Access to HIV testing and antiretrovirals for prevention of mother to child HIV transmission has grown substantially over the past four years in the countries most severely affected by HIV, UN agencies reported today – but around 40% of women in the high prevalence countries of southern Africa are still not being offered an HIV test during pregnancy.
HIV testing is essential during pregnancy if women and their infants are to benefit from antiretroviral prophylaxis to prevent mother to child HIV transmission.
Sixty per cent of women in the high prevalence countries of southern Africa underwent HIV testing during pregnancy in 2007, compared to 33% in 2004, but across the wider Eastern and Southern Africa region only 43% of women with HIV are estimated to receive antiretroviral drugs for prevention of mother to child transmission, compared to 11% in 2003.
Antiretroviral coverage was 57% in South Africa (compared to 15% in 2004) and 46% in Mozambique (compared to 3% in 2004). However coverage is still very low in Ethiopia; just 10% of women with HIV were able to receive antiretroviral prophylaxis in 2007, perhaps due to the country’s very low level of access to antenatal care (28% of women have access to it).
Access to antiretroviral prophylaxis is very poor in West and Central Africa, where only 11% of women with HIV received the drugs in 2007.
Across 60 low and middle-income countries, only 26% of women who receive antiretroviral prophylaxis are able to obtain two-drug prophylaxis despite a World Health Organization (WHO) recommendation that wherever possible women should receive a short course of one or two drugs in addition to single dose nevirapine, due to evidence showing a much greater reduction in mother to child transmission when multiple drugs are used. (Only 8% receive a three-drug combination).
The state of access to PMTCT (prevention of mother to child transmission) and paediatric HIV treatment is summarised in the Children and AIDS: Third stocktaking report published by UNICEF, UNAIDS, the World Health Organization and UNFPA.
The report also covers progress on access to antiretroviral treatment for children. WHO and UNAIDS estimate that around 2 million children were living with HIV in 2007, and 370,000 infants were infected with HIV that year.
While the report shows progress in providing treatment for children – up from 75,000 children on treatment in 2005 to 198,000 in 2007 – coverage still falls far short of the estimated need, due chiefly to lack of early diagnosis.
HIV diagnosis in infants is challenging in developing countries because it requires the use of a test to detect HIV DNA up until the age of 18 months, when HIV antibodies can be reliably detected in small children. Testing for HIV DNA requires a laboratory test called DNA PCR that can only be carried out by highly trained laboratory staff using special equipment.
Countries are attempting to improve the rate of infant HIV diagnosis by collecting blood spots on filter papers and sending them to a central laboratory, where the blood can be tested using DNA PCR. The number of countries using this method has grown from 17 to 30 since 2005, and testing of infants is now becoming possible even in remote areas.
However the report notes that in many countries routine testing of infants born to mothers with HIV is still not taking place, due to poor linkage between PMTCT services and child health services. Instead children are diagnosed only when they present at hospitals with serious illness.
But much childhood illness caused by HIV could be prevented by two proven interventions, prophylaxis with the cheap antibiotic cotrimoxazole, or where it is available, antiretroviral therapy started within three months of birth.
But the report notes that worldwide only 4% of infants born to mothers with HIV infection are estimated to be getting cotrimoxazole, although some countries have been more successful in making the drug available (83% coverage in Botswana, 63% coverage in Ukraine).
Antiretrovirals are reaching a small proportion of children in most countries (around 5% in Ethiopia, 10% in South Africa and 8% in Tanzania).
Scale up of early diagnosis is needed, the report recommends.
The report also highlights the needs of adolescents, including those already infected with HIV, with a call for a stronger focus on the vulnerability of girls to HIV infection, a greater role for the education sector in high-prevalence countries and more attention to how circumcision can be delivered to male adolescents when it forms part of a national HIV prevention programme.
Children and AIDS: Third Stocktaking Report can be downloaded here