It’s almost become a cliché: The Caribbean has the world’s second highest rate of HIV. Now here’s something that one doesn’t hear often: this could also be the first region to eliminate mother-to-child transmission of the virus. A regional Elimination Initiative aims to eradicate this form of HIV infection by 2015. And while stakeholders negotiate the stumbling blocks of “getting to zero new infections”, there are strides to celebrate.
The healthcare response to this issue—from HIV screening to the adoption of more effective treatment regimens—is paying off. From 2007 to 2010 Barbados had no HIV positive babies on record. In 2010 there were no cases of paediatric HIV infection in the Bahamas and only one in Antigua and Barbuda.
Caribbean countries’ first health interventions on prevention of mother to child treatment (PMTCT) started between 1995 and 2000. Before then, more than a quarter of all babies born to HIV positive women in many Caribbean countries were infected with HIV. Use of the drugs Zidovudine (AZT) and Nevirapine (NVP) in subsequent years lowered transmission rates considerably. But it is the advent of a combination therapy approach to PMTCT that holds the promise of reducing this mode of transmission to remarkable lows.
Amalia Del Riego, former Senior Adviser to the Pan American Health Organisation’s HIV Caribbean Office, explained that where there are strong foundations of primary healthcare delivery, there’s been rapid scale up of PMTCT programs. Countries with weaker infrastructures or those that attempted to set up their HIV services for this group of women as a stand-alone response, have had a tougher time.
But Dr. Rudolph Cummings, the Programme Manager for Health Sector Development at CARICOM, noted that the success of PMTCT hinges on far more than lab equipment, access to medicines, surveillance and staffing. One key factor is that women present early for antenatal care.
“Optimally entrants should be enrolled by the end of the first trimester and if positive, treatment should be applied… long before the end of the second trimester,” he said. (See the sidebar.) Across the Caribbean those at the frontline of the HIV response agree that it isn’t simply a question of drugs and doses. They point to gaps that are linked to actual or anticipated discrimination toward women who are positive and pregnant.
“Some mothers present late,” levelled Dr. Ruth Ramos, Director of Guyana’s National care and Treatment Centre. “Some of them know their status and only reveal it at delivery. Even then an HIV test is done for the safety of the baby and at this moment a single dose of Nevirapine is given to reduce the chance of transmission.” Ramos added that for women living in far-flung parts of Guyana, there are issues of proximity and access to healthcare services to be bridged.
Dr. Russell Pierre, a consultant paediatrician with the Department of Child & Adolescent Health in Jamaica, also pointed to late attendees and no-shows for antenatal care as cracks in the country’s HIV response.
“A number of women who know they have HIV do not want to be discriminated against so they show up in different locations around the country because they feel their status would be exposed. In other cases after the baby is born mothers fail to return to clinic post-delivery and move to other parts of the country,” he said.
Pierre has even encountered a few cases where it was likely that the babies contracted HIV through breastfeeding. Although the healthcare system provides baby formula, some women worry that relatives will figure out that they are HIV positive if they don’t breastfeed.
“That is one area that will continue to dog the success of PMTCT for Jamaica. We have done a lot to drop the transmission rate from more than 25 percent when no interventions were available to less than five percent currently in Kingston. But if we don’t address the gaps you won’t achieve the elimination goal. Those social, socio-economic and psychosocial drivers are so powerful,” Pierre stressed, “that they influence a mother’s decisions and actions. We have to find a way to walk with a mother and support her in doing what is optimally best for her and her child.”
Anton Best, the Senior Medical Officer of Health in Barbados, also pointed to the barrier stigma and discrimination pose to women accessing appropriate care.
“Some women do not adhere to referrals to a specialist HIV centre. The decentralisation of HIV care might help to mitigate this problem. Also, some women fail to return for follow-up or post natal care,” he listed. Best noted that non-nationals who are usually un-documented are less likely to access ante-natal care and so do not benefit from essential and free preventative services. Yet another important gap that the Bajan PMTCT programme now responds to is the fact that a mother’s HIV status might change after her initial screening.
“All women are offered a test at the time of booking and now they are reoffered at 34 weeks. What had been happening was that they were still sexually active and some actually seroconverted (became HIV positive) during pregnancy,” Best said.
Across the region PMTCT programs are learning from their experiences and modifying the response in ways that better suit the needs of HIV positive mothers. The stakeholders are upbeat about the chance for the region to wipe out mother-to-child HIV transmission in the same way it eliminated measles and rubella.
“In 2012 no Caribbean child should be born with HIV,” insisted UNAIDS Caribbean Regional Support Team Director, Dr. Ernest Massiah. “There is no reason to feel fear or shame. HIV is an illness, not a crime or a judgment. We have to move beyond that as a people and use the means available to us to prevent it.”