment policy. As such, we can comfortably say we are way ahead of the rest.