By 2010, at least 80% of pregnant women globally who need it should get PMTCT treatment, and 80% of children who need it should be on ART. This report assesses what progress has been made in this direction

In 2001, the UN General Assembly Special Session on AIDS set a 2010 target of reaching at least 80% of pregnant women in need of PMTCT (prevention of mother to child transmission) services through a dose of antiretroviral treatment (ART) drugs. In 2005 UNICEF gave a call for action -- Unite for Children, United against AIDS -- and set goals in four areas:

• provide PMTCT coverage to 80% of women who need it;
• provide ART, cotrimoxazole (a cheap antibiotic that improves the survival of children with HIV), or both, to 80% of children who need it;
• reduce the percentage of young people living with HIV  by 25% globally,
• ensure that support services reach 80% of children affected by HIV/AIDS who are most in need of these services.

This status report, Children and AIDS: Second Stock Taking Report:  Actions and Progress, UNICEF, April 2008, based on investigations in 13 countries (including India) by a team led by WHO and UNICEF gives a picture of how things have progressed, what the problems are in “scaling up”, and what needs to be done to address these problems.

The report analyses national data on PMTCT coverage in 2004-2006 reported by 108 countries. These 108 countries house 99% of the 1.5 million HIV-positive women in low- and middle-income countries who gave birth in 2006.

Overall, things are looking up, according to the report. Significant gains have been made in coverage. One important finding is that it is possible to scale up the PMTCT programme in low- and middle-income countries, as is proved by the progress in Eastern and Southern Africa over the last three years. As treatment access improves for adults, services have improved for children as well.  A growing number of vulnerable children have access to health, education and other social services.

By end-2006, 21 countries covered at least 48% of pregnant women in their PMTCT programme -- on schedule to meet the 2010 target. (India’s coverage in that same year: 10%.) There has been a 60% increase in PMTCT coverage from 2005 to 2006; a  70% increase in paediatric access to ART during the same period, and a decline in HIV prevalence among pregnant women attending antenatal clinics from 2000-2001, including in eight countries which had the highest prevalence of HIV among young people and adults. HIV prevalence has dropped among young pregnant women, condom use has increased and multi-partner sex has decreased in some countries. Finally, a growing number of affected children have access to social protection and education.  

Yet access to PMTCT and ART is overall low, prevention programmes for the young are insufficient, and interventions for children are on a very small scale.  Services are still reaching only a very small percentage of children and families in need. And despite the existence of a paediatric ARV programme, there is still a need for guidelines and training on consent, disclosure and psychosocial support for children living with HIV. Stigma and discrimination are still common. Prevention efforts among adolescents and young people have a long way to go in increasing individual knowledge, teaching risk-reduction skills and providing access to services and commodities including condoms. These also need changes in general social norms.

Integration into a strong health system

Perhaps the most important concern identified by the report is the need for strong health systems to bring together all aspects of the programme (whether coverage of ARV prophylaxis, paediatric ARV, or support to children affected by AIDS) and to integrate services for AIDS into general public health programmes.

Thus, while early diagnosis and treatment increase the survival of children with HIV, when PMTCT services and ARV treatment centres for adults are separated from child health services, children whose mothers are HIV-positive are not necessarily tracked for their HIV status and given treatment when it becomes necessary.  What is needed is a family centred approach to HIV which can also be integrated with other preventive health services such as mosquito nets, clean water tablets and treatment for tuberculosis. Government, NGO and other efforts should be complementary to and supportive of the efforts of communities and families, through, for example, ensuring access to basic services.

Second, governments, donors and agencies must set a common agenda to improve PMTCT services within maternal, newborn and child health (MNCH) services rather than addressing them separately. When they are viewed separately they can work against each other; simply increasing funding for the PMTCT programme will not work if funding for the MNCH programme is cut at the same time. Interventions for affected children are most effective when they form part of strong health, education and social welfare systems. Because MCH programmes are weak, millions of children go without basic interventions like immunisation that contribute to the overall goal of HIV-free survival. In order to reach children affected by AIDS, programmes should provide for all vulnerable children, regardless of their orphan or HIV status. (Incidentally, India has developed a national policy framework for children and AIDS that includes strategies, objectives and targets in the area of prevention, PMTCT, paediatric treatment and protection for children affected by AIDS.)

Promoting ‘opt-out’ testing in an environment of stigma and discrimination

The report notes that one of the major hurdles in access to treatment and other services for AIDS is stigma and discrimination associated with HIV: social stigma that can result in positive women suffering domestic violence; institutional discrimination that can deny health care, education and other social services to people who test positive and their children. Stigma preventing women from coming forward for testing is a significant barrier to wider coverage. Research in India, Pakistan, Nepal and Bangladesh has shown that stigma and discrimination against children affected by AIDS prevent children from using basic social services 

So it is puzzling that the report views routine ‘opt out testing’ – in which all women are tested unless they state that they do not want to participate -- as a key element of identifying and reaching children in need of treatment. It only suggests that an expansion in testing services should be accompanied by “referral to legal services or village authorities who can deal with such cases” – a practice that could be useless and even worsen the situation for women.

In India, 2006

• There were an estimated 70,489 pregnant, HIV-positive women in India.
• 7,007 HIV-positive pregnant women got ART through the PMTCT programme (in India renamed the Prevention of Parent To Child Transmission programme or PPTCT programme) – or 10% of those who needed it.  
• As of end-2006, 2,959 children (between the ages of 0 and 14 years) were on antiretrovirals).
• 17% of men aged 15-24 had “comprehensive knowledge of HIV in 2000-2002 (correctly identify the two major means of preventing HIV transmission, reject common misconceptions and know that healthy-looking people can transmit HIV), going up to 36% in 2003-2006.

InfoChange News & Features, May 2008