Preventing Mother to Child Transmission of HIV in Mwandi, Zambia- A Success

Welcome to this installment of the AIDS Pandemic, a podcast hosted by Dave Wessner of the Department of Biology at Davidson College. I am Sarah Bertram.

This past summer, I traveled to Mwandi, Zambia through a Davidson biology and pre-medical program. Mwandi is a predominantly Lozi village of about 7,000 people and the catchment area totals about 25,000 people. We spent 5 weeks in Africa, 3 of which were spent working in the Mwandi Mission Hospital, the Mwandi AIDS clinic, the Orphans and Vulnerable Children’s center, and the Mother and Child Health Center. We all went with a research topic to study that was based on some aspect of Mwandian life. I looked at Mwandi’s Prevention of Mother to Child Transmission of HIV, otherwise known as the PMTCT program, and its effectiveness over the past three years. Here, I will talk about my findings.

About out of every five pregnant women in Zambia is infected with HIV and without any prevention or treatment interventions, more than 300,000 babies would contract HIV from their mothers each year. Starting in 1999, many Zambian mission and government hospitals started PMTCT programs. The Mwandi PMTCT program was launched in 2005 by an American Pediatrician in conjunction with the Mwandi missionary who was going to serve as the leader of the program. The procedure for PMTCT at the Mwandi Mission Hospital is as follows: 1) discuss the PMTCT program and HIV/AIDS information during group antenatal care visits, 2) offer private pre-test counseling, 3) test the mother for HIV and CD4 counts and give her the results, and 4) offer post-test counseling and discuss further treatment and a re-test in three months. According to the hospital staff in Mwandi, HIV testing of any pregnant mother is required by law in Zambia.

If a woman tests positive, she is evaluated at the Pastoral Care Center for AIDS treatment. If she is considered a WHO stage IV or has multiple symptoms for WHO stage III, HAART treatment is usually started unless the woman chooses to undergo short-course treatment instead. Many of the HIV positive mothers choose to undergo HAART treatment because of its documented increased ability to treat HIV/AIDS symptoms and to lower the viral load by decreasing viral replication. The Mwandi hospital staff is good about giving options to the positive mothers and explaining each option and its risks and benefits. Due to the staff’s willingness to counsel and inform the HIV positive pregnant mothers of treatment options, a majority of these women decide to take part in a course of HIV/AIDS treatment in order to help themselves and to prevent the transmission of HIV to their babies.

Although record-keeping is sparse and sometimes hard to find and evaluate, some records for the PMTCT program proved helpful in evaluating the program’s success over the years. From March of 2005 to September of 2007 (before HIV testing was mandatory), 1,205 women attended an antenatal care appointment to sign up for the PMTCT program and of these 1,205 women, only 35 women or about 3% refused the HIV test. Of the 1,170 women who agreed to be tested, 24.4% tested positive for HIV. This statistic is quite high, but reflects the belief that about 1/3 to ¼ of Mwandi’s population is infected with HIV. Because the PMTCT program was in place, the HIV positive women were able to learn their status, get treatment, and prevent (for the most part) the transmission of HIV to their babies during pregnancy, delivery, and breastfeeding.

Mwandi’s PMTCT program has changed drug regimens in order to stay current with the most effective treatments. Originally, the program was based on a single dose of nevirapine given to the mother during delivery and to the baby right after birth. In April of 2006, the PMTCT program switched to a dual therapy involving both nevirapine and AZT for both mothers and babies. Starting in November of 2007, Mwandi updated its treatment regimen to the most current and effective triple therapy drug treatment. This drug therapy involves a mixture of AZT, 3TC, and NVP for the mother and baby. This new therapy has proven to be very effective and the PMTCT program workers approximate that transmission from mother-to-child rates have decreased to less than 10% and possibly even as low as 6% or 7%.

Possibly the most enticing aspect of the PMTCT program for pregnant women is the free formula feeding program provided to HIV-negative babies of HIV-positive mothers. Breastfeeding is the most common type of mother-to-child HIV transmission, so by providing free formula for those babies who test negative (after 6 weeks of age), the worry of transmission by breastfeeding can be alleviated. Currently there are over 100 babies receiving infant formula and most, but not all, are HIV-negative babies of HIV-positive mothers who participated in the PMTCT program. The program has never resulted in a case of child dysentery, a common negative outcome of formula feeding programs, which is often a result of incorrectly boiled water used to make the formula. This clean record is a result of the care and attention put forth into teaching the mothers how to correctly make the formula and clean the bottles.

Compared to many other Sub-Saharan African PMTCT programs, Mwandi’s program is doing a very good job of keeping the program advancing, as far as the number of women being treated and the updates to newer forms of drug therapies. The program could however still make larger strides in incorporating more women from far out in the catchment area and by possibly providing more rural village outreaches for the sole purpose of PMTCT.

HIV/AIDS Orphans in Sub-Saharan Africa

More than twenty-five million people have died from AIDS since it was first recognized in 1981, making it one of the most destructive epidemics in history. It is undeniable however, that sub-Saharan Africa is the hardest hit and most affected area in the world. Of the global 2.9 million AIDS related deaths in 2007, 72% occurred in this area. AIDS has devastated the social and economic framework of societies in sub-Saharan Africa by mostly infecting people in the age group of 15-49, while 63% of the 40 million people living with HIV/AIDS today live in Sub-Saharan Africa. What is also startling is that, of the 2.9 million people who died from AIDS in 2007 one in seven was children. HIV/AIDS also has many indirect effects. Children of HIV positive parents compose the largest group of secondary sufferers. Africa is home to 95% of the world’s 13 million children orphaned as a result of AIDS. It is estimated that by 2010 a third of African children will be orphaned.

Caring for these orphans has become a severe humanitarian disaster. With the rapidly increasing numbers it is difficult to care and provide for all of these children. However, the potential for these children to form a large group of dysfunctional adults, which could further destabilize societies already weakened by AIDS, has increased the urgency of finding an effective solution to the crisis. The response to the problem has been unsustainable given the number of children that need aide. In Zimbabwe, fewer than 4,000 orphans out of an estimated 800,000 are accommodated in the country’s 45 registered institutions.

As an entire generation is being devastated by HIV/AIDS, major secondary effects are occurring on the children watching it all unfold. These impacts arise in a number of overlapping ways, including, economic consequences, changes in position of caregiver, education, nutrition, long term psychological effects, and even the likelihood of infection. What overarches all of these is how children psychologically process and respond to the stresses HIV/AIDS adds to their lives. It is important to focus on the psychological impact on a child who is forced to drop out of school, who must care for themselves and younger siblings, and face losing a parent or family member. These psychological effects are what lead children to destructive or with drawn behaviors that could make them more likely to become infected. If an attempt is made to better understand what these children are experiencing, it may be possible to reach them on a level that would help encourage them to protect themselves from the dangers of HIV/AIDS.

A child’s age effects not only how they respond to and understand AIDS as a disease but in what ways they are most affected. Pre-school aged children show the primary effects on growth and health in relation to losing a caregiver. School-aged children show more effects related to loss of education and therefore the development of a vulnerability to internalization and anti-social behaviors. It appears in several studies that children over the age of ten years are most vulnerable to becoming orphaned, but are a group neither specifically targeted by many current programs nor institutions that house affected children. In these cases family, community, or school based intervention is essential.

The loss of a parent or loved one generally speaking is associated with psychological conditions including anxiety, rumination, depression, social isolation, survivor’s guilt and low self esteem. Mel Freeman, former director of Mental Health and Substance abuse in the South African Department of Health, states that children after losing a parent will have difficulties with modeling, boundary setting and development of value systems necessary for moral development; as well as the support, caring and discipline needed for emotional stability. If children have problems figuring out how to set boundaries and develop moral standards then it is likely they will also be at a higher risk for HIV infection. This secondary impact of HIV/AIDS is a catastrophic one because it will cause a whole new generation to be at an even higher risk and only further the HIV/AIDS epidemic. Orphaned children have an increased incidence of internalized psychological problems, and 34% of AIDS related orphans have contemplated suicide within the year after their parent or parents’ death.

In response to preventing the majority of psychological disorders and their related effects, the main goal is to postpone the death of a parent. When extending the life of the parents, you increase his or her chance to complete school and possess the proper mechanism to establish a sound value system. Nearly one half of children who lose a parent to HIV/AIDS drop out of school. This is a secondary impact that can be reduced by attempting to supply more infected people with ARV treatment that is both successful and easily attainable. It will both extend their life span and improve the quality of life for their children.

The Plight of AIDS Orphans

Since the 1980’s, our knowledge of HIV has expanded greatly. However, in developing countries this information is either lacking or has not been taken to heart by the people who live in these cultures. One of the main reasons people are so clandestine in conducting conversations about AIDS is due to the fear and stigma attached to the word. AIDS orphans have a particularly difficult experience. An AIDS orphan is defined as someone who has lost one or both parents to HIV/AIDS. These children struggle to obtain even the basic necessities of every day life.

Children whose lives become entangled with people infected with HIV/AIDS have a difficult time coping and understanding their situation. Currently, there are more than eighteen million children who have been orphaned as a result of losing someone to HIV/AIDS. More than an estimated twelve million live in sub-Saharan Africa. Although inaccurate, the projected number of orphans as a result of HIV/AIDS in Zambia was 710,000. Zambia had fifty seven percent of all orphans nationally in 2005. In sub-Saharan Africa more than 55% of people living with either HIV or AIDS are women and young girls. However, these numbers are severely inaccurate for reasons which range from reporting to people failing to get tested. The children often suffer physical and emotional neglect long before the passing of their parents. Many of these children observe their parents wilting away right before their eyes. This would no doubt present a traumatic experience for anyone. In speaking with the only social worker in Mwandi, I was told that many of these orphans suffer abuse and exploitation at the hands of the very people who are entrusted to care for them. Other children experience what is known as the “sugar-daddy/momma” phenomena. This occurs when young children perform favors, which are usually sexual in nature, for older adults. It is not uncommon for these children to have several sugar daddies/mommas. Many of these adults infected with HIV believe that by having sex with a virgin they would somehow cure themselves of the disease. Both the social worker and the head clinical officer stated to me that these children undergo a great deal of psychological distress. Many of the children must be treated for bouts of depression, anger, as well as anxiety. Orphaned children often experience greater anxiety and depression when they are separated from their siblings and placed in different homes.

HIV/AIDS has put such a strain on the family structure and had such an impact on household situations, that establishments like the Orphans and Vulnerable Children’s Center has become a necessity in Mwandi, Zambia. In Mwandi alone, there are an estimated one thousand three hundred orphans or vulnerable children. With thirty-five percent of the Mwandi population infected with HIV/AIDS, the number of orphans in the area is certain to rise. These establishments have provided a safe haven for AIDS orphans for approximately four years. The OVC met some opposition from townspeople when the idea was first brought to the forefront. Now a few members of the community assist the OVC by bringing firewood for the oven. In many cases, the one meal that the OVC provides on a daily basis is the only meal some of the children will eat all day. The objectives of the OVC are to provide nutritional support by utilizing the feeding a program that provides one meal a day for children ranging in ages from six months to fifteen years old. The Orphan and Vulnerable Children Center also provides children with a daily multivitamin, to keep them from becoming ill often. They also assist in the continuance of good health and hygiene, by conducting health checks as well as teeth cleaning. Children in the OVC who are HIV-positive are given extra food and must get monthly checkups at the local hospital, the UCZ Mission Hospital. Although the program is designed to feed well over one hundred children, there are still many children in Mwandi who go to work and school with little to eat. The director, Fiona Dixon, of the OVC in Mwandi has implemented a vegetable garden as a means of assisting the feeding program. They have also begun selling extra tomatoes in the village in order to raise more money for the OVC.
Clothing has also another problem that confronts children in the rural area of Mwandi. Most of the clothes children wear are third or even fourth generation clothing. The criteria for receiving clothing and becoming a part of the feeding program, consists of being listed as one of the following: a double orphan, child-run household, single orphan-no father, single orphan-no mother, or a vulnerable child. However, the OVC is more than just a place where children can come and eat. This past August, the center began a bathing program in which the children were afforded the opportunity to shower every Saturday with soap. In Mwandi, soap is a luxury item that many parents and guardians can not afford. The OVC also received containers filled with hygiene bags that consisted of soap, toothpaste, a toothbrush, nailbrush, a towel, and a face cloth. The OVC also covers the educational costs for some of the children to attend school in either Mwandi or Sesheke. These costs include items such as boarding fees, school fees, uniforms, shoes, as well as stationary.

It also serves as a place where the children of Mwandi can gather and enjoy recreational and educational activities. Many of the children play football, known in the United States as soccer. I had the opportunity to play soccer with a group of young boys one day. As I played, I had to remind myself that these children were potential AIDS orphans and that they could possibly have HIV themselves. I found that these children were living with loss and possibly HIV to be incredible because they seemed to be so happy playing and interacting with their peers. Later on, I was astounded to be informed that the children at the OVC are not told of their status if they are HIV-positive until they are eighteen years old. This is the harsh reality of AIDS orphans in Mwandi, Zambia with the OVC as their only refuge.
The orphans must undergo a great deal of emotional and physical hardships after the loss of one or both parents to AIDS. Plainly put, HIV/AIDS orphans are not stable. Many of them tend to be rough in nature and do not relate well with their peers. In their formative years AIDS orphans tend to be very agitated. Overall, AIDS orphans need to be seen as more than damaged goods. The discrimination they face on a daily basis needs to be put to rest, and their rights need to be acknowledged and enforced. Unless these steps and many others are completed, there will be a generation of young people who are affected financially, emotionally, and socially. Their status may also play a role on the future of politics.

My name is James Hammonds. Thanks for listening.

Testing and Treatment of HIV/AIDS in Children

According to a 2006 UNAIDS/WHO AIDS Epidemic Update, there are approximately 39.5 million people living with HIV/AIDS throughout the world. Of those infected, 2.3 million are aged 15 or younger. Approximately 90% of children infected with HIV acquire the virus perinatally, meaning it is transmitted from a mother to her child during pregnancy, labor, delivery or through breastfeeding. According to the CDC, the prevalence of mother-to-child transmission of AIDS in the US has dropped significantly due to effective testing of pregnant women and treatment of those found to be infected; in resource poor settings, however, the testing and treatment of infected women is far less common. In 2005, the UNAIDS/WHO AIDS Epidemic Update found that only 9% of pregnant women in resource poor countries were offered any sort of prevention services, leading to a higher prevalence of pediatric HIV/AIDS infection in less developed countries. As the prevalence of women of childbearing age who are infected with HIV increases in resource poor settings, it can be expected that the number of babies infected from mother-to-child transmission will likewise increase.

Children infected with HIV/AIDS are confronted with an extremely high rate of illness and death. The World Health Organization has found that because of their unique metabolic and immunologic circumstances, HIV progresses rapidly in children, with an estimated one third of infants dying by the time they reach their first birthday and half dying by their second birthday. Although in most developed countries identification and treatment of HIV infected babies is quite successful, which allows those children to lead healthier and longer lives, the situation is quite different in resource poor countries where testing, much less treatment of infants and children is relatively unavailable. To begin with, testing may be unavailable to individuals in developing countries due to the distance, expense and impracticality of reaching those hospitals and clinics that provide testing. Even when testing is locally available, parents may be unwilling to test their babies for fear of stigma and prejudice associated with an HIV positive status. Furthermore, testing of infants in developing countries can require far more time than in developed countries. PCR tests are among the fastest and most effective ways to diagnose infants as they can be done within 48 hours of birth and results are available to the mother within 6 weeks of the completion of the test. PCR tests are rarely accessible and prohibitively expensive in resource poor settings where antibody tests are the norm. These antibody tests only begin to give accurate results 18 months after birth, and so babies in developing countries are oftentimes diagnosed far later than in developed countries, if they are diagnosed at all.

Aside from the difficulties in testing infants and children for HIV in resource poor settings, there continues to be a dearth of treatment for children found to be positive for the virus. Although both prophylaxis and HAART or highly active antiretroviral therapy can be extremely effective in treating HIV/AIDS and preventing opportunistic infections in children, the unique difficulties associated with treating children in resource poor settings mean that these therapies are widely underused. UNAIDS found in 2006 that “an estimated 380,000 children died of AIDS-related causes” and that, “the vast majority of these deaths could have been prevented either by treating opportunistic infections or providing HAART.” Similarly, a UNAIDS/WHO report found that nearly 90% of children who could benefit from ARV treatments are not currently receiving it. This lack of treatment can be attributed to several factors.

In many resource poor settings, antiretroviral treatment may simply be unavailable. Those countries where the HIV/AIDS burden is greatest such as in Sub-Saharan Africa are oftentimes the least able to provide treatment, and so a lack of resources oftentimes translates into a lack of prophylaxis and/or antiretrovirals. Prophylaxis has been found to be extremely effective in staving off opportunistic infections in HIV positive children and is useful in delaying the need for HAART in pediatric populations. Although prophylactic drugs are widely available and relatively cheap, a UNAIDS/WHO study has found that currently nearly 4 million children who could benefit from such treatment are not receiving it. This is probably the result of lack of available treatment sites and infrastructure in resource poor settings. This dearth of available treatment translates to ARVs as well as prophylactic treatments. Even in areas where adult ARV treatment is present, there is rarely a comparable pediatric treatment site. This is due to the fact that suitable pediatric drug formulations are oftentimes prohibitively expensive and impractical. Little research had been conducted in the area of pediatric dosages because in the developed world effective mother to child prevention had limited the need for pediatric ARVs. Because so few drugs are available in pediatric dosages, and those that are available tend to be far more expensive than those made for adults, most caregivers in resource poor settings are limited to providing either expensive and unpleasant tasting syrup formulas or cutting and crushing adult tablets to provide ARVs for their pediatric patients. Crushing the pills provides an inexact measure of the amount of medication that is administered. Since under dosage can result in resistance of the virus to the drugs, and over dosage can result in amplified side-effects, the lack of correct dosages inherent in using adult drugs for pediatric patients means this mode of drug administration is far from ideal.

Important steps have been taken to begin to provide better treatment for pediatric AIDS patients. In August of 2007 the US Food and Drug Administration (FDA) approved a special tablet for children with HIV that combines three antiretroviral drugs into one pill. The tablet can be dissolved in water for ease of administration which is required only twice a day. The drug is produced by the manufacturer Cipla Limited, a generic pharmaceutical company based in India. Though unapproved for use in the US, the drug has been authorized for use in developing countries where the need and demand is greatest. Despite the enormous implications for successful treatment of pediatric AIDS that this drug will bring, there are still substantial obstacles to be overcome before pediatric care and treatment of AIDS is fully complete. Mother-to-child transmission must be diminished in resource poor settings. In situations where prevention of mother-to-child transmission is not achieved, suitable infrastructure for administration of prophylactic and antiretroviral drugs to pediatric patients must be established. Movements and groups such as the “Stop AIDS in Children” campaign are working towards prevention of mother-to-child transmission and improvement of treatment for infected children. With support of both developed and resource poor countries, the relatively ignored problem of HIV/AIDS in children can be successfully addressed.

Until next time, this is Dominique Maietta for the AIDS Pandemic Podcast.

AIDS Orphans in Sub-Saharan Africa

I'm Christie Brough

According to the AIDS Epidemic Update of December 2006, about 25 million people are living with HIV in sub-Saharan Africa, comprising 63 percent of all individuals with HIV globally. Approximately 13.3 million, or 59 percent, of these individuals are women, most of whom have children. Although considerable efforts have been made to provide these individuals increased access to antiretroviral therapy, 2.1 million Africans died in 2006, resulting in an increased number of AIDS orphans.

In 2001, 14 million children had already lost one or both of their parents to AIDS. Because of the difficulty of obtaining antiretroviral therapy, many more children will be affected. In fact, one estimate projects that the number of AIDS orphans will increase by approximately 150 percent by the year 2010, leaving 20 million children to raise themselves.

As children watch their parents succumb to AIDS, they often suffer psychological and emotional harm. Once a parent becomes too sick to work, children are forced to work themselves in order to raise money for their families or to take care of younger siblings, causing them to drop out of school. Another factor forcing children to drop out of school is their inability to pay for required items, like school uniforms, pencils, textbooks, and exam fees, which they no longer can afford. If they do not have these items for school every day, they may be sent home and told not to return until they have the proper materials. Children that continue to attend school despite their parent’s illness often display a lack of attention or inappropriate behavior in the classroom, which is thought to result from emotional stress. Academic performance is also negatively affected by child malnutrition. Malnutrition is common in AIDS-related poverty since most of the family’s resources must be spent on medication for the ill parent. As a result, school enrollment rates in sub-Saharan Africa are dropping as the death toll from AIDS continues to rise.

Children that grow up without parents and without an education are “trapped in a social and pedagogical vacuum.” These children are not only more vulnerable to contract HIV/AIDS, but they are also at higher risk of unemployment, exploitation, and other forms of social inequalities. In order to change the outlook for AIDS orphans in sub-Saharan Africa, international and national agencies must aid in providing greater access to antiretroviral treatment. One relatively successful example is the World Heath Organization’s 3-by-5 program. The 3-by-5 plan aimed at providing 3 million individuals worldwide antiretroviral treatment by 2005. Although the program did not meet its goal of treating 3 million HIV positive individuals in the 2-year period, the program successfully provided access to many individuals who were not receiving treatment before. According to the World Health Organization, the number of individuals receiving treatment in sub-Saharan Africa increased by more than 800 percent, increasing the distribution of antiretroviral drugs from 100,000 individuals to 810,000 individuals.

Although the success of the 3-by-5 program will decrease the number of AIDS orphans in future generations, programs must be implemented to save current AIDS orphans. One option is the development of vocational training programs, which could help orphans stay off the streets (especially, young girls who are forced into sex work). If funds from debt relief programs are channeled directly into schools, school enrollment might increase. Another option is to offer government subsidies to extended families, which might help children stay out of work and stay in school. Additionally, providing government subsidies would maintain a family structure for children, keeping them out of orphanages. While these appear to be wonderful programs, the effectiveness of these programs would be difficult to monitor. Thus, before any programs are employed, local, national, and international governments and agencies want to ensure their success. However, it is imperative that these agencies act quickly before it is too late.