Mother and newborn baby.
Jyoti knew little about AIDS when she came for her first check-up to a government-run maternity hospital in Hyderabad, the capital city of Andhra Pradesh, in southern India. But today, as she learns to live with the HIV virus that causes this syndrome, her only prayers are that her newborn daughter remain HIV negative.
Jyoti’s daughter had a 33 per cent chance of acquiring the infection. If infected, the baby would not be expected to survive beyond a few months, a couple of years at best. But Jyoti has been lucky. She was given nevirapine, an anti-retroviral drug that reduces the chances of a woman transmitting the virus to her baby.
It is a simple treatment: a 200 mg pill is given to the mother during labour and a spoonful of syrup to the baby within 72 hours of birth. This new treatment for the prevention of parent to child transmission (PPTCT) is an important component of the Indian government’s AIDS control programme. The National AIDS Control Organisation (NACO) has already extended this programme to 235 centres located in medical colleges and district hospitals across the country.
UNICEF support begins right at the start of the programme, helping train a five-member team at each of the designated PPTCT centres. The team consists of a gynaecologist, a paediatrician, a microbiologist, a counsellor and a staff nurse. At the end of training, the teams hold workshops in their respective hospitals to help initiate the programme.
Reducing HIV transmission
In Andhra Pradesh, 37 PPTCT centres are helping reduce the transmission of infection, and providing support to women who test HIV-positive. Of these 37 centres, 14 are in medical colleges and 23 in district hospitals. Andhra Pradesh has the second highest reported prevalence of AIDS in the country after Tamil Nadu and Maharashtra.
In such high-prevalence states, the government has expanded the reach of its programme to include the provision of anti-retroviral drugs to positive mothers before and after delivery and not just, as usually done, at the time of delivery.
The PPTCT project has helped reach out to thousands of women. Most of the hospitals covered under the project benefit poor, illiterate women, who cannot access expensive private health care. Between January and December 2003, at 235 centres across the country, more than 980,000 women were counselled. About 519,000 of these women agreed to be tested, of whom around 2 per cent turned out HIV positive.
In Andhra Pradesh, the project was piloted in Hyderabad’s Osmania Medical College hospital. Much has been achieved since the project was initiated in July 1999. When women visit the antenatal clinic at the hospital, they are at first given general counselling on pregnancy care. Women who agree to go in for HIV tests are then taken for individual counselling. Once the test reports are received, women who test positive go through a post-test counselling. They are encouraged to come back for their delivery to the hospital so that they can be given anti-retroviral drugs.
Counselling is the key
Progress is not all straightforward, however: many couples who test positive do not come back to pick up their test reports; women who test positive do not necessarily come back for delivery to the same hospital and fewer still come back after the birth of the child for follow up. Often, positive mothers do not get the required support from their families. As gynaecologist Dr Savita Desai remarks: “We can only provide antenatal care. There has to be a continuity of care after these women return home.”
Typically, the programme is initiated in the following way. When around 15 pregnant women are gathered in the room, counselling begins. “Please listen to me carefully. If you don’t understand anything, you can stop me any time and ask me questions,” says Mary, one of the counsellors and begins a detailed session on various issues related to pregnancy, including HIV/AIDS. She describes the nature of HIV/AIDS and how it spreads, and she explains its consequences.
“It takes a long time for a person to look sick. You will not be able to say that a person is living with HIV simply by looking at the physical appearance,” she explains, to emphasise that taking steps to prevent infection is the only way. She advises her audience on the use of condoms, on why they must buy a syringe each time they have an injection and on the dangers of having multiple partners. “If you agree, fill in the form. The test will take a week.”
There is little resistance. Most women agree to the test. If any of them test positive, they are encouraged to bring in their partners for testing.
Once an HIV positive mother delivers her baby though, the programme shifts its focus to the child. The risk of transmission through break-milk is about 15 per cent. But given India’s high infant mortality rate, the benefits of being fortified against diarrhoea and other life threatening infections far outweighs the risk of HIV transmission through breastfeeding. Parents are nevertheless encouraged to make an informed choice.
After delivery, HIV-positive women are kept in the general ward of the postnatal unit to avoid segregation.
Several other issues need attention. Adequate support systems need to be built within the community for affected or infected children. Care and support for HIV-positive mothers and their families need to be improved. But for now, a beginning has been made.