Every day, nearly 1,800 children under 15 are infected with HIV worldwide. About 21,000 children in India are infected with HIV every year. Yet even today, the emphasis of prevention, care and treatment is on adults – the productive and reproductive age-group, says Mariette Correa

“Are there children who are HIV-positive? I thought it was a disease of adults.” This is a commonly expressed belief, heard even today. In the initial years of the HIV epidemic, it was believed to be a disease affecting only homosexuals and haemophiliacs. Gradually, the focus shifted to include sex workers and injecting drug users. In other words, the spread of the epidemic continues to be attributed to individual 'immoral' behaviours.

Children, legally or otherwise, are not considered active agents who are responsible for their behaviours, and it was only in the late-1990s that people realised that something must be done to acknowledge and respond to the fact that a large number of children are getting infected. Yet, even today, the emphasis of prevention, care and treatment is on adults – the productive and reproductive age-group.

What does the data tell us?

Every day, nearly 1,800 children under 15 are infected with HIV worldwide. Children under 15 make up 13% of new global HIV infections and 17% of HIV/AIDS deaths every year. (1) An estimated 370,000 children younger than 15 years became infected with HIV in 2007. Globally, the number of children younger than 15 years living with HIV increased from 1.6 million in 2001 to 2.0 million in 2007. Most of these children (almost 90%) live in sub-Saharan Africa. (2) Still, the rate of increase of children getting infected seems to be reducing over the last few years. This is largely attributable to the strides made in reducing mother-to-child transmission.

In India, NACO's recent estimates of HIV infection show that of the 2.5 million people living with HIV in 2006, 3.8% are children, ie, below 15 years of age. The proportion of infections among children and adults above 50 years of age has been increasing during the past five years. In September 2007, Union Minister of State for Health and Family Welfare Panabaka Lakshmi told the upper house of Parliament, the Rajya Sabha, that there are 70,000 HIV-infected children in the country and nearly 21,000 new infections occur in children every year.(3)

How are estimates on HIV in children obtained?

The belief that most people are 'responsible' for their infections, and that children get infected due to the 'behaviour' of their mothers, blinds AIDS programmes to other sources of infection for children. This is evidenced by the current HIV surveillance systems from where HIV estimates of children are obtained.

Both, sentinel surveillance among pregnant women and national population-based surveys with HIV testing include only adults. HIV estimates for children are therefore obtained through modelling based primarily on HIV prevalence in adult women (ages 15-49), fertility rates, and assumptions about the survival of HIV-positive children.(4) The estimates seem, therefore, to essentially include children who have got infected through their mothers.

How are children getting infected?

The UNAIDS Global 2008 report estimates that more than 90% of children living with HIV acquired the virus during pregnancy, birth or breastfeeding. It is estimated that without any interventions to reduce the risk of mother-to-child HIV transmission, approximately one-third of children born to HIV-infected women will be infected. This includes 20% infected before or during delivery, and the remainder infected from breastfeeding.

The underlying assumption is that most children with HIV have been infected through their mothers. When children come for treatment for an opportunistic infection, doctors will not consider HIV infection if the mother is not HIV-positive.

Chandra, a middle-class, educated mother of an HIV-positive eight-year-old from a town in South India, narrated her ordeal: "My son kept falling sick for one reason or another when he was around four years old. We went to several doctors because the treatment seemed to work for some time and then he'd fall sick again, or get some other illness. He even had TB but luckily that was cured with treatment. Some of the doctors we visited seemed to suspect HIV, but when they found that I did not have the virus (in fact, one of them asked me to do the test for HIV) they said that my son could not be HIV-positive. A year ago, out of sheer desperation, my husband and I decided to get his test done. Our family doctor supported us in this decision. That's when we discovered my son was HIV-positive. We have no idea how he got the infection, nor can anyone explain it to us. He has not had any blood transfusions but, of course, he has had a lot of injections after falling sick."

In India, modelling estimates suggested that a quarter of the annual burden of HIV in children and 4% in adults may be due to healthcare injections. (5) Studies have reported several children in India to be HIV-positive with HIV-negative mothers. (5,6) Investigations of unexplained cases of HIV in children (when mothers were HIV-negative) led to the discovery of iatrogenic outbreaks among children in Romania, (8) Elista in the former Soviet Union, (9) Libya (10) and more recently, Kyrgyzstan. (11)

Unfortunately in Asia and Africa, when unexplained cases come to light in health facilities or in the course of research, they are considered isolated and inconsequential and are not investigated. In 1997, when seven children in a Mumbai hospital awaiting adoption seroconverted over a three-month period, a limited investigation, which included virus sequencing, demonstrated linked infections. The report of this outbreak is referenced in a well-known article in The Bulletin of the WHO (12) but it is unclear what has happened to the report, what was done for the children or where they are today.

Another area that lacks adequate study is the number of street and working children who are getting infected through various routes. Many of them are injecting users and many are sexually abused. Due to their 'minor' status they are often invisible both in records and in programmes. Yet another area that has not been adequately studied is child-to-mother transmission.

Challenges ahead

Irrespective of how estimates are arrived at, it is clear that the number of children living with HIV globally continues to increase steadily. Once mother-to-child transmission became preventable, focused programmes were implemented across the world to reduce the spread of infections through this route.

Still, several factors hinder access to programmes for prevention of MTCT, such as distance to the health facility, low numbers of institutional deliveries, lack of follow-up by the mothers after delivery, lack of testing facilities, lack of resources for safe deliveries and safe infant feeding options. Underlying structural vulnerabilities need to be addressed to enable every HIV-positive mother to prevent her baby from getting infected.

While still more needs to be done to make PPTCT universally accessible, other sources of HIV infection in children must also be addressed. One step in the right direction is the government-mandated use of auto-disable syringes for all centrally sponsored immunisation programmes in India. This recognises that injections in India are still unsafe and acknowledges that children are subjected to invasive procedures at least through the immunisation programme.

(Mariette Correa is an independent consultant who has been involved in HIV/AIDS programming for NGOs in Goa and South Asia)

Endnotes

1 http://www.unicef.org/voy/explore/sowc06/explore_2463.html
2 Global 2008 report
3 ‘Nearly 70,000 children living with HIV virus’, Hindustan Times, Press Trust of India, New Delhi, August 17, 2007: http://www.hindustantimes.com/storypage/storypage.aspx?id=
0756ba75-9829-4ca0-a819-0e7c8bded1c2&&Headline=Nearly+70%2C000
+children+living+with+HIV+virus
4 Stover J et al (2006): Projecting the demographic impact of AIDS and the number of people in need of treatment: updates to the Spectrum projection package. Sexually Transmitted Infections, 82 (Suppl. 3):45-50 June.
5 Singhal T (2002): ‘Burden of HIV in India due to unsafe injections and blood transfusions’, MSc thesis submitted to University of London, 2002.
6 Correa M, Gisselquist D. ‘HIV from blood exposures in India – an exploratory study’, Colombo: Norwegian Church Aid, 2005 http://www.ncasaga.org/Resources.html
7 Sehgal R, Baveja U K, Chattopadhya D, Chandra J, Lal S. ’Pediatric HIV infection’, Indian Journal of Pediatrics, Nov 2005;72(11):925-30.
8 Hersh B S, Popovici F, Jezek Z, et al (1993): ’Risk factors for HIV infection among abandoned Romanian children’, AIDS, Dec;7(12):1617-24.
9 Dehne K L, Podrovshiy V, Kobyshcha Y, Schwartlander B (2000): ‘Update on the epidemics of HIV and other sexually transmitted infections in the newly independent states of the former Soviet Union’, AIDS;14(suppl 3):S75±
10 Yerly S, Quadri R, Negro F, et al (2001): ‘Nosocomial outbreak of multiple bloodborne viral infections’, Journal of Infectious Diseases; 184:369± 72
11 ‘Breastfeeding babies infected with HIV in Kyrgyz hospitals pass virus to their mothers’, International Herald Tribune, The Associated Press, April 9, 2008, http://www.iht.com/articles/ap/2008/04/09/asia/
AS-GEN-Kyrgyzstan-HIV-Mothers.php
12 Simonsen L et al (1999): ’Unsafe Injections in the developing world and transmission of bloodborne pathogens: A review’, Bulletin of the World Health Organisation 77(10): 789-800. Available at: http://www.who.int/bulletin/pdf/issue10/simonsen.pdf.

InfoChange News & Features, October 2008