Standing in the delivery room wearing a flimsy pair of rewashed latex gloves and holding a pair of surgical scissors in my hands, I became acutely aware of one of the many statistics which had been shared with us on day one. I was a medical student working in a government hospital in KwaZulu Natal, South Africa; it was 1997. The figure flashing through my mind was that 50% of the women using the delivery unit were HIV positive. At that particular moment, the impact on me was largely selfish – fear of inadvertent injury leading to infection was almost paralysingly great. With the benefit of hindsight and perspective the true tragedy of course lies with the local population. HIV and AIDS was at that time (and remains to some extent) an overwhelming problem. The range of illness we encountered was hugely different to that which I was used to in the UK – and much of that difference was driven by HIV positive patients suffering from once almost forgotten diseases. The virus was so prevalent that doctors often presumed positivity rather than wasting valuable resources testing for it.
Not only were the adults affected, those newborns we were taking such care to guide safely into the world were also hugely vulnerable. Mother to child transmission (MTCT) during birth and early breastfeeding is tragically common. In untreated populations up to 40% of babies can be infected. In 1997 little was known about how to reduce this risk, and hugely expensive treatments were unthinkable for the vast majority of patients in that rural hospital.
In 2003 around 570,000 babies in sub-Saharan Africa were unwittingly infected by their mothers. By 2015 this number had dropped to 110,000. Whilst this is still an unacceptably large number (and represents over 70% of children infected worldwide) it is clearly a huge improvement.
So, what has led to the change, and what more can be done to further reduce the numbers affected? That HIV can be passed from mother to child during pregnancy, delivery and breast-feeding was recognised in the 1980s. By the 1990s trials were underway in resource-rich countries (most notably the USA) into ways to reduce transmission from somewhere between 15 and 40%. Trials which have enrolled tens of thousands of women, along with 20 years of accumulated experience mean that in those resource-rich nations, MTCT is now less than 1%. Much of this knowledge has been applied to resource poor settings and is having a real impact on those communities where the burden of HIV and AIDS is highest. We know that mothers with less virus in their bloodstream are less likely to infect their infants, we know that infection during pregnancy is most likely in the latter stages. We know which drugs are most cost-effective and most likely to be tolerated. We understand that delivery itself is a highly risky time for the baby and we know that delivery by a trained birthing practitioner (either in the community or in a health facility) helps. We also understand that HIV can be transmitted during breastfeeding – in untreated populations perhaps one third of infections happen his way. This knowledge is difficult to apply in poor rural communities, where the majority of women do not attend antenatal care, most babies are delivered at home and unreliable water supplies mean formula-feeding carries its own risks. However, the World Health Organisation working in partnership with local governments and health care providers are making huge progress.
Cost of treatment remains a huge factor. Whilst a multi-pronged approach led to medication costs to African countries being reduced by up to 80% in the late 1990s to early 2000s, the cost of treatment is still considerable (several hundred dollars per month per patient).
And what about South Africa? What of the populations I encountered back in 1997? Amongst the sub-Saharan countries, South Africa is making good progress. The uptake of antenatal testing is around 80%; and 90% of pregnant women identified as HIV positive receive effective treatment with antiretrovirals through pregnancy and the early life of their child. MTCT rates have fallen to 3.5%, with around 29,000 new cases of childhood HIV in 2011. The possibility of eliminating new childhood infections has been voiced.
So what is limiting further progress? From lack of resources on a National and International level through lack of education of the problem and lack of belief in the solution to poor compliance with medication and unacceptable side-effects; the barriers are numerous and complex. Each will contribute a little to missed targets, each will increase slightly a baby’s chances of being infected. However, there is no doubt that combined and concerted effort has led to a huge reduction in the number of infected infants, and a huge reduction in the burden of disease in communities least able to afford it.
Photo is wikimedia creative commons
Guest Author Profile
Nicola Comer is a freelance medical writer living in the South of France with her young family. Until recently she worked in the UK National Health Service as a Consultant Surgeon. She enjoys gardening and hopes to grow much of the family’s fruit and vegetables in their new home.