Lorna Hamilton Henry is an HIV and AIDS activist in the Caribbean. She is also very open about her HIV status and advocates for and behalf of all persons living with HIV. Lorna is also the mother of two healthy children, but as she reminds everyone, an HIV mother giving birth in the Caribbean is treated much differently than expectant mothers who are not living with the disease.
Lorna speaks openly of her life and as a mother living with the disease as she hopes that in so doing others would come forward about their own life experiences to help combat the stigma and discrimination association with HIV and AIDS.
"When you are pregnant and living with HIV you are not treated like other mothers. You notice the treatment from health care workers at clinics and even from other mothers. They look at you strangely because you don't breast feed. They even treat your children differently because they think that your children are also living with the disease."
However, the Caribbean is making new strides in the Prevention of Mother-to-Child transmission (PMTCT). A little over a year ago, the Pan American Health Organization (PAHO) and UNICEF hosted two meetings at the 17th International AIDS Conference in Mexico with Caribbean experts and policy makers, to assess the feasibility of eliminating Mother-to-Child Transmission of HIV and Syphilis in the Caribbean. As of October 2009, PAHO and UNICEF had implemented a programme titled "Towards Elimination of Mother-to-Child Transmission of HIV and Congenital Syphilis in Latin America and the Caribbean."
Speaking of the initiative, Dr. Amalia Del Riego, Head/Senior Adviser of the PAHO HIV and AIDS Caribbean Office (PHCO), the Caribbean was the first region to publicly and boldly consider the target of elimination of mother-to-child transmission of HIV and Syphilis, beyond academic boundaries.
She explained that the Caribbean region, with an estimated 0.9–1.2% of HIV prevalence rate in the general population, has the second highest estimated burden of HIV infection in the world. Mother-to-child transmission of HIV constitutes an estimated 8-10% of all transmissions in the region.
After careful consideration, the stakeholders, including Ministers of Health and regional and international health care providers among others concluded at the last International AIDS Conference in Mexico target of elimination of transmission of HIV and Syphilis in the Caribbean is feasible and necessary based on the following:
- Antenatal care service coverage is reasonable to high in most Caribbean states and territories
- In most countries screening of pregnant women for Syphilis is part of the routine antenatal care services package. However, the coverage of Syphilis screening is not universal, and remains lower than 50% in some countries
- The Americas have committed to eliminate Congenital Syphilis since 1995
- In their 2008 Universal Access and UNGASS progress reports, most countries in the region reported promising and significant achievements in the screening of pregnant women for HIV as part of their PMTCT programs, but significant gaps remain in some countries
- Antiretrovirals (ARVs) and other interventions are available in most countries and territories in the Caribbean region for HIV positive pregnant women to reduce the vertical transmission of HIV to their newborns.
Investigators have found that illness early in pregnancy and bacterial vaginosis are both associated with MTCT of HIV in the womb. The use of antiretroviral treatment during pregnancy and the avoidance of breastfeeding can cut the risk of MTCT of HIV.
Such interventions are now widely implemented and it is estimated that 20-50% of the transmissions that still occur take place in the womb (or in utero). Previous research has identified viral load, lack of antiretroviral treatment during pregnancy and low birth weight as risk factors for HIV transmission in the womb.
"We are very pleased to conclude that the Elimination Initiative has been adopted by the whole Americas region, and has even gone global" Dr. Del Riego noted. Ms. Carla Bruni-Sarkozy, the Global Fund's Ambassador for the protection of mothers and children against AIDS at last year's opening of the United Nations General Assembly in New York called on everyone to commit to eliminating the transmission of HIV from mothers to children by 2015.
To combat mother-to-child transmission, a comprehensive four pronged strategy to prevent HIV among infants and young children was initiated in 2003. The approach recommends a set of key interventions to be implemented as an integral component of essential maternal, newborn and child health services.
The first and second prongs emphasize the important role of primary prevention of HIV among women of reproductive age and of preventing unintended pregnancies among women living with HIV. The third prong of the strategy targets pregnant women already infected and demands that HIV testing be integrated in maternal child health units where ARVs are provided to prevent infection being passed on to their babies and also the woman's own health; and adequate counseling is provided in the best feeding options for the baby. Finally, the fourth prong calls for better integration of HIV care, treatment and support for women found to be positive and their families.
Over the past year, the Caribbean has made firm progress in the development of the Elimination Initiative. In partnership with UNICEF and PAHO, a concept document was prepared that outlines the strategic approaches to be applied on regional and national levels, guidelines were developed, and a monitoring and evaluation framework was drafted. Countries initiated implementation of the initiative, through development and adaptation of national protocols and guidelines, horizontal collaboration to share and exchange experiences and expertise and training of staff.
Dr. Del Riego said: "The Caribbean has demonstrated public health leadership in the past, and we are convinced that the region has the potential to become the first region in the developing world to achieve the elimination targets."
Additionally, the elimination initiative provides a challenge and an opportunity to put in-country and cross country solidarity into action, and genuinely work together to achieve this ambitious but feasible target through sharing of lessons learned, expertise and other resources.
In many Caribbean countries, dedicated efforts aimed at routine control have resulted in very low incidence of mother-to-child transmission of HIV and Congenital Syphilis. Elimination will need a qualitatively more intense application of the Caribbean resources and energies. As such, effective implementation will require political and technical leadership with the full support of the governments and medical practitioners.
This initiative provides both challenges and opportunities for the Caribbean to intensify its efforts to fix their health care systems to reach and provide quality services for the under-served and the vulnerable and to rally around a cause that affects the region's children and women.
PMTCT Around the World
Most countries are making remarkable progress towards PMTCT of HIV, particularly in sub-Saharan Africa, however, mother-to-child transmission of HIV continues to occur in children during pregnancy, labour and delivery, or breast feeding, at a time, when there are available effective interventions to curb the infection and better resourced countries have been able to bring the risk of children infected to less than 2%.
UNICEF estimates indicate that in 2007 approximately 420,000 children were newly infected in 2007, over 90% of them in sub-Saharan Africa. Without treatment, an estimated half of these infected children will die before their second birthday.
With 77% of women (70 million) in these countries having access to at least one antenatal care visit, this provides the opportunity for all these women to have access to PMTCT. However, this remains a missed opportunity for many women. In 2005, approximately 123 million women were estimated to have given birth globally in low and middle income countries. Additionally, in the same year, the proportion of women accessing testing in these countries was estimated to be around 10% and of the estimated number of infected pregnant women, only 11% received PMTCT ARVs. The near universal acceptance of HIV testing among pregnant women who received counseling for PMTCT illustrates that women desire and need this important bridge to prevention and treatment services.
Taking PMTCT programmes to scale remains a challenge. In 2005, only seven countries including Argentina, Botswana, Brazil, Jamaica, Russian Federation, Thailand and Ukraine; provided ARV prophylaxis to more than 40% of HIV infected pregnant women. Except for Botswana, all of these countries lie outside sub-Saharan Africa, the most affected region.
Allison S. Ali
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