Are we failing children in the HIV response?

Shobha Shukla

The promise was that by 2020, no child will be born with HIV or newly infected with HIV during breastfeeding across the world. Even before the Covid-19 pandemic posed an unprecedented challenge to health systems, the progress towards the HIV-related 2020 goalpost, despite some commendable gains, was not very encouraging.

Despite global efforts to prevent HIV transmission, 150,000 children were either born with or were newly infected with HIV during breastfeeding in 2019, bringing the total number of children (aged 0 to 9 years) living with HIV to 1.1 million. Also, about 310 children died from AIDS-related causes every day in 2019, mostly because of inadequate access to HIV prevention, care and treatment services.

This is unacceptable – inflicting HIV on kids for no fault of theirs. It is our moral duty to eliminate vertical transmission of HIV from parent to child and ensure every baby’s right to enter the world free of HIV.

Start free, stay free, AIDS free

This is also one of the aims of the Start Free, Stay Free, AIDS Free super fast-track framework launched by UNAIDS in 2015 for ending AIDS as a public health threat among children, adolescents and young women by 2020. One of its main goals was to reduce the number of children newly infected with HIV annually to less than 20000 by 2020. But with 150,000 new pediatric HIV infections in 2019, we are far away from achieving it.

Unfulfilled promise of prevention of parent to child transmission of HIV

HIV can be transmitted from an HIV-positive mother to her baby during pregnancy, childbirth or breastfeeding. Mother-to-child transmission, which is also known as vertical transmission, accounts for the vast majority of infections in children.

Factors contributing to vertical transmission are:

(i) mothers get infected during pregnancy/ breastfeeding;

(ii) mothers do not receive lifesaving antiretroviral treatment (ART) during pregnancy/ breastfeeding;

(iii) mothers drop off ART during pregnancy/ breastfeeding

If a pregnant woman living with HIV is not on ART, the likelihood of the virus passing from her to her baby is 15% to 45%. However, ART interventions, to her and her new-born, could reduce this risk to less than 2%. In the last 10 years there has been a 40% decline in new HIV infections annually in children, thanks to increase in coverage of HIV positive pregnant women with ART. But 20% of such women are still not on treatment which they urgently require.

To be fully effective, a full gamut of services should be offered to HIV positive women before conception, throughout pregnancy, labour and breastfeeding as per standards of prevention of mother to child transmission of HIV. These include early infant diagnosis at 4 to 6 weeks after birth, testing at 18 months or when breastfeeding ends, and ART initiation as soon as possible for HIV-exposed infants to prevent HIV acquisition. However, retaining women and infants in programmes for prevention of mother to child transmission of HIV, post-delivery, could be challenging. In some countries more infant infections are now occurring during the breastfeeding period than during pregnancy.

Closely linked to prevention of mother to child transmission of HIV, is the goal of achieving elimination of mother to child transmission, along with Syphilis, by 2030. Here also we are lagging behind. As of 2019 only 14 countries had achieved elimination of mother to child transmission – Cuba, Thailand, 6 Caribbean territories, Malaysia, Sri Lanka, Maldives, Armenia, Belarus and Moldova.

The required WHO criteria for validation of elimination of mother to child transmission includes 95% of all pregnant women to receive antenatal care, 95% of all pregnant women to receive testing for HIV and syphilis during pregnancy; and 95% of all pregnant women diagnosed with HIV or syphilis to receive treatment.

At 2.4 million, India has the 2nd highest population of people living with HIV (PLHIV) after South Africa (7.6 million). As per available national data, out of the 30 million annual pregnancies in India, an estimated 20,520 occur in those HIV positive pregnant women who are in need of ART to prevent mother-to-child transmission of HIV.

According to noted gynaecologist Dr Hema Divakar, who is senior technical advisor to the Ministry of Health and Family Welfare, Government of India and Medical Director of Divakars Speciality Hospital, there is an urgent need for proactive involvement of women in seeking antenatal care.

“As against 90% pregnant women opting for institutional deliveries in India, only 25% of them seek antenatal care. This gap has to be bridged. It is time that women themselves wake up and access care. The importance of integrated antenatal care for the long-term benefit of the mother and the baby has to be positioned in such a way that the opportunity for optimal comprehensive care during pregnancy is not missed out. If antenatal care coverage becomes 100%, it will be a gateway to elimination of mother to child transmission of HIV. Universal access to antenatal care with essential interventions to prevent mother to child transmission of HIV as well as syphilis, is a must. Also, where breastfeeding or mixed feeding is the norm, infants should be followed for up to 18 months for establishment of final HIV negative status”, she said.

However, despite the best interventions at hand, more than 2000 new HIV infections occur daily among women of child bearing age, and about 400 infants get infected with the virus every day. Perhaps ART alone is not enough to eliminate pediatric HIV and so researchers have been working on various immune strategies to address the gap.

Delegates at the recent 4th global conference on HIV Research For Prevention (HIVR4P), discussed new prevention strategies to address HIV acquisition in children through mother to child transmission of HIV. Sallie Permar, Professor of Pediatrics, Weill Cornell Medical Centre shared that the epidemiology of pediatric HIV is very unique in that the transmission risk falls into two distinct periods. The first is the HIV infection risk that occurs just after birth and through the 1-2 years of breastfeeding. The second is the long childhood period of little to zero HIV risk- from the period of weaning to the period of 1st sexual contact. After sexual debut the rate of HIV acquisition goes up very steeply in that there are more than 1600 infections in adolescents every day.

She said that this bi-modal distribution of HIV transmission risk in childhood provides opportunities for implementing unique protection strategies against pediatric and life-long HIV acquisition. Passive immunisation can be administered to an infant to cover the period around birth due to breastfeeding, and this can be combined with the strategy of multi-dose active vaccination that can be initiated at childhood and boosted all the way till pre-adolescence. This combined immunisation strategy is already in use to prevent transmission of Hepatitis B virus from the mother to the baby.

Agreed Lynda Stranix-Chibanda, a pediatrician and researcher at College of Health Sciences Zimbabwe University, that the goals of immune strategy for pediatric HIV prevention, are to

(i) prevent HIV infection in high risk infants by administering subcutaneous antibody injection at birth and every 3-6 months while breast feeding and

(ii) develop long term immunity against HIV in them prior to sexual debut through a safe and effective HIV vaccine as part of the routine childhood immunisation schedule.

She shared that multiple HIV antibodies are in development. Some passive monoclonal antibody prevention studies have been conducted in human infants and have shown very encouraging data so far. Currently we have the IMPAACT P1112 (phase 1/2) study for administering antibodies to HIV exposed infants at birth and while breastfeeding.

Thus, in future, passive immunisation given in early infancy could reduce HIV transmission during breastfeeding, and, when combined with multiple doses of an effective HIV vaccine, immune strategies could be a viable approach to close the gap and induce lifelong immunity to HIV prior to sexual exposure as a young adult.

Philippa Musoke, Professor of Pediatrics and Child Health at Makerere University, Uganda, believes that an AIDS-free generation is on the horizon. “But if we are to meet the target for elimination of mother to child transmission of HIV by 2030, a lot still needs to be done. It requires political commitment to identify pregnant women who seroconvert during pregnancy and breastfeeding and ensure that they initiate ART quickly. In addition, all HIV infected pregnant and breastfeeding women should be supported to adhere to ART and be retained in care so as to reduce vertical transmission. Governments, community stakeholders, civil society and people living with HIV – all will have to commit themselves to push for elimination of mother to child transmission of HIV”, she said.

Let us not forget that HIV positive children born to HIV positive parent(s) are innocent sufferers of the tragic consequence of the HIV epidemic. We have the tools to bring down pediatric HIV transmission rates to less than 2%. Improved surveillance of pregnant women, strengthening of prevention of mother to child transmission of HIV, as well as ART services, with adequate follow up to ensure adherence, will help us achieve the goal of zero new infections in children at least – as we advance progress towards ending AIDS worldwide.