World AIDS Day 2012: From Cleveland to Kigali: Why We Work for an AIDS-Free Generation

World AIDS Day 2012: From Cleveland to Kigali: Why We Work for an AIDS-Free Generation

Malawi mother and children {Photo credit: MSH.}Photo credit: MSH.

I got a call from the resident doctor to come to exam room 6. As soon as I entered the room, I prepared myself. The little girl, 7- or maybe 8-years-old, didn't look well; she was “floppy,” combative, and not entirely aware of where she was or what we were doing to her. She was HIV-positive, and my colleague needed to get an IV line in her arm to test the latest in experimental treatments for kids with HIV– and needed the four of us interns to help hold her still.

It was 1993 during my residency in pediatrics in Cleveland, Ohio. We were at one of the best children’s hospitals in the world; it didn’t matter. The young girl died a few months later.

With the advent of antiretroviral therapy (ART) a few years later, the whole world changed. The world of HIV medicine blossomed; new drugs and drug combinations literally exploded with amazing effect. HIV-positive mothers could give birth to HIV-negative babies, and HIV-positive children and their moms could get treatment.

Now, eliminating pediatric HIV is on the agenda. US Global AIDS Coordinator Ambassador Eric Goosby and Executive Director of UNAIDS Michel Sidibé announced the goal to eliminate pediatric HIV by 2015 last year.

We want our policymakers to think big and to provide the support and resources to make the impossible possible. But how are we actually going to get there? Do we have the required funding and innovative thinking devoted to the effort? What is really possible on the frontlines -- and what is not?

Yesterday, the President’s Emergency Program for AIDS Relief (PEPFAR) outlined how the US will achieve its goals through its Blueprint: Creating an AIDS-free Generation (PDF).

The Blueprint is challenging and bold.

We applaud PEPFAR for the emphasis on the evidence base and on investing in implementation science and research. This is exactly the type of work that MSH can contribute to: figuring out the best way to find kids who may be HIV-exposed or infected and get them to the care they need.

Our best bet toward eliminating pediatric HIV? Ensure prevention of mother-to-child transmission (PMTCT).

While many amazing and dedicated clinicians and program folks have worked long and hard to make Option A and B for PMTCT work, the truth is that too many women and babies are still lost in the process. We need to beef up existing PMTCT programs using Option A or B, and where it’s not working, move to creative and innovative approaches such as the Option B+ model started in Malawi. With Option B+, if a mom gets diagnosed during pregnancy, she is offered ART for life --- even without a CD4 count. Other countries are exploring Option B+, yet Malawi is currently the only country implementing it.

It’s time for more countries to follow Malawi’s lead.

In addition to considering new methods for PMTCT, we need to come up with ways of finding the babies and children who are missed because they never have the opportunity to get diagnosed in antenatal care. Despite our best efforts, nearly half of all moms never make it into antenatal care. A proportion of those women are infected with HIV and, of course, their babies are born exposed or infected. We never know about these infected and affected children – until they get sick. In Malawi, for example, we found that we could reach women and children through immunization clinics, who otherwise had fallen off the PMTCT cascade, or were never tested in the first place. Testing all children who present sick to hospitals is another option. We need the political will and resources to seek and find those at-risk babies and moms.

Lastly, a strategic focus on key vulnerable populations—drug users, sex workers and men who have sex with men--- is long overdue. We hope this will translate into real and effective programming on the ground.

Today, we’ve achieved the goal of elimination of mother to child transmission and hence pediatric HIV in places like New York City, London and Melbourne --- too late for the little girl from Cleveland. But in Kigali, Nairobi, and Johannesburg and elsewhere in the Global South --- we’ve got a long way to go. As we commemorate World AIDS Day, it is time to start thinking seriously about what it will take to eliminate pediatric HIV.

Scott Kellerman, MD, MPH, is MSH's Global Technical Lead for HIV & AIDS.

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Michael Kanyingi
In order to get to Zero infection, We also need to realize that fear of getting tested for HIV in pregnant mothers is real in a great percentage of women in Africa especially in Kenya. This make some of them seek the services of private clinics and delivery by TBAs. Considering that most TBA and traditional motherhood mentors are older women 50+, we need to involve older women in all pediatric HIV interventions. Older people are also key to the breastfeeding activities by their daughters and daughters in law, we cannot ignore them. It is high time we put emphasis in this critical area.
Dr Mulwani Eris...
let us mobilize all the pregnant women in our communities through the community structures including all leaders both political and non political. in the pregnant mother come for Option B+ then we shall have to eliminate pead HIV. Not forgetting the prevention strategies of ABC +D and SMC
Irene Amadu
Pediatric HIV/AIDS is increasing in Nigeria through mother-to-child transmission. Lack of diagnostic facility and affordability of therapy are major constraints. In remote areas in Nigeria the risk of mother to child transmission has been high due to low attendance of ANC resulting in lack of awareness. A mix of religion and culture have affected a lot of expectant mothers in certain areas of the country were attendance of ANC is only allowed when necessary by senior family members. Traditional birth attendances are preferred to skilled birth attendance in these areas. The TBAs have little or no Knowledge of HIV or mother to child transmission. Women are only referred to hospitals by TBAs under emergency condition so most times an HIV expectant mother gives birth at home thus increasing the chances of transmission of infection to new burn.
Ezati Eric
I really appreciate the efforts put in fighting the war against HIV/AIDS through PMTCT and all the available means. As someone in the field of HIV/AIDS medicine, the reality is it is the poor and the most at risk population where a lot needs to be done and the call for political leaders and policy makers is commendable one and we hope these wonderful words will find way to the right people. We have HIV/AIDS progrmms that are non-govrnmental organizations that are doing wonderful job but their contributions are like a drop in the ocean. Governments need to adress the issues of human resource both in recruitment and retention which is really in need especially rural areas which are hit hard the most in terms of human resource for health in general, problems of medical supplies which are lacking in forms of drugs and equipment for PMTCT services in most rural areas and follow up of such mothers and children after discharge from hospitals and healh facilities is also another challenge which needs to be addressed to achieve zero transmission of HIV to the as targeted. This will need full involvement of the community to own such a programme so that they take the lead from down as leading from up is not easy as seen, therefore all stakeholders politicians, church leaders, cultural leaders and above all bringing men in the fore front can work as leaving out men who have the lead in deciding family affairs will still have lots of gaps to fill
Tom Rogers Muyu...
re: ELIMINATION OF HIV among children Thanks for sharing. I got my interest in HIV Medicine during my work in Uganda since 1993. I have worked with rural, semi-urban, urban, displaced camps and island communities. In all these communities the expectation of a child or child-birthing is a ceremony many look forward to. But, still in many cases where we had expectant mothers, a casual talk with them around their delivery plans showed they preferred TRADITIONAL BIRTH ATTENDANTS-TBA's. Universal practices that will help eliminate HIV in children will require TBA's to be empowered as anti-HIV health workers. The second step would incentivising attendances of expectant mothers at clinics with their male partners as it provides learning about risks of transmission and how to avoid them. Teenage pregnancies among sexually active young persons are common and there is need to increase young persons friendly services that endeavour to empower them with safer sex negotiation skills. Testing for HIV should be made free and universal at various levels of communities. This will help in providing entry points to treatment, prevention and care for many beneficiaries among who include potential partners.If this can be added to the treatment and prevention components we are destined for an HIV-free childhood.

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