TT could get to zero

The strides and challenges of prevention of mother-to-child (PMTCT) HIV transmission in T&T

“In 2012 no Caribbean child should be born with HIV,” says Joint United Nations Programme on HIV/AIDS (UNAIDS) Caribbean Regional Support Team Director, Dr. Ernest Massiah.  “We have the means to prevent it.”

T&T has made strides toward achieving this vision. In 2010 148 babies born to HIV positive mothers in the Trinidad and Tobago public healthcare system were tested.  None of them were born with the virus. T&T joins a growing list of Caribbean countries that are achieving stellar outcomes from their prevention of mother-to-child treatment (PMTCT) programmes and bringing the region closer to eliminating this form of HIV transmission by 2015.

“This is the oldest HIV treatment program in T&T. It was started even before we were doing comprehensive antiretroviral treatment,” explained Deputy Programme Director at the Ministry of Health, Dr. Ayanna Sebro. “The program is very comprehensive and it’s fully integrated into the antenatal clinic.”

Sebro is cautious about heralding the success of the effort, however, noting that there is a gap in terms of babies who are not tested. (This screening does not take place at birth. See sidebar.) Sebro credits community and treatment site nurses, PMTCT coordinators and County Surveillance nurses for doing a “fabulous job” of staying connected with mothers and ensuring that there is monitoring, treatment support and follow-through. Nevertheless, a few slip through the cracks.

“We have to find the mothers and bring the infants in for testing. We need to follow up with the mothers who don’t come in and try to figure out why,” she said. In Trinidad there are dedicated nurses responsible for PMTCT coordination. In Tobago and County St George Central, however, the role of responding to the special needs of families affected by HIV is more integrated into the primary healthcare programme.

Tobagonian paediatrician, Dr. Maria Dillon-Remy, calls for the increased involvement of midwives in PMTCT efforts.

“At present our babies routinely receive immunisations because our midwives know them,” Dillon-Remy said. “Getting midwives integrally involved means that babies are not lost for lack of follow-up.”

The paediatrician calls for other refinements of the current system including the adoption of rapid HIV testing at the antenatal level so that women learn their status immediately rather than at the next clinic visit. In a response where time is of the essence, she says that the extra cost of rapid testing is worthwhile.  She also thinks that the programme needs to move in the direction of partner testing and treatment of the family as opposed to the mother alone. Dillon-Remy helped pilot PMTCT in Tobago in 1999 before it was rolled out to Trinidad the following year.

"In the beginning medical personnel didn't believe women would want to be tested for HIV but once women understood what it meant for their babies—that it was possible to treat them and so reduce the chance of passing it on—they agreed," Dillon-Remy reflected.

Today screening of pregnant women for HIV in T&T’s public sector stands at 95 percent.   Sebro clarified that some women refuse the test because they already know their HIV positive status.

In the early years the PMTCT program used a type of antiretroviral (ARV) drug popularly known as AZT on its own. Now a combination of ARVs is used to suppress the virus. This has led to a significant decrease in the number of infants being born HIV positive.

“The current approach is to reduce the virus to undetectable levels by the 36^th week of pregnancy. In that case,” Sebro stressed, “the risk of transmission to the baby is less than one percent.”

Following birth, all infants born of HIV positive mothers are given post exposure prophylaxis, drugs that reduce the chance of contracting HIV following exposure. They are also given free infant milk formula by the Ministry of Health for the first year of life as breastfeeding is another way in which transmission can occur. If a baby is found to be HIV positive he or she is immediately referred for treatment.

On the issue of stigma and discrimination, stakeholders agree that while there is room for improvement, much progress has been made in terms of workers’ approach to dealing with women living with HIV. Lorna Henry, Founder of the Trinidad and Tobago arm of Mothers 2 Mothers, a support group for mothers living with HIV, cautioned that there is still work to be done.

“Yes, some positive changes have been made to the system but some women living with HIV are still treated differently from those who aren’t. There is still the problem of women being so afraid of discrimination that they don’t come to clinic and then they present themselves only when they’re in labour,” she said. Henry shared Sebro’s concern that while there were no recorded cases of babies being infected at birth in 2010, this does not account for the private healthcare system or those children who have not returned to their healthcare providers to be tested.

 “I think we can get pretty close to zero,” Sebro said. “Maintaining a less-than-one percent transmission rate is not a pie in the sky goal. We are on our way already and we have to work together to get there. We have to maintain what we are doing and build on what we have, all the while looking at the people we missed. It is going to be a difficult group: they are mothers who have social challenges. It’s not something that one person will be able to do on their own. The entire health sector has to respond,” she said.

“I am convinced that we can do it,” Dillon-Remy added. “We did it with polio and measles and though getting down to zero with PMTCT is more complex, we have the ability to do it now.”

Photo Caption: Paediatrician Maria Dillon-Remy (Credit: UNAIDS Caribbean)