Posted on plusnews.org
JOHANNESBURG, 3 August 2009 (PlusNews) - While a number of countries in southern Africa have made great strides in improving access to antiretroviral (ARV) treatment for HIV-infected adults, progress in rolling out treatment for HIV-positive infants and children has lagged behind. Namibia is a notable exception.
Over 7,600 children are receiving ARV treatment - 100 percent of those estimated to be in need of the life-prolonging medicine - according to Dr Angela Mushavi of the US Centres for Disease Control and Prevention (CDC), a technical advisor to Namibia's prevention of mother-to-child HIV transmission (PMTCT) programme.
The HI virus progresses rapidly in children; without treatment one-third die in their first year of life, and almost half by the age of two, the UN Children's Fund (UNICEF) has said.
Tests used to diagnose HIV in adults cannot be used for infants under the age of 18 months, who still carry their mother's antibodies; polymerase chain reaction (PCR) tests, which can detect HIV in newborns as young as six weeks, are not available in all parts of southern Africa.
The Namibian government began rolling out PCR testing as part of an Early Infant Diagnosis (EID) programme in January 2006, with support from the US President's Emergency Plan for AIDS Relief, the Global Fund to Fight AIDS, Tuberculosis and Malaria and the CDC.
It is now available at 202 health facilities throughout this sparsely populated country of two million, where nearly 20 percent of pregnant women are HIV-positive, according to government figures. Mushavi estimates that around 75 percent of infants born to HIV-positive mothers are now being tested.
Trained nurses collect dried blood-spot samples from the children and send them to the Namibian Institute of Pathology in the capital, Windhoek, for testing. A computerized database relays the results to district health offices, which then communicate them to individual clinics.
All infants under 12 months who test positive are started on ARV treatment; World Health Organization (WHO) criteria are used to determine when to start older children on the drugs.
Gaps remain
The EID programme has helped many Namibian children access ARV treatment, but Mushavi admitted that gaps remain, and too many babies found by PMTCT programmes are lost from the system after delivery.
"We are meeting targets for children on ARVs, but they are starting late," said Dr Agostino Munyiri, chief of health and nutrition at UNICEF, which recently commissioned a team of experts to look into the reasons why some HIV-positive children were falling through the cracks.
Children born to HIV-positive mothers should ideally be tested when they are six weeks old, but the median age for testing is currently 17 weeks. "Many present with malnutrition and only then are tested for HIV, and even then not all are tested," Munyiri told IRIN/PlusNews. "We know they come back for immunization [against various diseases]; we need to catch them at that stage."
The turnaround time for conducting the PCR tests is only two days, but it can take up to a month for the results to filter back to the most far-flung rural clinics, and some mothers do not return to find out what they are.
Mushavi suspects that they either have not received sufficient counselling about how important early diagnosis and treatment is for their babies, or are deterred by the high levels of HIV-related stigma that persist in Namibia. "As health workers, we need to be more proactive," she said. "There are still barriers there that need to be broken."
UNICEF has not yet published its findings, but Mushavi hopes they will include a recommendation for children's patient cards to have information about whether they have come through a PMTCT programme, so that healthcare workers can quickly refer them for testing without having to question their mothers.
Of the 71 percent of pregnant women in Namibia who attend antenatal clinics, 90 percent agree to be tested for HIV.
The rollout of a more effective combination PMTCT regimen at the end of 2008 meant that in the first three months of 2009, only 2 percent of infants tested at six weeks were HIV-positive, but Mushavi emphasized that this did not represent the whole picture.
Most HIV-positive mothers in Namibia cannot afford to buy formula milk and are advised to breastfeed exclusively for the first six months. Those infants who test negative at six weeks but are being breastfed need to be re-tested at six months.
