Pregnant mothers, traditional birth attendants and rising cases of HIV in children

There is a rising cases of children being infected with the Human Immunodeficiency Virus (HIV) in the country due to failure by many pregnant women to register for antenatal services in hospitals, instead patronise traditional birth attendants (TBAs) among other factors fuelling the rate of Child-HIV in the country. CHIJIOKE IREMEKA writes on how the situation makes unborn children vulnerable to the disease and increases the burden of HIV-infected kids as well as the way forward ahead of 2030 world target of eliminating mother-to-child transmission of HIV/AIDS.

Recently, the United Nations Children’s Fund, originally referred to as the United Nations International Children’s Emergency Fund (UNICEF) revealed that the progress in Human Immunodeficiency Virus (HIV) prevention and treatment for children, adolescents and pregnant women across the world has become very low over the past few years.

According to the report released some months ago, the situation has put the lives of many young people at risk of sickness and death. The Guardian learnt from the latest UNICEF global snapshot on children with HIV and AIDS that about 110, 000 children and adolescents between the ages of zero and 19 years died from AIDs-related causes in 2021 and another 310, 000 were newly infected, bringing the total number of young people living with HIV to 2.7 million globally.

It was gathered that ahead of last year’s World AIDS Day, UNICEF warned that progress in HIV prevention and treatment for children, adolescents and pregnant women had nearly become flat over the past three years.

The Associate Chief of HIV/AIDS, UNICEF, Anurita Bains said though children had long lagged behind adults in the AIDS response, the stagnation seen in the last three years was unprecedented.

“Children are falling through the cracks because we are collectively failing to find, test and get them on life-saving treatment. Every day that goes by without progress, over 300 children and adolescents lose their fight against AIDS in the world,” Bains said.

Despite accounting for only seven per cent of overall people living with HIV, the UNICEF report revealed that children and adolescents constitute 17 per cent of all AIDS-related deaths, and 21 per cent of new HIV infections in 2021. “Between 2014 and 2021, the number of new infections among children and adolescents aged 0 to 14 decreased globally by roughly 27 per cent, but rose by 13 per cent in Nigeria.”

Unless the drivers of inequities are addressed, UNICEF warned that ending AIDS in children and adolescents would continue to be a distant dream in the country.

Similarly, coverage of lifelong antiretroviral treatment (ART) – a medication taken by people living with HIV/AIDS to reduce the viral load of the virus and render it inactive – among pregnant women living with HIV increased from 46 per cent to 81per cent in a single decade.

The Guardian learnt that in the last seven years, the percentage of pregnant women with HIV who are receiving lifetime antiretroviral treatment (ART) grew slightly from 79 per cent to 81 per cent globally but declined from 57 per cent to 34 per cent in Nigeria.

In UNICEF’s HIV-priority countries, including Nigeria, ARV coverage for children stood at 56 per cent in 2020 but fell to 54 per cent in 2021. This decline is due to several factors, including the COVID-19 pandemic, which increased marginalisation and poverty. The situation is being perceived to be a reflection of waning political will to tackle the health challenge and a flagging response to AIDS in children.

The issues
Disturbingly, the percentage of children between the ages of 0 and four years living with HIV and are not on ART has been rising over the past seven years, reaching 72 per cent in 2021, as high as it was in 2012. In 2021, over 75, 000 new child infections occurred because pregnant women were not diagnosed and placed on treatment.

“But with renewed political commitment to reaching the most vulnerable, and strategic partnership and resources to scale up programmes, we can end AIDS in children, adolescents and pregnant women,” Bains said.

According to a consultant gyneacologist at the Epe General Hospital, Epe, Lagos State, Dr. Cynthia Obiora, one of the major reasons the number of HIV-infected children is increasing in the country is non-registration of expectant mothers for antennal care services for a number of reasons.

She said that the virus could be passed from an HIV-positive mother to her child during pregnancy, childbirth or breastfeeding. It is the commonest way children under 13 years of age get HIV in the United States.

“One major issue in the country is that most women do not go for antenatal care services in due to poverty. The risk in this is very high when they decide to patronise the local birth attendants in one village or the other. It’s very unfortunate that these attendants do not prioritise the HIV status of the pregnant women waiting to be delivered.

“At that place, the birth attendants do not check them for HIV status until they have delivered their babies. And at this point, during the child’s birth and post birth periods, the child would have contracted HIV from the mother, unknowing to her. Worse still, some of these mothers do not know that they are positive to HIV.

“What it takes for mother-to-child transmission to take place is small. All that is required for a baby to contract it is for the blood of the HIV-infected mother to splash in the baby’s eyes. Also, when the women do not know that they are positive, they do not take the ATR to reduce the viral load of the HIV to the point that it cannot infect the baby.

“What ATR does is to reduce the viral load of the HIV to ensure that it’s no longer potent to transmit the disease to the baby. But when they visit uninformed birth attendants, who do not check pregnant women for the things hospitals check them for, especially the government hospitals, their HIV status will be unknown and so they transit the virus to their children. Ordinarily, an HIV-positive mother goes through CS instead of normal childbirth so as not to transmit the virus to the baby,” she said.

The Guardian learnt that on the average, 56.8 per cent of pregnant women in Nigeria visit the hospital for their antenatal care at least four times during pregnancy. Unfortunately, report has it that 15 out of the 20 northern states have fewer proportions of their pregnant women attending antenatal clinics than the national average. All the North West states, particularly, fall in this category.

It was gathered from the World Health Organisation (WHO) that every pregnant woman should make, at least, four antenatal care (ANC) visits to the hospital. The first visit is expected during the 8th to 12th week of the pregnancy. The second visit will be between the 24th to 26th week, the 32nd week will be for the third visit and the 36th to 38th week for the fourth visit to improve the outcome of the pregnancy and the health of the newborn.

Unfortunately, women in the northern states of Nigeria receive less antenatal care when they are pregnant, unlike the majority of their peers in the southern part of the country, a 2020 statistical report on women and men by the National Bureau of Statistics (NBS) has shown. They patronise traditional birth attendant (TBA). 

A TBA, according to WHO, is a person who assists a mother during childbirth and who had initially acquired her skills by delivering babies herself or through apprenticeship to other traditional birth attendants,

Despite their limitations in handling some complications in childbirth, TBAs are widely accepted and patronised, especially in rural areas. Low socio-economic status, illiteracy, poor awareness of modern maternal health facilities, strong family influence and easy access to TBA services are some of the factors promoting patronage of traditional midwives, especially in rural areas.

A birth attendant based in Ajegunle, Lagos, Mrs. Agnes Otubo, said she did not have access to HIV test and as such was not testing any expectant mother to know their HIV status before delivering them of their babies. She only massages and helps women to give birth to their babies.

It was gathered that some of the TBAs contract HIV as well as other diseases from the pregnant mothers for not knowing their HIV status before getting in contact with their blood and other body fluids.

To Otubo, the TBAs are only filling the vacuum created by the inability of some pregnant mothers to access orthodox hospitals for antenatal care due to poverty.

“Many of our clients are poor, and poverty frustrates efforts to get good services. Some of our clients are unable to adequately prepare for childbirth or cater for their babies later. They are often unable to set aside money for emergencies. These factors often undermine our good works.

“The fact that some women still patronise us is an acknowledgment of the quality services. Women come to us because they trust our capacity. They only go to hospital when they know they will develop complications that we can’t handle.

“The hospitals are good and we are equally good. They prefer us because some of them allege that they are being insulted or ignored at orthodox clinics and hospitals. But because I value my work, I treat my clients with respect and provide quality services. Sometimes, medical personnel don’t have time to take care of patients or they have tight schedule, which has led to some women giving birth to their babies elsewhere.

“So, rather than waste time going to the hospitals, some of these women prefer coming to us. There is also the cultural aspect of the issue. Our services are cheap and affordable, which is why people come here. Our herbs are very effective. When a pregnant woman is about to deliver, our herbal mixtures help her deliver safely.

“We do not have issues of pregnant women delivering through operations, unlike hospitals where a growing number of pregnant women are delivered through Caesarian Section because they want to make money. The method is more expensive than the natural one.

“The major challenge we face is the misconception circulating about us, which frequently accuses us of providing services we know nothing about. The hospital care providers look down on us because they feel they have been to school to study it. They sometimes also treat our referral cases badly. For instance, if we refer a case to them, they would tell the patient: ‘when you knew TBAs are better, why are you here now? You women wait until you have problem, then you rush to us for help.’ There is need for cooperation between the orthodox doctors, nurses and the traditional birth attendants so that we are able to work together to save lives,” Otubo said.

In her view, the government is also part of the problem, as it dismisses the TBAs rather than train, equip and encourage them. On why pregnant mothers still patronise TBAs, Mrs. Dolapo Ogunbunmi said: “Going for antenatal and giving birth to babies in the hospital is expensive. Before now, General Hospitals used to collect between N6, 000 and N8, 000 for antenatal care but now, it’s as high as between N28, 000 and N38, 000. This is not the amount for delivery, because for delivery, you will pay N42, 000, while you pay over N80, 000 if there is complication.

“The pricing is the major factor here; it does not allow us the low class people to go to hospital. We have discovered that the birth attendants are equally very good and do not charge much. How will a woman whose husband is a commercial motorcyclist pay N80, 000 to bail his wife out of the hospital? This is why you hear the stories that a man abandoned his wife in the hospital after being delivered of a baby. It’s because he doesn’t have the money that the hospital is charging.

“So, it is better I go to a TBA who charges less and brings results than going to the hospital and become imprisoned after child birth. I have never visited any hospital for child delivery. I have an Ijaw woman, who delivered me of my two children without any complication,” Ogunbunmi said.

On how the HIV affects the children, a trained midwife at Iyi-Enu College Of Nursing, Department of Midwifery, Ogidi, Anambra State, Esther Christian, said due to the fact that children’s immune system is not fully developed, children living with HIV get sick more severely than adults.

According to her, HIV-positive children may experience the same common paediatrics infections as HIV-negative children, but cannot fight these infections as effectively. Common infections in HIV-positive children include ear and sinus infection, sepsis, pneumonia, tuberculosis, urinary tract infections, intestinal illness, skin disease, and meningitis.

Christian stated that in developing countries in particular, tuberculosis, diarrhoea, and respiratory illnesses are common in HIV-positive children. On how to prevent and treat HIV infection in children, she said: “The most effective method for preventing mother-to-child transmission (PMTCT) of HIV is by placing HIV-positive pregnant women on antiretroviral therapy (ART) as early as possible. ART decreases viral levels in the mother’s bloodstream, thus reducing the risk that she will transmit the infection to her infant. ART should also be administered to a child before and after birth; treatment will help a baby’s body resist infection.

“There is no cure yet for HIV infection. Early infant diagnosis is critical, however. When ART is administered as early as possible in the course of infection, it can help children with HIV to live longer and healthier life. If taken every day, the medicines will drastically reduce the concentration of HIV in the bloodstream and increase levels of CD4 cells, thereby slowing the progression of the disease.

“Sadly, most children still do not have access to ART. Without diagnosis and treatment, one-third of infected infants will die before the age of one, and almost one-half before their second birthday.”

Concerned by the slow progress in the fight against HIV, particularly in children, the Joint United Nations Programme on HIV/AIDS (UNAIDS), UNICEF, World Health Organisation (WHO) and partners have created a global alliance to ensure that no child living with HIV is denied treatment by the end of the decade and to prevent new infant HIV infections.

The new Global Alliance for Ending AIDS in Children by 2030 was announced by leading figures at the International AIDS Conference that took place in Montreal, Canada.

Apart from the United Nations agencies, the alliance comprises of civil society groups such as the Global Network of People Living with HIV, national governments in the most affected countries and international partners, including the United States President’s Emergency Plan For AIDS Relief (PEPFAR) and the Global Fund.

PEPFAR is a United States governmental initiative to address the global HIV/AIDS epidemic and help save the lives of those suffering from the disease. This is the largest commitment by any nation to address a single disease in the history of the world’s epidemic.

The Guardian learnt that 12 countries that have joined the alliance in the first phase include Nigeria, Angola, Cameroon, Côte d’Ivoire, the Democratic Republic of the Congo (DRC), Kenya, Mozambique, South Africa, Uganda, the United Republic of Tanzania and Zambia.

The alliance has identified four pillars for collective action, which include closing the treatment gap for pregnant and breastfeeding adolescent girls and women living with HIV; preventing and detecting new HIV infections among pregnant and breastfeeding adolescent girls and women; accessible testing, optimised treatment, and comprehensive care for infants, children, and adolescents exposed to and living with HIV; and addressing rights, gender equality, and the social and structural barriers that hinder access to services. 

“The wide gap in treatment coverage between children and adults is an outrage,” UNAIDS Executive Director, Winnie Byanyima said.

“Through this alliance, we will channel that outrage into action. By bringing together new improved medicines, new political commitment, and the determined activism of communities, we can be the generation who end AIDS in children. We can win this – but we can only win together.

“Despite progress to reduce vertical transmission, increase testing and treatment, and expand access to information, children around the world are still far less likely than adults to have access to HIV prevention, care, and treatment services,” UNICEF Executive Director Catherine Russell said.

According to the Director-General, WHO, Dr. Tedros Adhanom Ghebreyesus, no child should be born with or grow up with HIV, and no child with HIV should go without treatment. The fact that only half of children with HIV receive antiretrovirals is a scandal, and a stain on our collective conscience.

“The Global Alliance to End AIDS in Children is an opportunity to renew our commitment to children and their families to unite, to speak and to act with purpose and in solidarity with all mothers, children and adolescents,” he added.

Stakeholders across the country have called on the government to harmonise the services of orthodox medics and traditional birth attendants in such a way that would see both groups working for the purpose of life saving to reduce the cases of HIV among children in Nigeria.

An official of the UNICEF, Jideofor Nelson, said: “The government should co-opt these people and train them on how to test their patients for HIV or advised their patients where they would go and have the test before attending to them since they cannot be phased out due to the number of people they attend to on daily basis.

“By so doing, they will be saving the unborn children and also saving their own lives. They can work together with the trained midwives and hospital, especially to know when to refer a patient to them. While those who can afford the hospital should go, others who cannot, or who for some reasons or the other choose TBAs, should go ahead. But the government should hold seminars occasionally to train and update these TBAs to enable them to do the work effectively.”