When in 2011 Malawi adopted Option B+, where HIV-positive pregnant mothers are put on Antiretroviral Therapy (ART) regardless of their viral load, to protect the baby from HIV infection, there was hope for a possible end to new HIV infections through prevention of mother-to-child transmission (PMTC).
However, years later, the country continues to register an increasing number of babies born with HIV.
The 2021 HIV Epidemiological estimates show that Malawi has 7 909 children between the ages of 0 to 14 who are HIV-positive. The year 2020 registered 2 300 new infections and 1 500 new deaths of children from HIV-related illnesses.
Despite achieving remarkable progress in the fight against HIV in adults, Malawi is struggling with HIV management in children. Pediatric viral suppression remains a major challenge leading to hundreds of children under the age of five dying from Aids-related illnesses.
LightHouse-Blantyre Umodzi Family Centre clinic nurse Nakari Osman attributed the challenge of failure to protect the babies through PMTC, to poor adherence to ART by mothers when they are pregnant and lack of awareness on how to administer the drugs to the babies.
“This issue is complex; it also has to do with gender-based violence, we have had scenarios where a woman is not comfortable to disclose her status to her husband after testing positive during antenatal. This is because she is afraid of being accused of bringing the virus into the family through infidelity, a thing which may result in the husband ending the marriage,” Osman explains.
She observed that due to this challenge, such women hide the ARVs or even throw them away.
She further says lack of awareness on the administration of the ARVs on children and poverty are also contributing factors adding that most children are malnourished which does not go well with the medication.
To help avert the challenge, the institution introduced a kindergarten programme whereby the babies are being extensively monitored and the mothers are supervised in terms of child care.
Umodzi Family Centre has since November last year, enrolled 145 under-five children in the kindergarten programme.
“We observed that despite the efforts, a lot of children were dying; when we started the programme, viral load suppression in children was at 38 percent, meaning that only 38 children out of 100 were having their viral load suppressed. This was very dangerous,” says Osman.
She says now through the programme, they have managed to push the viral load suppression up to 67 percent, they aim to reach 80 percent by the end of the year.
Osman, however, bemoans that babies continue to die, with the clinic registering more than 12 deaths this year alone. She says, most of the babies die of Tuberculosis.
“Most of the babies come here very sick already, we try to provide them with utmost care but probably it’s too late. It’s really sad.”
She wished there was more funding to incorporate a nutrition component in the programme because most of the babies are malnourished as they come from poor backgrounds.
”We need to support these children because they are our future. If they don’t take the medication properly they either develop resistance or die. This programme needs holistic support,” says Osman.
In a separate interview, National TB Control Programme director Dr James Mpunga explains that TB is an opportunistic infection and if one has HIV, and the immunity has gone down then TB surfaces.
“The challenge with children is that diagnosis of TB is not as easy as compared to the adult population. The diagnostic technologies for children are not as straight forward, so as a country we want to build the capacity of our health care workers so that they are able to diagnose TB in children and put them on treatment,” says Mpunga.
In 2016, Malawi registered 16 959 TB cases (NTP 2016 report). Childhood TB made 8.6 of those cases. Most TB patients were HIV positive.
Elizabeth Glaser Pediatric Aids Foundation (Egpaf) communications officer Prince Henderson, sees light at the end of the tunnel following the introduction of a new child-friendly regimen of ART called Dolutegravir (DTG).
The regimen provides a greater chance of child survival as it provides faster viral suppression, has an improved taste, is easy to consume and will thereby improve adherence.
“For example, some important benefits of Paediatric DTG regimens for children include faster and more durable viral suppression, better tolerated—very few patients experience significant side effects—Lower risk of opportunistic infections and death, they are easy to administer and they have an appealing strawberry flavour,” he says.
Henderson concurs with Osman that some of the poor suppression in children originated from the use of less efficacious regimens (NNRTIs -nevirapine based ART), poor adherence, poor drug administration, and use of drugs that were not friendly to children, like LPV/r which has a bitter taste.
Malawi commits to eradicating HIV by 2030, however, this can’t be achieved if pregnant mothers are not responsible enough to protect their babies from HIV.
Lighthouse, Umodzi Family Centre chief programmes manager Boniface Chione believes the country needs proper funding and more awareness through outreach programmes to reach out to the masses on the importance of adherence to ART.
“The medicine is there and there is evidence that if a mother is taking the medication correctly, she may not transmit the virus to the baby, but there are women who are not taking this information seriously. Poor healthcare-seeking behaviour is still a challenge, with some women not visiting the hospital throughout the pregnancy,” says Chione.n