ICMR BULLETIN VOL. 27-No.-12-DECEMBER-1997.pdf
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Vol. 27, No. 12
December, 1997
CHILDREN WITH HIV/AIDS: CHALLENGES AND OPPORTUNITIES
Though a syndrome of immunodeficiency with
opportunistic infections in children was described in 1982,
and the first publication on children with HIV-l/AIDS
appeared in 1983, children seemed to be considered at the
periphery of the AIDS epidemic. But the situation is rapidly
changing. The ratio of infected men to women is fast
approaching 1:1. Most of the HIV-1 infected women are
of child bearing age, and it is from them that the majority
of children will get the infection.
It is not only the HIV infected children but even those
uninfected who are at risk because oftheir parents inability
to care for them. It is estimated that there would be millions
of children on their own by the end of this decade in the
countries affected by HIV/AIDS. Orphaned, abandoned
or runaways, vulnerable in their turn to HIV infection as
they take to life on the streets. It will be the children and
young adolescents affected by HIV who will shape the
future course of the epidemic.
Aids in Children
Current Situation
It is estimated1 that in 1996 of the 1.5 million people
who died of AIDS globally, 3,50,000 (23%) were children
(below 15*yr of age) and about 4,00,000 children became
infected with HIV. Of the 23 million people world-wide
living with HTV, 8,30,000 (3.6%) are children. UNAIDS
expects this number to rise to 1 million by end of 1997.
Over 90 per cent of these children live in developing
countries.
Since the beginning of the epidemic, according to
UNAIDS and WHO estimates, well over 2 million HIV
positive children under the age of 15 years have been bom
to HTV positive mothers, and thousands have acquired HIV
infection from blood transfusions or through sex’. Unfor
tunately for India there are no firm figures for the infec
tion rate among children and adolescents.
Future Projections and Impact
Cumulatively by the year 2000 as many as 5 million
under fives will be HIV infected through their mothers,
the majority of them in Sub-Saharan Africa2.
Projections of the number of AIDS cases in infants
and children are based on perinatal transmission rates of
about 30 per cent and specific fertility rates. However,
because the infected mothers are likely to die of AIDS
within 5-10 years of their giving birth, the uninfected
infants will constitute a growing population of orphans.
According to WHO estimates close to 5 million children
(under 10 yr of age) will be orphaned by the end of the
1990s as a result of HIV related deaths of their mothers.
How many infants will die of AIDS in the year 2010?
According to the UN .Population Division, the figure could
be anywhere between 83,000 and 3,57,000 in just 19 of
the high risk countries. But the United States Bureau of
F Division of Publication & Information, ICMR, New Delhi - 110 029
This issue commemorates the World AIDS Day (December 1,1997)
Census paints a gloomier picture. AIDS took 1,05,000 in
fant lives in 1995 in the 19 countries, and the toll will
increase to more than 3 times that number in 20 1 03.
older children including sexual abuse and sexual
exploitation.
One of the main reasons for difference between these
two projections is their assumptions as to the timing ofthe
peak ofthe epidemic in these countries. The Census Bureau
believes that the peak will come in 2010, while the UN
believes that it peaked in 1995. In the 19 countries, the
Census Bureau attributes 26 per cent of infant mortality to
AIDS in 2010, whereas the UN estimate is 8 per cent3.
Mother-to-child transmission
A recent survey of the impact of AIDS on child mor
tality in ten central and eastern African countries suggests
that the death toll from AIDS in children under 5 years is
likely to rise from 159 to 189 per 1000 by the year 20004.
By the year 2010, the US Bureau of Census estimates,
if the spread of HIV is not contained, that AIDS may
increase infant mortality by as much as 75 per cent and
under five mortality by more than 100 per cent in the worst
affected regions1.
Even for those children who escape perinatal infection,
survival rates will decrease because of loss of one or both
parents to AIDS. For each women dying of AIDS in Africa
an average of two children will be orphaned. By the year
2000, 5-10 million children under 10 years may be
orphaned because of premature death of HIV infected
parents. Overall infant and child mortality rates have
exceeded previous projections by as much as 30 per cent
as a direct consequence of perinatal HIV infection.
Consequently, paediatric AIDS is now threatening much
of the progress that has been made in child survival in
developing countries during the past 20 years. Life
expectancy, which had been increasing in most of these
countries, is now declining in many of them. In 2010, the
projected life expectancy will be about 10-30 years lower
in countries than it would have been without AIDS5.
Routes of Infection
The predominant route of infection in children is from
an infected mother to her child. This route accounts for
close to. 90 per cent of all instances of paediatric infection.
About 10 per cent of children become infected through
other routes.
Transfusion of HIV positive blood and blood products
is still an important route of infection in countries where
screening of donated blood is not universal because of
economic or technical constraints. Also of growing concern
is the transmission of HIV-1 through sexual contact among
118
Mother-to-child transmission can occur prenatally, at
the time of delivery and postnatal ly through breast feed
ing. Evidence for early transmission was shown by detec
tion of the HIV-1 virus in foetal specimens6, and also by
the presence of p24 antigen in foetal serum7.
The role of the placenta is still not clear. In vivo in
fection of placental cells, trophoblast and villous Hofbauer
cells has been shown as early as 8 weeks of gestation8.
Differences in the ability of placental cells to sustain
virus replication may influence the selection of virus
variants during transmission. Intercurrent infections of the
placenta may favour leakage of virus into the amniotic
cavity. However, it is uncertain whether placental infection
always results in infection of the foetus.
The child can get infected at the time of delivery
through mixing of maternal and foetal blood during uterine
contraction, contamination through mucous membranes,
or by swallowing maternal blood or cervico-vaginal
secretions during passage through the birth canal. In
addition, recent reports have indicated that the mode oT
delivery may also affect the transmission rate. Caesarian
section has been shown to decrease9 and prolonged rupture
of the membranes (more than 4h )to increase the risk of
transmission10.
Not all children bom to HIV infected mothers will
become infected. The rate varies from 13 per cent in
Europe to about 45 per cent in Sub-Saharan Africa11.
The risk of transmission is higher in women with clini
cal, immunological or virological markers of advanced
HTV-1 infection. A high viral load has been associated as
a key factor in mother-to-child transmission. Recent stud
ies have also found a correlation between viral load and
transmission12. In addition, the phenotype of the mother’s
virus is also believed to contribute to the risk of infec
tion13.
Rapid/high virus isolates have been associated with
mothers who transmit the virus whereas slow/low virus
isolates were associated with non-transmitting mothers.
A low CD4 count also correlates with an increased risk.
Immunological factors such as the presence of neutralizing
antibodies may also play a role in minimizing
transmission14.
One meta-analysis has suggested that breast feeding
may increase the risk of infection by an additional 14 per
cent (95% confidence interval 7-21 %)15. In the studies in
cluded for this meta-analysis the median duration of breast
feeding was short (4-8 weeks), which points to a high risk
of transmission in the first few weeks of breast feeding.
Some children of HIV infected women bom HIV antibody
positive have seroconverted to become antibody negative,
but later, while being breastfed have become positive16"18.
Other studies have been able to detect HIV DNA upto 12
months postpartum in milk samples of about one-third to
one-half of HIV infected women19.
Transfusion of blood and blood products
Transfusion/infusion of blood or blood products
containing HIV is considered the most efficient method of
transmission of HIV infection. Children suffering from
thalassaemia, sickle cell anaemia, haemophilia, etc., require
frequent transfusion/infusion of blood/blood products. In
a study that examined the role of blood transfusion in
transmission of HIV-1 among African children, 147 of
1046 (14%) paediatric patients in Kinshasa, Zaire had a
history of previous blood transfusion. Forty of these 1046
children (3.8%) were HIV-1 seropositive, and there was a
strong dose response association between blood transfusion
and HIV-1 seropositivity. The odds ratio of being HIV-1
seropositive increased to 43 in children who had received
3 or more blood transfusions20.
The potential association of blood transfusion in
HIV-1 transmission is exemplified by the high rate of
seroprevalence of HIV-1 among blood donors in many
developing countries.
Transmission of HIV-1 through blood products
accounted for 19 per cent ofthe new AIDS cases in children
reported in 1985 to the Centres for Disease Control (CDC),
USA. This figure had come down to 6 per cent by 1995.
The decrease reflects more rigorous screening of donors
and donated blood as well as improved manufacturing
techniques for coagulation factor concentrates21.
Sexual contact
In sexually active teenage girls, susceptibility to HIV
and other sexually transmitted diseases may be increased
because of the immature epithelium of the cervical canal.
High risk behaviours, including unprotected sex, and use
of illicit drugs potentiates this problem.
Is Immunization Safe in HIV Infected Infants?
Increasing prevalence and awareness of HIV
infection in infancy has led to concern about the
efficacy and safety of immunization of HIV infected
infants and children. Experience with live and
inactivated vaccines in HIV infected children suggest
that these immunizations are free from major short
term side effects. Risks and known consequences of
natural infection are likely to be graver than the risks
associated with vaccination even with live attenuated
vaccines.
Taking all these factors into consideration, WHO
has recommended that all asymptomatic HIV infected
children should receive all standard vaccines, both live
and inactivated; Those with symptoms of AIDS should
receive all other vaccines except BCG.
Source: AIDS prevention: What maternal and child health
service providers need to know. Regional Health Paper,
SEAROno.23, WHO, New Delhi. 1992.
Diagnosis
Diagnosis of HIV in a child older than one and a half
years can confidently be done using enzyme-linked im
munoassay and confirmatory tests. It is the diagnosis at an
earlier age that poses challenges. It is known that anti
HIV antibodies from the mother can be detected in the
child’s blood for a median of 13.3 months (range 10.4 15.6 month)22.
A child less than one and a half years of age is consid
ered to be HIV infected if positive oh two separate occa
sions (excluding on cord blood) by one or more of the
following HIV detection tests: HIV culture, HIV PCR, or
HIV antigen (P24)23 or the child meets the criteria for an
AIDS surveillance case definition24.
The sensitivity of the various diagnostic tests by the
age of the infant at the time of testing is summarized in
Table I25.
Virus culture and PCR are believed to be the most
reliable techniques for determining infection during the
first 2 months of age in non-breastfed children. Detection
of p24 antigen in serum or plasma is less sensitive in
younger children but recent reports indicate that it can
achieve similar sensitivity by 6 months of age26. Even
higher sensitivity can be achieved by disrupting the
119
Table I.
Sensitivity (percentage) of early diagnostic tests for
HIV-1 infection in infants23
Laboratory_____________________ Age at testing___________________
method
1 week
2-4 week
1-2 months
3-6 months
> 6 months
<10
10-30
20-50
50-80
70-90
10-25
20-50
30-60
30-50
20-40
PCR
30-50
50
70-90
>95
>95
Viral
30-50
50
70-90
>95
>95
HIV IgA
antibodies
HIV-1 p24
antigen
culture
Superscript no. refers to the si. no. in the reference list.
immune complexes by acid treatment of sera. Using this
technique, it is claimed, that HIV-1 infection can be
diagnosed within the first few months of life26.
Early diagnosis of infection has improved with the
availability of more sensitive and specific tests. HIV cul
ture remains the gold standard but is very costly and not
widely available.
Staging of Paediatric Aids
The Centres for Disease Control and Prevention re
vised the classification of paediatric HIV infection in
19942’. There are 4 clinical stages viz. N, asymptomatic;
A, mild; B, moderate; and C, severely symptomatic chil
dren.
(i) Category N; asymptomatic : Children who have no
signs or symptoms considered to be the result of HIV
infection or who have only one of the conditions listed
in Category A.
(ii) Category A; mildly symptomatic : Children with two
or more of the following conditions, but none of
the conditions listed in categories B and C. The
conditions include lymphadenopathy, hepatomegaly,
splenomegaly, dermatitis, parotitis, recurrent or
persistent upper respiratory infection, sinusitis or otitis
media.
Category
(iii)
B; moderately symptomatic : Children who
have symptomatic conditions other than those listed
for categories A and C that are attributed to HIV
infection. A single episode of severe bacterial
infection, lymphocytic interstitial pneumonitis,
anaemia, neutropaenia, thrombocytopaenia
cardiomyopathy, nephropathy, hepatitis, diarrhoea,
candidiasis, severe varicella/zoster or herpes simplex
virus infections.
120
(iv) Category C: severely symptomatic : Children who
have any condition listed in the 1987 surveillance case
definition for AIDS with the exception of lymphoid
interstitial pneumonia. These include two serious
bacterial infections, encephalopathy (acquired
microcephaly, cognitive delay, abnormal neurology),
opportunistic infections {Pneumocystis carinii
pneumonia, cytomegalovirus, toxoplasmosis,
disseminated fungal infections); disseminated
mycobacterial diseases, cancer (Kaposi’s sarcoma,
lymphomas).
The progressive loss of CD4+lymphocytes is a
hallmark of the course of HIV disease in children. But
their number and sub-groups undergo age related changes.
An absolute CD4 count below 500 cells/mm3 in untreated
children is strongly correlated with rapid progression of
the disease, and the presence of a very low CD4 count
(<21 % ofthe lower limit for age) is significantly associated
with an increased risk of death within 2 years21.
Accordingly, age dependent changes in the CD4 count and
percentage have been incorporated into the definition of
AIDS in children (Table II)23.
Table II. Immunologic categories based on age-specific CD4+T-lymphocyte counts and percentage of total lymphocytes23
Age of child
Immunologic
category
__ ’< 12 months
1: No evidence
6-12 Years
1-5 Years
cells/mm*1
%
cells/mm3
%
cells/mm3
%
£1500
£25
£1000
£25
£500
£25
750-1499
15-24
500-999
15-24
200-499
15-24
<750
<15
<500
<15
<200
<15
of suppression
2: Evidence of
moderate supp
ression
3: Severe suppr
ession
Superscript no. refers to the si. no. in the reference list.
Natural History Of Vertically Acquired HIV
Infection
Most of the information on the natural history of ver
tically acquired HIV infection in children comes from pae
diatric HIV registers and prospective follow up of infants
bom to HIV infected mothers.
The Women and Infant Transmission Study (WITS)
in USA is a multicentric longitudinal study of the natural
history of HIV-1 infection in pregnant women and their
infants initiated in 1989. Plasma HIV-1 RNA levels, mea
sured in 106 infants, were found to increase rapidly after
birth, peak at one to two months of age (median value:
318000 and 256000 copies/ml respectively) and then
slowly decline to a median of 34000 copies/ml at 24
months. Newborns with a first positive HIV-1 culture
within 48 h after birth had significantly higher HIV-1 RNA
levels. Infants with a rapid progression of the disease had
higher peak HIV-1 RNA levels in the first two months of
life than those without rapid progression (median value
724000 vs 219000 copies/ml)27.
The low levels of HIV-1 RNA at birth suggest that
most of the children were infected very close to the time
of birth. The steep rise in viral load within the next two
months reflects a rapid multiplication of the virus. The
subsequent slow decline contrasts with the rapid decline
in adults. This suggests that the still immature neonatal
immune system has difficulty in containing the infection.
The similarity in the general pattern of plasma and serum
HIV-1 RNA loads in children, as measured in smaller pro
spective studies and cross-sectional studies is striking.
Although the number of studies of HIV-1 RNA in chil
dren is much less than those in adults, the collective data
clearly indicate a unique pattern of viral replication and
containment28'30.
After birth and in. the immediate perinatal period a
trimodal rate of disease progression has been observed.
Approximately one-third of these children become symp
tomatic within the first few months of life and are consid
ered ‘rapid progressors’. They have a rapid down-hill
course. Nearly 70 per cent are ‘less rapid progressors’
becoming symptomatic within the first seven years of life.
A small percentage do not develop evidence of disease
progression until after 8-10 years of age, behaving more
like ‘adult equivalents’.
The age at onset of any sign of HIV-1 infection predicts
the duration of survival. The mortality rate for children
who develop features of AIDS early in life is substantially
higher than for those who become symptomatic later during
childhood31’32.
The European Collaborative Study33 was set up in 1986
to estimate the rate and natural history of vertical trans
mission of HIV infection. At ten European centres 124
children bom to HIV positive women and known to be
infected at or before the time of delivery were enrolled for
natural history analysis. In this cohort, less than 10 per
cent of children had been treated with zidovudine or intra
venous gamma globulin before 6 months of age. About a
quarter developed AIDS in the first year of life, and nearly
40 per cent by 4 years. Ten per cent died before age one
and 28 per cent before the age of 5 years. Two years after
AIDS diagnosis an estimated 48 per cent of children were
still alive. Similar mortality rates were reported in the
Italian Multicentre Register34.
A total of 182 perinatally HIV infected children who
survived longer than 5 years (long-term survivors - LTS)
and 120 children who died of HIV-1 related disease before
5 years (short-term survivors - STS) enrolled in the Italian
Register for HIV infection in children were studied.
Information was generated on the factors that contribute
to long-term survival. Results indicated that a substantial
number of children »do survive after early childhood^
Severe disease or low CD4 cell counts early in life can be
predictive of outcome. However, the association of CD4
count with the progression of the disease was not observed
in the European study.
Since 1986, the French Prospective Study and the
European Collaborative Study have collected clinical and
immunological data on children bom to HIV infected
mothers35. Nearly 400 infected children from about 3500
mothers were enrolled in the two studies. Most children
had developed minor (A) or moderately severe (B) illness
in the first 4 years of life. Progression to group C disease
or HIV-related death was seen in an estimated 20 per cent
during the first year of life, and close to 5 per cent per
year thereafter, giving a cumulative incidence of 36 per
cent by 6 years. The mortality rate at 6 years was 26 per
cent, two-thirds of children were alive at 6 years and had
only minor symptoms, and one-third had a CD4 cell
distribution of more than 25 per cent despite previous
clinical manifestations and a transient period of moderate
immune deficiency.
There are marked differences between the French and
the European cohorts in the timing and type of treatment
given. Zidovudine monotherapy was initiated at an earlier
age and more frequently in the French Study than the Eu
ropean Study, but the morbidity and mortality in the two
cohorts were similar. Wider use of trimethoprim
sulphamethoxazole prophylaxis for Pneumocystis carinii
pneumonia in the French Study probably resulted in lower
frequency of bacterial infections. These findings have im
plications for health care planning. The causes of rapid
progression in some children is not clear. It has been sug
gested that it could be associated with host factors, viral
phenotype and timing of transmission.
121
The survival scenario is likely to change in future, as
effective retroviral drugs become available for use in
children and with better management and prevention of
opportunistic infections.
Despite growing optimism, serious hurdles need to be
overcome before such therapy can be routinely applied to
children. These include lack of data to ensure safe and
effective dosing and the unavailability of these drugs in
palatable suspension.
Antiretroviral Therapy
Three agents are approved for use in HIV infected
children viz. zidovudine, didanosine and a combination of
lamivudine and zidovudine. But as results of the ongoing
and newer clinical trials become available, this lis - is ex
pected to grow. Zidovudine was the first drug to oe ap
proved for use in children with symptomatic HIV infec
tion. This was followed by approval of didanosine and
lamivudine in combination with zidovudine.
Till recently zidovudine has been the drug of choice .
for the initial treatment of symptomatic children. The re
sults of Delta and ACTG adult treatment trials both showed
that for nucleoside naive patients combinations of AZT
and didanosine or AZT and zalcitabine were significantly
more effective than AZT alone in delaying disease pro
gression. Clinical trial has been conducted in children to
assess the efficacy and safety oftreatment with zidovudine
alone as compared with either didanosine alone or in com
bination with zidovudine (ACTG-152)36.
An interim analysis of the trial has showed that in
symptomatic HIV infected children, treatment with either
didanosine alone or zidovudine plus didanosine was'more
effective than treatment with zidovudine alone. The effi
cacy of didanosine alone was similar to that of combina
tion therapy and was associated with less haematologic
toxicity36.
Paediatricians in Europe, Canada and South America
are collaborating in a series of studies coordinated by the
Paediatric European Network for Treatment of AIDS. A
Phase II study of adding lamivudine (3TC) to current treat
ment in symptomatic children is underway. Another Phase
II trial evaluating a new nucleoside analogue with a pro
tease inhibitor in antiretroviral naive children is also in
the pipe-line37.
Combination therapy for treatment of HIV infected
children is being pursued to develop regimen that are more
potent, more tolerable, or more capable of delaying or pre
venting the emergence of resistant HIV-1 isolates. As new
agents are developed that act on different parts of the life
cycle of the virus, new combination regimens will become
possible.
122
Gene Therapy
A large number of babies continue to be bom who are
infected but with limited access to antiretroviral agents.
Even though conventional approaches using a
combination of antiviral drugs have been successful in
decreasing viraemia to a varying degree, there is always a
possibility of multi-drug resistant viral mutants appearing
late after infection. A multidimensional approach that
considers the recovery ofthe immune system is still needed.
Gene therapy is one of the alternatives to treat HIV
infection. It is envisaged that gene therapy if applied before
the architectural damage appears on the lymphoid organs
in advance disease, would enable normal lymphocyte
development of genetically modified cells. The idea is to
generate cells capable of inhibiting HIV replication and
pathogenesis. If the cells that are the target of HIV infection
acquire anti HIV protection, cells differentiating from them
will also be stably protected. The ideal therapeutic anti
HIV gene is expected to be effective, nontoxic and active
against different viruses.
Presently, the most appropriate gene vector to trans
duce haemopoietic cells is a murine retrovirus. The pro
posed treatment plan consists of the identification of HIV
infected mothers, collection of cord blood cells at birth as
a source of haemopoietic stem cells, diagnosis of HIV in
fection, transduction of stem cells with the anti HIV gene,
and reinfusion of the modified cells to the patient. The
goal is to regenerate the immune lymphocytes which will
have a check on virus replication.
The results obtained so far on survival advantage of
peripheral T- cells from HIV infected patients transfected
with a Rev transdominant negative gene, called Rev M1038
are encouraging. The successful gene therapy strategies
for HIV infected children would also help to elucidate
whether the progressive deterioration of the immune sys
tem is caused by the viral pathogenic effects that are not
directly related to viral replication. Technology of suc
cessful gene therapy is also a consideration in reducing
the current cost of prolonged treatment for cure of AIDS
patients and allow a wider affordable application.
Prevention of Mother-to-Child Transmission
In most instances of paediatric AIDS, vertical
transmission is the predominant route of infection. Hence
strategies aimed at preventing infection among women will
also help reduce the infection among children. Over the
years, it has been realized that behavioural change is
perhaps the best but most difficult means to prevent HIV.
Development of programmes with an integrated approach
to induce behavioural change, promoting condom use, and
controlling STDs is likely to reduce the infectivity of the
transmitters as also the susceptibility of HIV exposed
persons. Needle sharing is another risk behaviour among
injecting drug users (IDUs). Needle exchange programmes
have helped stabilize and in some instances even reduce
HIV incidence among IDUs. Raising awareness through
information, education and communication (IEC) activities
has helped to lift the veil of ignorance surrounding sexual
attitudes and behaviour.
A variety of factors may increase the risk of transmis
sion of HIV from mother to infant. Some potential means
of reducing this risk have been suggested.
(i) The use of zidovudine by asymptomatic infected
woman with CD4 cell count of more than 200/ mm3
has been shown to reduce transmission by two-thirds.
These women were treated with zidovudine orally
during pregnancy, and intravenously during labour.
Infants received oral zidovudine for six weeks after
birth39. This approach may be feasible in countries
where zidovudine is available and affordable. For
countries where the cost of this regimen is prohibi
tive, trials of modified timing doses of antiretroviral
drugs are needed to find most cost-effective methods
for reducing perinatal transmission.
transmission. This temporal relation may suggest that
supplementing vitamin A intake during pregnancy may
lower the vertical transmission of HTV.
(iv) A critical and much debated issue has been whether to
advise mothers in developing countries against breast
feeding because of the risk of HIV transmission
through breast milk. This potential risk can be
eliminated in a population with access to breast milk
alternatives. Breast feeding by HIV infected mothers
is not recommended in the US and other industrialized
countries.
This strategy is, however, not feasible for most
developing countries where an affordable and safe
alternative may not be available. Because the risk
associated with the use of contaminated water for the
preparation of powdered infant’ formulae outweighs
the risk for HIV infection from breast milk, the WHO
recommends that mothers in developing countries
where water supplies are unsafe continue to breastfeed
their infants. In regions of the world where infectious
diseases and malnutrition are primary causes of death,
mothers should continue to breastfeed regardless of
their HIV status.
(v) The role of other potential interventions like vaginal
microbicides is still under evaluation.
Children in Families Affected by HTV : Social Issues
No other children are more at risk of loss of permanent
family than children whose mothers have HIV disease.
Both infected and non-infected children of these mothers
are at risk.
Children, especially in the developing world, have
become vulnerable to HIV infection due to various social,
(ii) The observation that the risk of transmission from
economic and cultural factors. Some are infected
mother-to-child increases when foetal membranes rup
themselves by HIV, and others are affected as they are
ture more than 4 hours before delivery may lead to
closely related to people living with HIV/AIDS. The
simple precautions so as not to intentionally rupture
number of street children in metropolitan cities is
membranes. Though every effort should be made to
constantly increasing. These children are vulnerable to riskshorten the time between rupture of membranes and
ridden life situations. The risk of HIV comes from being
delivery, this should not be taken to mean using inter
lured into intravenous drug use, sharing of needles, from
ventions that could increase morbidity for the mother
sexual exploitation, and from poor nutritional and health
or her infant.
status due to the life style. Misconceptions like sex with a
(iii) Vitamin A stores are depleted during birth and preg virgin cures STD also lead people into deplorable acts and
a girl child on the street is an easy target. There is an
nancy. It is known that vitamin A deficiency leads to
unending stream of children being pushed into the flesh
weakening of the already weakened immune system.
trade.
These children are constantly at threat of getting not
Vitamin A deficiency has been shown to be associ
only
HIV
but also other STDs. With the spread of HIV/
ated with a three to four fold increased risk of vertical
123
AIDS more of the uninfected children are experiencing
the social and economic impact of having a relative living
with HIV/AIDS.
Special strategies need to be developed to help chil
dren living on the street to have greater control over their
lives, and to seek alternatives to the street. A broad range
of measures need to be provided to help increase their
safety, health, and well being40.
Components of Strategic Programme for Children
•
Assess needs, monitor the situation and its im
pact.
•
Create national awareness and engagement.
•
Develop a national policy framework.
•
Create consensus on the most effective and sus
tainable responses.
•
Develop mechanisms to ensure that resources are
used effectively and equitably.
•
Strengthen national capacity to implement the
programme.
Source : Reid, E. Children in families affected by the HIV
epidemic: A strategic approach. Issue Paper no. 13, HIV
and Development Programme, UNDP, New York, 1993.
Until now, many of the policies and programmes ad
dressing the needs of HIV affected children and adoles
cents have assumed that these needs start with the death of
their 'mothers or parents and consist of predominantly
material needs. It is important to broaden this focus. It is
being realized that the needs of these young people start
with the knowledge that someone in the family is HIV
infected. Their needs are psychological, emotional, ethi
cal, legal, spiritual, financial, material, educational, health
and social development.
The needs of these children cannot be met by policies
and programmes addressed to children and youth. There
are at least three other types of interventions required;
assistance to their parents, to their communities and to their
governments. The breadth and diversity of the interventions
required to respond adequately to the needs of children in
families affected by the HIV epidemic present particular
challenges to programme development and ii.iplementation.
124
Few of the NGOs in India have made significant
progress in their efforts while addressing some of the so
cial problems’. The Association Francois-Xavier Bagnoud
(AFXB) has set up houses for HIV infected children in
Goa, the purpose of the AFXB Asha Sadan (house of hope)
is to keep the children of prostitues off the street while
their mothers are at work. Th .y are given shelter and ba
sic education materials, preparing them for the public
school system later.
The CINI Asha in Calcutta, India, runs drop-in centres
and night shelters for vulnerable children in Calcutta’s red
light district and around the city railway station.
Educational and vocational training are provided by peer
educators as part ofthe sexual health programme, targeting
children between 10-16 years. The peer educators are
provided with information, education and communication
materials for dissemination and are referred to children
who are particularly vulnerable. Free condoms are available
at the CINI Asha office in small quantities. Girls because
they are especially vulnerable are given separate training,
intensive counselling and are encouraged to attend the night
shelters. Assessment within the first year shows that peer
educators reached 90 boys and 60 girls out of the target
group of 200 children.
The Naz Foundation in New Delhi, India, is working
with NGOs to increase awareness ofsexual health and offer
counselling to street children. Naz organises HIV
awareness workshops and peer education training, focusing
on risk reduction and children’s sexual behaviour.
Although no formal monitoring and evaluation has been
conducted to date, reports indicate that condom use has
increased among street boys visiting sex workers, but has
not resulted in increased sexual activity.
Conclusions
Infection with HIV has continued its relentless march
across the world. The infection is becoming increasingly
acquired as a sexually transmitted disease in a heterosexual
population. This exacts an equal toll from men and women
and creates an ever increasing proportion of infected and
affected children.
A clearer picture of the natural history and better
understanding of risk factors associated with vertical
transmission have provided windows of opportunities for
developing appropriate and effective interventions. The
evidence of viral replication even at an early age has
important implications for clinical management. With
rapid advances in drug treatment, significantly improved
Rights of the Child in the Context of HIV/AIDS
The United Nations Convention on Rights of the Child in the context of HIV/AIDS has spelled out principles for reducing
children’s vulnerability to infection and for protecting children from discrimination because of their real or perceived HIV/AIDS
status;
• Children should have access to HIV/AIDS prevention education, information, and to the means of prevention. Measures
should be taken to remove social, cultural, political or religious barriers that block children’s access to these.
•
Children’s right to confidentiality and privacy in regard to their HIV status should be recognized. This includes the recogni
tion that HIV testing should be voluntary and done with the informed consent of the person involved which should be
obtained in the context of pretest counselling. If children’s legal guardians are involved, they should pay due regard to the
child’s view, if the child is of an age or maturity to have such views.
•
All children should receive adequate treatment and care for HIV/AIDS, including those children for whom this may require
additional costs because of their circumstances, such as orphans. States should include HIV/AIDS as a disability, if disability
laws exist to strengthen the protection of people living with HIV/AIDS against discrimination.
•
Children should have access to HIV/AIDS prevention education and information both in school and out of school, irrespec
tive of their HIV/AIDS status.
•
No discrimination should be Suffered by children in leisure, recreational, sport, and cultural activities because of their HIV/
AIDS status.
•
Special measures should be taken by governments to prevent and minimize the impact of HIV/AIDS caused by trafficking,
forced prostitution, sexual exploitation, inability to negotiate safe sex, sexual abuse, use of injecting drugs, and harmful
traditional practices.
Source: The role ofthe Committee on the Rights ofthe Child and its impact on HIV/AIDS: Problems andprospects. Presentation
by the WHO Global Programme on AIDS at Bangkok, Thailand on AIDS and child rights: The impact on the Asia-Pacific region,
21-26 November, 1995.
survival with HIV is now a reality. The challenge is to
find regimens that are effective, short, simple, and
affordable to communities who need it most. Advances in
technology has now made it possible to detect HIV
infection in early childhood, but the challenge is to improve
diagnostic capabilities so that infection can be defined
immediately following birth. Providing social support to
children living in a world with AIDS is an opportunity to
create an environment that is sensitive to their needs and
concerns. In this era of AIDS, there is a need to express
care and compassion rather than fear, hostility or alienation.
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126
This write-up has been contributed by Dr. Lalit Kant Sr. Dy.
Director-General, 1CMR Headquarters, New Delhi with inputs
from Dr. Neeta Mawar, Asstt. Director, National AIDS Research
Institute, Pune and Dr. Q.B. Saxena, Dy. Director, 1CMR Head
quarters, New Delhi.
AIDS/HIV UPDATE
Estimated Global Burden of HIV/AIDS: June, 1997
According to reports published in the Weekly
Epidemiological Record (WHO 72:197-204, 1997) as of
30th June, 1997, a cumulative total of 1,644,183 AIDS
cases in adults and children has been reported to WHO
since the onset of the pandemic. This represents an 18 per
cent increase from the 1,393,649 cases reported up to 30th
June 1996. Allowing for under diagnosis, incomplete
reporting and reporting delay, and based on HIV infection
data from around the world, the UNAIDS/WHO Working
Group on Global HIV/AIDS and Sexually Transmitted
Diseases Surveillance has estimated that by the end of
1996, approximately 8.4 million men, women and children
had contracted AIDS world-wide, since the beginning of
the pandemic. Continental totals are as follows:
Africa
Americas
Asia
Europe
Oceania
5,76,972
7,97,227
70,949
1,91,005
8,030
Total
16,44,183
Situation of AIDS in India
According to the reports provided by the National
AIDS Control Organisation (NACO) a total of 67,311
persons have been reported to be HIV positive to NACO
(cumulative till October 1997) out of3.2 millions screened,
giving a seropositivity rate of 2.1 per cent. The
corresponding figure for the period ending October 1996
was 1.7 per cent. The number of AIDS cases reported is
5002. This figure has increased by 2006 during the last
one year. Though there has been improvement in detection
and reporting of AIDS cases, these figures may still
underestimate the true cumulative prevalence.
•
Heterosexual contact is by far the most prevalent mode
of infection.
•
Maharashtra has a seropositivity rate of 10.2 per cent,
Punjab 4.3 per cent, Tamil Nadu 1.4 per cent, and
Pondicherry 3.2 per cent.
•
•
Increasing seropositivity rate has been found among
states where injectable drug usage is prevalent, par
ticularly Manipur (17.2%) and Nagaland (5.5%).
Close to 1 per cent of total HIV seropositives are
antenatal mothers.
•
The age distribution of AIDS cases reported to NACO
(till Dec. 1996) shows that 4 per cent were between 014 years, 44 per cent: 15-19 years, 45 per cent: 30-45
years, and 7 per cent were more than 45 years of age.
•
The highest number of AIDS cases have been reported
from Maharashtra (2451), followed by Tamil Nadu
(1092), Manipur (286), Gujarat (133), and Delhi (125).
•
Arunachal Pradesh is the only state to report zero posi
tivity among the 495 blood samples screened.
•
No case of AIDS has been reported from Arunachal
Pradesh, Andaman & Nicobar Islands, Dadra & Nagar
Haveli, Lakshadweep and Tripura.
AIDS cases in India (till October 31, 1997)
Number of AIDS cases
Male
3941 (78.7)
Female
1061 (213)
Total
5002
Probable source of infection
Heterosexual promiscuous
3715 (74.2)
Blood transfusion and
Blood products infusion
350 (7.0)
Homosexual contact
30(0.6)
Intravenous drug addicts
356 (7.2)
Other
551 (11.0)
Total
5002 (100.0)
Figures in parentheses are the percentages.
Surveillance data for HIV infection in India
(till October 31, 1997)
Details of seropositive individuals
Seropositive (%)
Group
Heterosexually promiscuous
30734 (45.8)
Homosexuals
229 (0.3)
Blood donors
4432 (6.5)
Dialysis patients
267(0.3)
Antenatal mothers
568 (0.9)
Recipients of blood/blood products
884(1.3)
Suspected ARC/AIDS cases
Intravenous drug users
Others
No. of persons screened
Total seropositive
11277(16.9)
2657 (3.9)
16263(24.1)
3200357
67311
Seropositivity rate 2.1 per cent (cumulative)
127
COUNCIL’S TRAINING PROGRAMMES
Reproductive Biology
Nutrition
At the Institutefor Research in Reproduction, Mumbai:
At the National Institute of Nutrition, Hyderabad:
•
Workshop on Basic Molecular Biology for Clinicians
(December 2-11,1997).
•
Postgraduate Certificate Course in Nutrition (December 1, 1997-February 28,1998).
ICMR BULLETIN INDEX
VOL. 27,1997
Main Feature
Page No.
Month
Changing Paradigms of Infectious Diseases in Developing
Countries
1
January
Application of Molecular Biological Techniques in the
Studies on Vector Mosquitoes - Current Status
9
February
Emergency Contraception
19
March
Pathophysiology of Diarrhoea due to Giardia lamblia
35
April
Role and Relevance of Poison Information Centres in India
43
May
Air Pollution: Problems and Perspectives
51
June
Programmed Cell Death in the Ovary: Development to Disorder
69
July
Decreasing Sperm Counts — Fact or Fiction
77
August
50th Year of the Independence of India:
Inauguration of ICMR’s Celebrations
87
September
A Reappraisal of the Iron Status Indicators
99
October
Mansonioides Control - An Economic Activity
109
November
Children with HIV/AIDS: Challenges and Opportunities
117
December
EDITORIAL BOARD
Members
Dr. Badri N. Saxena
Dr. Bela Shah
Dr. Lalit Kant
Chairman
Director-General
ICMR
Editor
Dr. N. Medappa
Printed and Published by Shri J.N. Mathur for the Indian Council of Medical Research, New Delhi
at the ICMR Offset Press, New Delhi-110 029
R.N. 21813/71
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