REDUCING MOTHER TO CHILD TRANSMISSION OF HIV:
A Child Survival Programme For The Caribbean
Dr B. Camara, Dr M. de Groulard, Dr C. J. Hospedales*
Since 1982, the Caribbean has been challenged by a
growing AIDS epidemic. This epidemic has already
had negative impacts on various population subsets
and it is compromising successes achieved in public
health in this region and specifically in the area of
the child survival programmes. If not addressed this
epidemic will hamper the social and economic
development of this region. The implementation of
adequate programmes aimed at reducing mother-tochild transmission (MTCT) of HIV will contribute
to minimising the adverse impact of AIDS among
Caribbean children and communities.
NATURAL HISTORY OF MOTHER TO
CHILD TRANSMISSION OF HIV
The human immuno-deficiency virus (HIV) can be
isolated from abortion products (1) within weeks of
conception. As other known pathogens (Treponema
Pallidum, Rubella Virus, etc.) the virus reaches the
foetus through the physiological blood exchange
between the mother and child through the placenta
during pregnancy, labour and delivery. For HIV the
risk of transmission to the child also exists through
breast milk.
From many studies conducted world wide,
the rate of mother to child transmission on HIV
ranges from 13% to 48%. 2/3 of this transmission
occurs in the prenatal and intra-partum period and
1/3 in the postpartum period due to breastfeeding
(2,3). According to these studies, the risk factors (14)
influencing mother to child transmission of HIV
are: degree of maternal immune deficiency, low
maternal CD4 cell count, increased maternal plasma
viral load, other prevalent endemic communicable
diseases, low maternal serum Vitamin A
concentration, prolonged labour, vaginal or
traumatic deliver, presence of other Sexually
Transmitted Infections chorioamnionitis, HIV
biological phenotype/subtype, premature rupture
of membranes, prematurity, breastfeeding and
mastitis during breastfeeding.
Among HIV infected children, mother-to-child
transmission is the most important category of
transmission. In the Caribbean, results of studies
conducted on the natural history of mother to child transmission of HIV have shown that the rate of mother to
child transmission of HIV is 28% (4).
PUBLIC HEALTH IMPORTANCE OF HIV/AIDS
AMONG CHILDREN IN THE CARIBBEAN
Since the first AIDS case was described in Jamaica in
1982 (5) to the end of 1998, CAREC estimates that more
than 15,000 cumulative AIDS cases have occurred in its
21 Member Countries, representing 230 cases per
100,000 population (6). Gradually, the AIDS epidemic is
taking a heavy toll on the Caribbean population. Since
1995, AIDS has become the leading cause of death
among the 15-49 years old in many CAREC Member
Countries (7). The Caribbean leads the Western
Hemisphere in terms of annual incidence of AIDS cases
(8)
. and is second in the world after sub-Saharan Africa in
terms of HIV prevalence among adults (9).
This epidemic which has started as a homo/bisexual epidemic, became a primarily heterosexual epidemic three years later in 1985 with steady increasing
number of AIDS cases among women (30% of the total
cumulative adult cases) and children (7% of the total
cumulative cases) being observed in this region. However, ten years later, at the end of 1995, CAREC, through
a critical analysis of available HIV and AIDS epidemiological, behavioural and socio-cultural information,
has concluded that the Caribbean HIV epidemic is a
mixed, homo/bi and heterosexual epidemic continuously
fuelling one another (10). The immediate implication of
that situation is that young adults (hetero and homo/bisexual) and children are infected and developing the
disease alike with parallel increasing trend in both
groups.
To understand the real impact of the HIV
epidemic on Caribbean children, this analysis will
underline the magnitude of the AIDS epidemic and its
related mortality among this group. It will also focus on
the benefit to be gained if public health interventions
Reducing Mother to Child Transmission of HIV : A Child Survival Programme for the Caribbean
1
aimed at reducing mother to child transmission of
HIV were implemented in the Caribbean. To
achieve that perspective, the three important
following parameters will be taken into
consideration:
Graph1:
HIV Prevalence among Pregnant Women 1990-1996
8%
7%
6%
5%
HIV Prevalence Among Pregnant Women
4%
(11,12,13)
AIDS Incidence Among Children: 1982-1998
Three years after the first AIDS case was described
in Jamaica, the first 16 cases among children were
reported. Since that period to the end of 1998, a
steadily increasing AIDS incidence trend in
children is observed with a peak in 1996 when 122
cases were reported. At the end of 1998 a total of
824 AIDS cases were reported among children from
19 of 21 CAREC Member Countries (see Graph 2).
2
3%
2%
1%
0%
1990
1992/3
1994
1996
Jamaica
0.14%
0.44%
0.6%
2%
Trinidad and Tobago
0.3%
0.6%
1%
3.7%
7.1%
Guyana
1%
Belize
2%
Graph 2:
Reported AIDS Cases Among Children: 1982 –1998
140
120
100
80
60
40
20
*1998
1996
*1997
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
0
1982
Since 1990, HIV prevalence surveys
have
been established and implemented using different
methodologies depending on the existing national
policies. In a few countries many periodic
anonymous and unlinked surveys have been
conducted, and in others voluntary counselling and
testing of cohorts of pregnant women undertaken.
To minimise bias introduced by selfselection, the focus in this article will be on
anonymous and unlinked surveys conducted among
pregnant women in CAREC Member Countries. To
understand the HIV trend among this group, only
countries where successive surveys were conducted
will be included in this analysis. These countries
are: Belize, Guyana, Jamaica and Trinidad and
Tobago.
The HIV trend among pregnant women is
increasing in all those four countries (see Graph 1).
The dynamic varies from country to country. The
interpretation of the observed trends should take
into consideration the different methodologies used
to conduct those surveys (cross sectional in some
and sentinel sites in others). However, it is important to underline that in many instances, high HIV
seroprevalence rate was observed among the young
mothers (15-24 years old) compared to the older
age groups. These young mothers are the ones who
have the opportunity to make multiple children.
This underlines the urgent need for the programmes
in the Caribbean aimed at reducing mother to child
transmission of HIV.
*Turks and Caicos, Suriname, St Kitts and Nevis, Belize and Anguilla have
not reported in 1997 and 1998.
AIDS cases among Caribbean children are mainly due to mother-to-child transmission of HIV (95 per
cent). There is no case attributed to child-to-child horizontal transmission through routine close contact even
after biting. There is therefore no reason for excluding
HIV infected children from communities (family life,
day-care, school). A particular exceptional case would
be mental disorder or a terminally ill child with AIDS.
Other possible category of HIV transmission in children
includes child abuse about which information is not
available.
Overall the underreporting of AIDS cases among
children is probably substantial (14-15). This conclusion is
supported by the difficulties to diagnose HIV infection
Dr. B. Camara ; Dr. M. De Groulard ; Dr. C. J. Hospedales
among children, the increasing HIV prevalence
among pregnant women and the large percentage
represented by neonatal mortality in the infant
mortality figure as observed in many countries (16).
Taking into account the HIV prevalence
among pregnant women in Jamaica in 1994 and
1996, and in Trinidad and Tobago in 1992 and 1996
(See Graph 1), the expected HIV infected children
in those two years (assuming a 28% transmission
rate, and a total of 50,000 live births per year) will
be 84 and 280 respectively in Jamaica, and in
Trinidad and Tobago (assuming a 28% transmission
rate and a total of 18,000 live births per year) will
be 30 and 50 respectively (14).
AIDS Epidemic And Child Mortality
In several studies conducted in sub-Saharan Africa,
HIV 1 infection among mothers was significantly
associated with increased rates of neonatal death,
prematurity and malnutrition (1) compared to children born to HIV negative mothers. However, the
evolution of HIV infection among children varies
according to different factors (socio-economic status of the mother, the status of her immune system
and the availability of good health care systems) but
essentially to the timing of the transmission.
In the Caribbean, the impact of the AIDS
epidemic on this specific group is reflected by high
infant mortality rates in some instances. As
demonstrated in the Bahamas (16) from 1989 to 1994
AIDS moved from fifth to being the third ranked
cause of death in infants. The mortality rate due to
AIDS increased more than twice, from 1.2 in 1989
to 2.8 per 1000, live births in 1994.
In Barbados (17) from 1985 to 1995, 47 children were diagnosed with HIV, and their medical
records showed that among them 41 were symptomatic (87%), while 6 remained asymptomatic
(13%). Among the symptomatic children 19 (46%)
developed symptoms during infancy and 22 (54%)
in the post infancy period. The median time of diagnosis was 13 months and the median survival time
was 10 weeks after diagnosis. During the period of
observation, mortality among symptomatic children
who developed symptoms during infancy was higher than in the symptomatic children who
developed symptoms in the post infancy period
(74% versus 43%). The analysis of AIDS related
deaths among children in Barbados indicated that
early mother-to- child transmission of HIV
represented 40% of the total HIV infected children, and
that it was associated with a high percentage of early deaths.
In this region, even in instances where infant
mortality has stabilised, the neonatal mortality has
remained high (16). This could mean that the gain
expected in the infant mortality due to successful public
health programmes for mothers and children (e.g.
immunisation programmes) is being eroded because of
this high neonatal mortality rate.
Despite the fact that CAREC is not collecting
information related to AIDS orphans, a few country
reports mention their existence (e.g. Antigua and
Barbuda has reported 9 cases of AIDS orphans (15) and
their difficult living conditions. Because of the fact that
the majority of the reported AIDS cases in the region are
among the 15 to 44 age group - the pillar of any socioeconomic development and stability in any given country caring for its children and supporting the elderly and because of the high AIDS related mortality (63%) (6),
it can be concluded that at the beginning of a new
millennium, AIDS poses a double challenge to the
Caribbean children: It is killing them as well as their
natural supports.
Although any accurate evaluation is yet to be
conducted, it is safe to conclude the AIDS epidemic is
impacting on the infant mortality rate and consequently
on the life expectancy at birth in the Caribbean, as it has
been demonstrated in many instances in Sub-Saharan
Africa (9).
SELECTED REGIMENS USED TO REDUCE
MOTHER TO CHILD TRANSMISSION OF HIV
AND THEIR RESULTS
Since 1994 when the first study was conducted in France
and the USA on reduction of mother-to-child
transmission of HIV, a number of protocols (18) have
been developed aimed at reducing the cost to make them
affordable for developing countries, and at simplifying
the compliance in order to improve the adherence to the
intervention (see Table 1).
The Caribbean Cooperation in Health (CCH)
initiative has set the target of reducing by 50% the rate
of mother-child transmission of HIV in the Caribbean by
2003. In October 1998, a regional consensus meeting
convened by CAREC agreed to the policy that all
pregnant women should be offered an HIV test, and, if
infected, offered at least the Thai-CDC short regimen
Reducing Mother to Child Transmission HIV: A Child Survival Programme for the Caribbean
3
(14)
. The use of Nevirapine would also appear to be a
good alternative, and will be the intervention used
by Jamaica.
country, the number of reported AIDS cases in children
dropped from 20 in 1997 to 6 in 1998 (6).
At the end of 1997, in the Caribbean estimating
that the HIV prevalence rate among pregnant women
was between 1% and 2%, it was expected that during
that year between 1,300 to 2,600 children would be born
to HIV+ mothers. Taking into account the mother to
child HIV transmission rate of 30%, between 390 and
780 children (1 or 2 on daily basis) were born infected or
contracted HIV from post natal exposure. If the CDCThailand regimen were in place (50% reduction rate)
between 195 and 390 lives would have been saved on an
annual basis (18). This could have reached 324 and 648
lives saved with the Nevirapine regimen (with an
adjusted estimate of 83% reduction rate of transmission).
Economic gains will be achieved through the
cost per averted HIV infection which, using the ThaiCDC regimen, is estimated at between US$ 6,000 to
7,000, (18) assuming a 1% to 2% HIV prevalence rate
among pregnant women in the Caribbean during 1997,
making this a demonstrably cost effective public health
intervention. This cost per averted HIV infection could
even be higher when the Nevirapine regimen is used.
BENEFITS FROM PROGRAMMES AIMED
AT REDUCING MOTHER TO CHILD
TRANSMISSION OF HIV FOR THE
CARIBBEAN
There are many benefits (19) to be derived
from the implementation of programmes aimed at
reducing mother to child transmission in the region.
Health benefits will be achieved through a
rapid decreasing trend in child mortality. To date
only a few Caribbean countries have embarked on
programmes aimed at reducing mother to child
transmission of HIV and most of them started very
recently. The results of their impact are therefore
limited. There are however a few important results
to be reported. For example, studies conducted in
Barbados have shown that during the last five years,
the number of children under 1 year old who died
from AIDS has decreased relatively because of the
use of AZT during pregnancy among HIV positive
women (16). Similarly in the Bahamas, the mortality
rate due to AIDS dropped from 2.8 in 1994 to 1.1
per 1,000 live births in 1995 because of the universal uptake of programmes aimed at reducing
mother-to-child transmission of HIV (with
immediate reduction rate of 57% (4). In the same
RECOMMENDATIONS
The AIDS epidemic is having a negative impact on child
survival in the Caribbean. As demonstrated in the
Bahamas, public health interventions aimed at reducing
mother to child transmission of HIV can have immediate
Table 1: Antiretroviral Interventions to reduce Mother-to-Child Transmission of HIV
Study
ACTG 076
/ANRS024 France
Modified ACTG076
Bahamas
Thailand-CDC
Modified
Uganda HIVNET
012
4
Pregnancy
ZDV 100mg orally
5 times daily from
14-34 weeks
CD4>200
ZDV 100mg orally
5 times daily from
14weeks to end
pregnancy
ZDV 300 mg twice
daily from 36
weeks
Nevirapine single
200mg dose orally
at onset of labour
Labour
New-born
Efficacy
Breastfeeding
ZDV 2mg/kg IV in 1
hr. then 1mg/kg/hr
IV (infusion)
2mg/kg orally 6 th
hourly for 6 weeks
68% (infection
status at age 18
months)
No
Infant formula is
provided
ZDV 2mg/kg IV in 1
hr. then 1mg/kg/hr
IV (infusion)
2mg/kg orally 6 th
hourly for 6 weeks
57% (infection
status at age 4
months PCR)
No
Infant formula is
provided
ZDV 300 mg orally
every 3 hours
No
No
Nevirapine single
dose of 2mg/kg
within 72 hours of
birth
51% (infection
status at age 6
months)
50% (infection
status at age 1416 weeks). Could
be 83% in non
breastfeeding
population
No
Infant formula is
provided
Done in
breastfeeding
population.
Dr. B. Camara ; Dr. M. De Groulard ; Dr. C. J. Hospedales
impact by reducing child mortality, and the
immediate cost efficacy of these interventions are
demonstrable. Therefore to continue to save lives
and improve the health status of Caribbean children,
CAREC recommends that:
-
Programmes aimed at reducing mother to child
transmission of HIV should be implemented in
the region with clear policy guidelines that
protect individual rights and use the health
promotion strategies.
-
Adequate
voluntary
counselling
and
confidential HIV testing programmes should be
made available to sexually active youths, and
women in child bearing age.
-
Effective and expanded information and
education programmes related to reproductive
health and to prevention of HIV/AIDS and
other Sexually Transmitted Infections should be
implemented, targeting youths, women in
childbearing age and their sexual partners.
-
-
-
-
Prior to pregnancy, all women should have
access to consistent and updated information
related to protection against HIV infection and
the benefit of the programmes aimed at
reducing mother to child transmission of HIV.
All pregnant women and their partners should
be adequately prepared through counselling and
psychosocial support to understand and adhere
to the process of voluntary testing for HIV, and
the interventions needed if the result is positive.
All HIV+ pregnant women should receive at
least the Thai-CDC regimen or the Nevirapine
HIVNET 012 regimen.
Counselling and psychosocial support of HIV +
pregnant women and their partners and children
is complex and resource and time consuming.
The expertise and resources available at
community level should be drawn upon. This
should include the establishment of networking
systems between the health sector and
community based organisations.
-
A network of specialists should be established at
country and regional levels to assist and advise on
the treatment and follow-up of HIV+ individuals
including HIV + pregnant women.
- At country level, mechanisms should be
implemented to offer confidential tracing or
notification, and voluntary and confidential HIV
testing to partner of HIV+ pregnant women.
This will enhance the impact of the programme.
-
All children born to HIV positive mothers who have
received AZT or Nevirapine treatment should, under
optimum hygienic conditions, receive alternatives to
breastfeeding provided by the family or the
government when families cannot afford these
alternatives.
-
All HIV- children born to HIV+ mothers should
benefit from child survival programmes such as
immunisation and other postnatal services
-
All HIV+ children born to HIV+ mothers should
benefit from a management plan, taking into account
the prophylaxis measures and the restrictions on the
use of live vaccines.
-
Social welfare packages including adoption, foster
care and schooling possibilities should be
implemented for all children born to HIV+ mothers,
regardless of their HIV status.
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*Correspondence: Dr Bilali Camara
Caribbean Epidemiology Centre (CAREC)
Pan American Health Organization/
World Health Organisation
P.O.Box 164,
16-18 Jamaica Boulevard,
Federation Park, Port-Of-Spain
Tinidad and Tobago, West Indies.
6
Dr. B. Camara ; Dr. M. De Groulard ; Dr. C. J. Hospedales