HIV and AIDS — The fear of knowing

Friday, July 30, 2010 (Daily Graphic Pg 16/17)

By: Lucy Adoma Yeboah and Rebecca Quaicoe-Duho

The 18th International HIV/AIDS Conference ended last week in Vienna, Austria, with the chilling disclosure that about 10 million people are in dire need of treatment from the pandemic. In poor countries, the situation is further aggravated by the multiplicity of ignorance, the fear of knowing one’s status and the stigma associated with it. But, in all, Ghana appears to be making giant strides.

THIRTY-SIX-year-old Emelia (not her real name) did not know her HIV status when she got pregnant in 1999. Although she was delivered of a baby boy, he died from complications of pneumonia after a month.
In 2002, she got pregnant again, did not check her HIV status and was delivered of a dead foetus prematurely in her seventh month.
Testifying about her experience in Accra, she said she had always believed she was a healthy person, knowing little about her HIV positive status until her first child died and her second was aborted prematurely.
Today, because of the informed decision to undergo voluntary counselling and testing (VCT), she now has a five-year- old daughter delivered successfully at the Korle-Bu Teaching Hospital and a year-old son delivered at the Ridge Hospital in Accra.
According to Emelia, with her knowledge of her HIV status, she informed her doctor, together with her husband who, however, tested negative, when they were ready to have children.
She was put on special drugs and the two were counselled on techniques of sex without passing on the infection to the husband or the children who might result from the union.
Within a month of close monitoring by her doctor, Emelia got pregnant and was referred to Korle-Bu, where she was put on a prevention of mother to child therapy (PMTCT) when she was 14 weeks into the pregnancy.
With all the effort, her laboratory results proved that she and her baby were healthy and she opted for normal delivery, which was successful.
She repeated the same process for her second child, who is a year old and was negative as of the first test conducted on him when he was six months, although subsequent tests would have to be done to confirm his status.
For Emelia and others like her, the introduction of the PMTCT has facilitated the safe delivery of healthy babies who are HIV free.
Apart from the counselling, it involves the education of HIV positive mothers by health professionals on safe breast-feeding techniques in order not to pass the virus on to their children,
Emelia now encourages all women to arm themselves with the knowledge of their HIV status to help them make informed decisions for the health of their children.
Currently, she belongs to a women's support group made up of those living with HIV and, according to her, through informed choices, they and their children, together with their husbands, are living positively.

Doctor’s perspective
Dr Joseph Oliver-Commey of the Fevers Unit at the Korle-Bu Teaching Hospital said positive cases such as Emelia's were possible if women took the destiny of their unborn children into their own hands and opted for VCT.
According to him, the unit taught discordant couples, that is, couples who have the woman positive and the man negative, the technique of having sex to achieve pregnancy without the woman infecting the man.
He made reference to a case in which a couple who had the woman positive had three children, with the eldest, nine, being HIV positive, the second, seven, negative, while the third, six months, was yet to be tested when it was a year and a half.
He said the PMTCT, which reduced new infection, was doing well in the country and called on pregnant women not to think about themselves alone but also think about the health of their babies to reduce new infections in the country.
He said women whose CD4 count was above 400 were, however, put on prophylactics when they were 28 weeks pregnant, while those who, although positive, had not undergone any treatment, were given a single dose drug to prevent mother-to-child transmission.
Sometimes, according to him, to ensure double safety, babies delivered were put on infant formulas to ensure that they were totally prevented from getting into contact with the virus, as the virus was easily transmitted through fluids, such as breast milk and vaginal fluid.

Treatment
Mother-to-child transmission (MTCT) is when an HIV-infected pregnant woman passes the virus on to her baby.
This can occur during pregnancy, labour and delivery, or breast-feeding.
According to a World Health Organisation (WHO) research, without treatment, around 15-30 per cent of babies born to HIV positive women will become infected during pregnancy and delivery.
A further 5-20 per cent will be infected through breast-feeding.
The PMTCT, according to the WHO, accounted for more than 700,000 estimated new HIV infections in children world-wide annually.
Without intervention, experts say, HIV-infected mothers have a 35 per cent overall risk of transmitting the virus to their children during pregnancy, delivery and breast-feeding.
However, an effective prevention of MTCT can occur when HIV testing and other preventive interventions are made available in services related to sexual health, such as, ante-natal and post-partum care.
Clinical trials have demonstrated that anti-retroviral (ARV) prophylactics, when administered to mothers and their newly born babies, can reduce the risk of MTCT by approximately 75 per cent.
A PMTCT guideline by the WHO indicates that mothers, when identified in pregnancy as being HIV positive, should have a CD4 test to determine whether they need to take medication for their own health or that of their unborn infants. If their CD4 count is below or equal to 350, they are required to start taking anti-retroviral drugs for their own health. If a woman has a CD4 count higher than 350, then she does not need to take medication for her own health. However, she will need to take medication to prevent HIV transmission to her infant.
In a November 2009 HIV and AIDS guidelines on PMTCT, HIV and breast-feeding by the WHO, the international body on health prescribed that all HIV positive mothers, identified during pregnancy, should receive a course of anti-retroviral drugs to prevent MTCT. Also, all infants born to HIV positive mothers should also receive a course of anti-retroviral drugs and should receive exclusive breast-feeding for six months, with other complementary feed for up to a year when the breast-feeding had to be stopped.
According to Dr Oliver-Commey, providing appropriate counselling and support for women living with HIV to enable them to make informed decisions about their reproductive lives and prevent the transmission of HIV from positive mothers to infants during pregnancy, labour, delivery and breast-feeding were gold standards approved by the WHO.

Benefits
The Fevers Unit of the Korle-Bu Teaching Hospital in Accra started the PMTCT intervention in 2005 and since then a lot of HIV positive mothers and their babies have benefited from the service.
A resent survey of 80 pregnant women who underwent treatment at the Children's Hospital at Korle-Bu saw only three being positive, emphasising the recommendations of doctors at the unit that pregnant women opt for VCT to save the lives of their unborn children.
Dr Oliver-Commey said to help reduce MTCT, a single dose of nevirapine was given to the mother at the onset of labour and to the baby after delivery and that roughly halved the rate of HIV transmission.
He explained that it was possible for an infected mother to successfully wean her child, as the ART taken during and after birth was aimed at reducing the viral load, a situation which suppresses the virus, making it impossible to be transmitted.
Many children's lives had been saved since the intervention was introduced, the doctor said, adding that the unit could boast of its oldest child who was currently five and who had benefited from PMTCT and was living an HIV free life.
Today, he said, over 50 women were on PMTCT at the unit, since the hospital was a referral centre and received a lot of cases from other health centres from across the country.
To achieve better results, an integrated HIV care, treatment and support for women found to be positive and their families, known as PMTCT plus (PMTCT+), was recommended by Dr Oliver-Commey.
He said the PMTCT+ targeted partners who, when tested and found to be negative, were encouraged to support their wives who were positive. However, when they were found to be positive themselves, both were linked to appropriate care at the unit.
All is not rosy at the unit, as indicated by Dr Oliver-Commey, as it faced difficult challenges which made it impossible for it to meet recommended WHO standards on PMTCT.
He indicated that although it was ideal that HIV positive women went through caesarean sections (CS) to prevent the mother transmitting the virus to the baby when delivering, the problem in the country, however, was that a lot of hospitals and clinics did not have the capacity to perform CS on HIV positive mothers and, therefore, referred them to the three teaching hospitals and other few health facilities that provided the service.

Risks
Dr Oliver-Commey indicated that most of those women ended up opting for normal delivery because they would have to join a long queue of women who were also waiting for CS to be performed on them, placing their babies at a higher risk of being infected with the virus.
However, he pointed out, when babies were born through the normal delivery process by an HIV infected mother, within the first week they were taken through an early infant diagnosis with polymerise chain reaction (PCR), which is a device used to determine their status, or they were put on ART and linked to the Child Health Department where they were referred to special clinics for children exposed to HIV.
Those babies were then tested after a year and a half when, by then, they were believed to have shed off their mothers anti-bodies and were able to produce their own anti-bodies.
In spite of the availability of life-saving interventions for both mother and child, some pregnant women who test positive for HIV refuse to avail themselves for medical care.

Stigma
That deadly decision could be attributed to the fear of stigmatisation people who are known to have contracted the virus go through.
Some of the women take that decision, having at the back of their minds the notion that their partners may abandon them if they get to know of their status.
At a recent review meeting organised by the Ghana AIDS Commission (GAC) in Accra, a private midwife and proprietress of God’s Gift Maternity Home at Ekumfi Ekrawfo in the Mfantseman District in the Central Region, Madam Gifty Mante, talked about how some pregnant women who tested positive pleaded with her to keep the information to herself.
The sad aspect of the situation, according to her, was that those HIV positive pregnant women failed to return to the facility for the needed medical care which could save them and their unborn babies. For fear of stigmatisation, they would rather prefer to keep the infection to themselves and die, instead of visiting the hospital where they could be provided with anti-retroviral therapy for their survival and that of their babies.
The fear of others knowing about their predicament was enough to keep them away from the appropriate medical care.
A typical example could be drawn from the case of a member of an association of People Living with HIV (PLHIV) in Koforidua in the Eastern Region (Matthew Chapter 25) in which a middle-aged woman narrated to journalists how her husband of 15 years abandoned her and her children when he got to know that she had tested positive for HIV. Her husband refused to heed a doctor’s advice to also go for counselling and testing but left her and went ahead to stay with another woman.
Currently, health workers the world over are trying hard to prevent as many babies as possible from getting infected by their mothers.
Another member indicated that she was dismissed from a private school where she was teaching and also ejected from her rented accommodation when a nurse allegedly told her employer about her HIV status.
The provision of anti-retroviral therapy in the public healthcare system started in Ghana in June 2003 at two pilot sites in the Manya Krobo District. This was part of a comprehensive care package that also included the provision of Counselling and Testing, and Prevention of Mother to Child Transmission (CT/PMTCT).
Currently, 138 sites are available nation-wide for the administration of ART and other HIV prevention services, including PMTCT.
A success story of that programme (PMTCT) could be found at the St Dominic Hospital at Akwatia in the Eastern Region where the hospital was considered the first health facility in Ghana to prevent the highest number of children from being infected with HIV from their HIV-positive mothers.

Statistics
Reports from the hospital gathered in 2009 indicated that only one out of 32 babies whose mothers were HIV positive and were, therefore, put on treatment under the PMTCT tested positive.
The figure represents 96.9 per cent of the children whose mothers received the intervention.
The Head of the Public Health Department of the hospital, Dr Nana Owusu-Ensaw, said as part of the preventive measures, mothers of the children were given special medication during labour and their babies placed under formula feeding for 18 months.
He said that was to prevent the children from being breast-fed, which could have exposed them to HIV infection from their infected mothers.
In an interview with The Mirror, Dr Owusu-Ensaw said the PMTCT programme was established at the hospital in 2005 to educate all pregnant mothers on HIV and AIDS due to the high prevalence of MTCT of HIV in the district and the country as a whole.
He explained that from July 2007 to May 2008, 62 children born to mothers who were given special care during labour were put under monitoring for 18 months.
Dr Owusu-Ensaw said out of the 62 children, 32, which stood for 51.6 per cent, could be traced, while 30, representing 48.4 per cent, could not be traced and were, therefore, not monitored.
He said after the 18-month period, the 32 children who were traced were tested for HIV and that was when it came out that only one had the virus.

Negative

“That means 31 of them, which represents 96.9 per cent, were negative, while the remaining one, which is 3.1 per cent, was positive,” he stressed.
Dr Owusu-Ensaw said the facility was able to trace those 32 children because they were placed under formula feeding which was given to them by the Public Health Unit of the hospital free of charge.
“The above results indicate that PMTCT works and we hereby encourage all pregnant women to undergo HIV testing to know their status so that interventions can be put in place to save their babies,” he said.
He said a challenge involved the high cost of baby formula for feeding the babies, noting that one baby consumed about six tins a month.
He also said monitoring the mothers was expensive in terms of the transportation cost involved and expressed concern over the issue of pregnant women who gave wrong addresses for fear of stigmatisation, which resulted in the inability to trace them.
That, according to the doctor, was why some babies could not be traced for final testing after the 18-month period.
The first AIDS cases were reported in Ghana in 1986. By the end of September 2003, a cumulative total of 72,541 AIDS cases had been reported. This figure is probably 30 per cent of the estimated AIDS cases in the country. Current estimates, however, put the actual number of cases closer to 370,000.
Cases have been reported in all the 10 regions, as well as in all age groups. There are, however, important regional variations in the reported AIDS cases. This can be attributed to various factors, such as the composition of the population of the regions, availability of public health institutions, the stage of the epidemic and the health seeking behaviour of the people.
To eliminate stigmatisation and discrimination against PLHIV, the Director-General of the GAC, Dr Angela El-Adas, and the other officials in her outfit has, on numerous occasions, spoken against that, knowing very well that if not stopped, it will continue to hamper control of the pandemic.