by Andrew Tomkins.
Recent years have seen huge changes both in awareness and in the availability of medicines for the treatment of adults with HIV and AIDS. Effective international advocacy has helped to reduce the prices of anti-retroviral drugs (ARVs). Many more people with HIV and AIDS can now receive treatment, often free of charge. At a recent AIDS conference in Bangkok, there were many reports of success. The World Health Organisation aims to support treatment for an extra three million HIV-infected people before the end of 2005. However, most of these are adults – children have been largely neglected.
There are several reasons for this. Firstly, if funding is limited, people tend to treat adults before children. Secondly, most people believe that all HIV-infected children will die young. A young HIV-infected mother in Cape Town recently named her baby ‘No hope’ because she was convinced that he was going to die quickly. In fact, that is just not true. For reasons that we still do not understand, many HIV-infected children grow and develop quite well, as long as any childhood infections are properly treated and they are well fed. Their immune system continues to be able to fight off infection. We care for HIV-infected children in our hospital here in London. Only half of these children have such poor immunity that they need anti-retroviral treatment.
Reading Matthew’s Gospel, we can be sure that Jesus would include children among the HIV-infected patients he might meet. The challenge now is to include children among those selected to receive ARVs in more and more countries.
However, prevention is always best. There are several new ways of preventing the transmission of HIV from mothers to children.
In some countries HIV is transmitted by mothers who inject themselves with drugs. In the Ukraine, the proportion of women injecting themselves during preg-nancy (infecting both themselves and their babies) has reduced from 30% to 5% as a result of clear, consistent health messages and support. Fewer babies are now being born with HIV in such countries.
HIV-infected mothers can pass the virus to their babies in the womb, during delivery, and through breastmilk. If HIV-infected mothers receive ARVs in pregnancy and do not breastfeed their babies, the risk of passing on HIV infection to their babies reduces from about 30% to 1%. However, this is only possible for those who can afford to buy breastmilk substitutes and can make it up cleanly and in sufficient concentration. Most mothers in poor countries cannot afford this. However, if HIV-infected mothers receive a dose of nevirapine during delivery, and the baby soon after birth, and they exclusively breastfeed for just six months, then only 10% of babies become infected. This is an area where new research and work is bringing rapid change and improvements. If more pregnant mothers could be treated with ARVs, fewer babies would become infected.
Stigma is a huge problem in many communities. The churches have many opportunities to encourage more openness about HIV and how to treat and prevent it. Sadly, many women do not receive ARVs because they do not agree to have an HIV test in the antenatal clinic.
Giving HIV-infected children a daily dose of co-trimoxazole – a cheap, effective antibiotic – for the first year of life, prevents a number of infections which children with HIV often get, especially pneumonia. It improves their health and survival, even if they are not on ARVs.
Exclusive breastfeeding (no other foods or liquids – not even water) is safer for the baby than mixed feeding, as there is less risk of passing on the virus. Firstly, water and other foods may be contaminated with germs and dirt that damage the baby’s intestine and allow the virus to enter the baby’s body. Secondly, frequent emptying of the breasts with exclusive breastfeeding reduces the amount of virus in the milk.
Exclusive breastfeeding meets all the baby’s nutritional needs for 4–6 months. After that, the baby needs a mixture of nutritious foods. If mothers then continue with breastfeeding as well as giving other foods, they are more likely to infect their babies. This is a challenge for mothers – they need to stop breastfeeding as soon as they introduce other foods. However, many mothers fear the stigma they face if they do not breastfeed.
In Entebbe, Uganda, most HIV-infected mothers stop breastfeeding at around 4–6 months and feed their children porridge cooked with cow’s milk. Taking aspirin for 48 hours reduces the pain from swollen breasts when breastfeeding is stopped suddenly. Which is more important – suffering stigma or preventing a child getting HIV?
Researchers are now testing ways of improving local foods so that babies can grow and develop well without breast-milk. Animal milks should be boiled or mixed with porridges. Affordable porridges fortified with minerals and vitamins are being developed and will become more widely available.
It would be good to hear if readers of Footsteps have found effective ways of feeding babies of HIV-infected mothers without breastmilk.
Professor Andrew Tomkins leads the Centre for International Child Health, Institute of Child Health, London, UK.
- HIV and AIDS affect all kinds of people in every country. 20 million people have so far died of AIDS.
- There are about 40 million people now living with HIV.
- The problem is growing: in 2003 there were about 5 million new infections.
- More than half of all new infections now occur in young people.