|Year : 2016 | Volume
| Issue : 1 | Page : 17-21
Trend of HIV seropositivity among children attending ICTC SMS Medical College Jaipur, Rajasthan
Anshu Mittal, Babita Sharma, Nazneen Pathan, Saloni Garg, Nitya Vyas
Department of Microbiology, Sawai Man Singh Medical College and Attached Hospitals, Jaipur, Rajasthan, India
|Date of Web Publication||2-Jun-2016|
Department of Microbiology, Sawai Man Singh Medical College and Attached Hospitals, Jaipur - 302 004, Rajasthan
Source of Support: None, Conflict of Interest: None
Background: In India about 0.1 million children are living with HIV and most of these infections are acquired by perinatal transmission. The prevention of parent-to-child transmission (PPTCT) program aims to prevent the perinatal transmission by interruption of transmission at different levels. This study was conducted to see the trend of HIV seropositivity among children after the implementation of the PPTCT program. Aims: The aim of this study was to investigate the magnitude of pediatric HIV seropositivity and its time trend in last 11 years at a tertiary care hospital in Rajasthan. Materials and Methods: Children of aged less than 14 years attending the Integrated Counseling and Testing Centre (ICTC) were screened for HIV antibodies. A detailed history about age, sex, HIV serostatus of the parents, and history of blood transfusion was recorded. Statistical Analysis: The level of significance was recorded using P value. Results: Out of the 17,612 subjects, a total of 887 (5.03%) children were positive for HIV infection. Out of these 887 subjects, 567 were male children (m:f = 1.77:1) and most of them (59.9%) were of age less than 5 years. Perinatal transmission was the commonest mode of transmission. A decreasing trend of HIV seropositivity is observed among children of age less than 14 years after year 2005 (x 2 for trend = 503.445, P< 0.001). Conclusion: Despite all this, combined efforts are still needed to prevent new HIV infection, to keep their mothers healthy and alive, and to improve the diagnosis and treatment of HIV for children.
Keywords: Acquired immunodeficiency syndrome (AIDS), human immunodeficiency syndrome (HIV), pediatric HIV, prevention of parent-to-child transmission (PPTCT)
|How to cite this article:|
Mittal A, Sharma B, Pathan N, Garg S, Vyas N. Trend of HIV seropositivity among children attending ICTC SMS Medical College Jaipur, Rajasthan. Arch Med Health Sci 2016;4:17-21
|How to cite this URL:|
Mittal A, Sharma B, Pathan N, Garg S, Vyas N. Trend of HIV seropositivity among children attending ICTC SMS Medical College Jaipur, Rajasthan. Arch Med Health Sci [serial online] 2016 [cited 2022 Jan 26];4:17-21. Available from: https://www.amhsjournal.org/text.asp?2016/4/1/17/183346
| Introduction|| |
The first case of pediatric acquired immunodeficiency syndrome (AIDS) was reported in 1982 in the United States, and since then its number has increased dramatically and it is a major cause of morbidity and mortality worldwide. In 2013, approximately 2,40,000 children of age less than 15 years were newly infected with HIV and about 3.2 million people were living with HIV or AIDS worldwide. Greatest burden of the disease is in Asia and Africa with over 1.9 million (82.6%) children infected with HIV. Though India is a low-prevalence country, there are about 2.1 million people living with human immunodeficiency virus (HIV) with an adult HIV prevalence of about 0.27% (2011) and has the third highest number of people living with HIV in world. Women and children of age less than 15 years constitute 39% and 7% of all cases of HIV infections, respectively. As on March 2013, 0.1 million HIV-positive children were registered under an antiretroviral therapy (ART) program and 38,579 children were receiving free ART.
HIV infection is most common in the age group of 15-30 years, and it constitutes about 65% of new HIV infections in India and the infection rate is more in females than in comparison to males. [National AIDS Control Organization (NACO) English]. In India the adult HIV prevalence has continued its steady decline from estimated level of 0.41% in 2001 to 0.27% in 2011. Most of the HIV infections in children are acquired through mother-to-child transmission during pregnancy, labor, or breastfeeding. In the absence of any interventions, the vertical transmission rate is estimated to be 20-45% that drops down to less than 10% with effective antenatal, intranatal, and postnatal interventions. The prevention of parent-to-child transmission (PPTCT) program aims to prevent the perinatal transmission by interruption at different levels. Major elements responsible for seropositive children born to HIV-positive women are early initiation of ART in pregnant females, Nevirapine (NVP) to mother–baby pair, mode of delivery, and type of infant feeding  that lead to the decline in pediatric HIV seropositivity. Epidemiology of pediatric HIV is associated with the PPTCT efforts.
Due to the decentralization of the program, the number of pregnant women tested annually under the PPTCT program has increased from 0.8 million in 2004 to 8.83 million in 2013, and this leads to timely access to life-saving antiretroviral drugs for their own health and to stop HIV transmission to the children.
The objective of this study was to investigate magnitude of pediatric HIV seropositivity and its time trend in last 11 years at Integrated Counseling and Testing Centre (ICTC), Sawai Man Singh Medical College, Jaipur Rajasthan.
| Materials and Methods|| |
This retrospective study was conducted from available records at a tertiary care hospital in Rajasthan from January 2004 to December 2014. Children of age less than 14 years, suspected of HIV infection and referred to ICTC, were screened for HIV antibodies. The counselors provided pretest and posttest counseling and collected data in registers as per the National AIDS Control Organization (NACO) guidelines under strict confidentiality. Written informed consent was obtained from parents after counseling. The data included age, sex, HIV status of the parents, history of blood transfusion, and other mode of HIV transmission. All the clients were given a unique patient identification number. If samples were reactive by all three different methods, they were considered HIV positive. Testing strategy was according to the NACO guidelines strategy III (NACO testing guidelines) and test kits were also received from the NACO. The samples tested positive in the first kit were subjected to tests with two different kits. All tests were done according to the manufacturer's instructions. Strict external quality assurance program was also followed with state reference laboratory (SRL).
The data were entered in Excel sheet. The level of significance was conducted using P value. The P value of ≤0.05 was considered significant.
| Results|| |
A total of 17,612 children were screened for HIV antibodies. This includes 11,448 males and 6,164 females. Out of 17,612 subjects, a total of 887 (5.03%) children were positive for HIV antibodies. [Table 1] presents year-wise distribution of children tested for HIV and their serostatus. Of the 887 seropositive children, 567 were males (m:f = 1.77:1). [Figure 1] shows a trend of HIV seropositivity in the last 11 years. Male-to-female ratio in the seropositive group over the years is shown in [Figure 2].
[Table 2] shows the age-wise distribution of children with HIV infection. Most of the children (59.9%) were below the age of 5 years.
Parent-to-child transmission was the most frequent mode of transmission and was documented in 853 (96.1%) patients. Probable transmission through blood transfusion was recorded in three children, while in one child the transmission was most probably due to the use of nonsterile needle. Source of infection was unidentified in 30 (3.38%) cases.
| Discussion|| |
Pediatric HIV is a rapidly emerging problem worldwide. Till now, as there is no curative therapy or vaccine for HIV, counseling, testing, and early initiation of medical treatment are important tools for prevention and control of HIV. Early diagnosis, timely initiation of treatment, and free availability of ART lead to increased survival rate of HIV-infected children.
In the present study, the total number of children tested for HIV are increasing continuously. This may be attributed to either increased awareness about the disease, expanded coverage of testing, institutional deliveries, free medical HIV services at the ICTCs, decrease in stigma associated with HIV leading to more number of people getting tested, or due to provider initiated testing as they request for HIV testing before doing any intervention.
The overall seropositivity in the present study is 5.03% (887/17612). Other studies from India reported higher seropositivity.,, In our study this low seropositivity could be reflecting the low prevalence of pediatric HIV infection in Rajasthan or may be due to large number of children incorporated.
A large difference in male-to-female HIV testing ratio is seen in the present study. These findings are similar to other studies reported from India., High sex ratio in the state could be due to gender discrimination as female child is considered unimportant so not availing medical facilities as much as males, poverty, and social stigma associated with the disease. However, there was no significant difference in gender seropositivity (P value = 0.513). This shows that there is no genetic predilection in gender for HIV seropositivity.
In the present study, 59.9% of HIV/AIDS children were of less than 5 years old. Tindyewa et al. noted that 25-30% of the perinatally acquired HIV infection in children manifest the disease before their first birthday. These findings reflect the influence of maternal HIV infection in their children and a shorter incubation period of this infection in children due to their undeveloped immune system. In this study, a significant number of children in the age group of 11-14 years were diagnosed as HIV positive. This could be either due to slow progressive or nonprogressive HIV, sexual abuse of children or due to injection malpractices. Parents of these children were HIV positive so the route of transmission was considered perinatal only but this should be studied further.
Due to use of highly sensitive and specific HIV screening tests for blood transfusion and conservative use of blood, transfusion of HIV through blood transfusion has been nearly eliminated in developed countries. In developing countries HIV screening is mandatory, though transfusion transmitted infection persist as the tests used are for detecting antibodies only and in circumstances where the donor is in window period, HIV antibodies may not be detected. According to the World health Organization (WHO) approximately 10% of AIDS cases in India result from the transfusion of infected blood. In the present study, estimated transmission through infected blood or blood products was in three (0.33%) cases therefore it becomes apparent that majority of the cases are due to vertical transmission. In the present study, the source of infection could not be identified in 30 (3.38%) cases. As some children are brought to the centre by nongovernment organizations (NGOs) or other agencies, and most of them were orphan, therefore, the history of HIV transmission could not be elicited.
The noteworthy finding of this study is that there was increasing trend of HIV seropositivity in children of less than 14 years of age till the year 2005 [highest seropositivity for HIV (11.77%)] after that a declining trend is observed (1.52% seropositivity in year 2014). Although there was not much difference in number of seropositive children but in comparison to number of tested children, seropositivity is continuously declining (significant P value < 0.001).
In India, PPTCT program was started in the year 2002 and the declining trend of seropositivity is seen afterwards. This may be due to success of the PPTCT program in the state. Initially in this program, HIV-positive pregnant women were given single dose of NVP tablet at the time of labor; their newborn babies also get a single dose of syrup NVP within 72 h after birth to prevent transmission of HIV from mother to child but recently according to newer guidelines (December 2013), syp NVP to the infants should be continued for minimum of 6 weeks after birth. Among the babies of HIV positive mothers who received full coverage of the PPTCT program, 85% HIV negative status was achieved that indicated the protective role of NVP in vertical transmission.,,
The main determinant of pediatric HIV infection is the scale and magnitude of adult HIV infection. There is an overall reduction of 57% in the new HIV infections per year among adult population from 2.74 lakh in 2000 to 1.16 lakh in 2011, that demonstrates the impact of various preventive strategies under the National AIDS Control Programme (NACP). and if this trend is maintained, the burden of pediatric HIV infection will become very less. Eastern and South Africa are also progressing toward the elimination of number of new pediatric HIV infections. The goal of global plan of United Nations Programme on HIV and AIDS (UNAIDS) toward elimination of new HIV infection among children and keep their mothers alive includes two targets: To reduce number of children newly infected with HIV by 90% and to reduce the number of mothers dying from AIDS by 50%. According to UNAIDS report, the number of children newly infected with HIV in the low- and middle-income countries has decreased since the year 2000.
The key component for success of PPTCT program is to make services accessible to all needed people. PPTCT phase IV was launched in the year 2007 with the aim to increase coverage. To improve access, PPTCT services are made available in government hospitals and all anti natal care (ANC) with necessary awareness campaigns. Nowadays more patients are opting for institutional delivery, and this leads to the widespread coverage of PPTCT services. A major challenge is to increase antenatal care services that can provide services for eliminating perinatal transmission. ICTC plays an important role in preventing HIV transmission by promoting behavioral changes, client oriented counselling, and testing services in an confidential environment, and this leads to improved early diagnosis and treatment of HIV. Currently, there are more than 4000 ICTCs in India that offer PPTCT services to pregnant women. If this declining trend of pediatric HIV is maintained, we will achieve the global target for eliminating new HIV infection among children very soon.
| Conclusion|| |
Despite all these efforts to stop new HIV infections among children, there are still many challenges in ensuring access to ART for children living with HIV. Combined efforts are needed to prevent new HIV infection, to keep their mothers healthy and alive, and to improve the diagnosis and treatment of HIV for children.
The authors sincerely thank all the participants of the study. We would like to acknowledge the help given by ICTC counsellors Mrs. Prerna Mittal and Mr. Nand Kishore for the study.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Lindegren ML, Steinberg S, Byers RH Jr. Epidemiology of HIV/AIDS in children. Pediatr Clin North Am 2000;47:1-20, v.
Guha P, Sardar P. Prevalence of paediatric HIV infection in eastern India-First report. J AIDS Clinic Res 2011;2:127.
Joshi U, Patel S, Shah K, Oza U, Modi H. Studying PPTCT services, interventions, coverage and utilization in India. J Glob Infect Dis 2011;3:371-7.
Madkar SS, Nilekar SL, Vankudre AJ. Prevalence of HIV infection among persons attending integrated counseling and testing centre, Ambajogai. Natl J Community Med 2011;2:213-5.
Agrawal S, Sawant S, Shastri J. Pediatric HIV in Mumbai. Indian J Sex Transm Dis 2011;32:57-8.
Sherwal BL, Gupta P, Nayak R, Gogoi S, Suri S, Dutta R. Prevalence of HIV in a tertiary care centre in Delhi: A five-year ICTC based study. World J AIDS 2015;5:1-9.
Vyas N, Hooja S, Sinha P, Mathur A, Singhal A, Vyas L. Prevalence of HIV/AIDS and prediction of future trends in north-west region of India: A six-year ICTC-based study. Indian J Community Med 2009;34:212-7.
Tindyebwa D, Kayita J, Musoke P, Eley B, Nduati R, Coovadia H, et al
. In Handbook on Paediatric AIDS in Africa by the African Network for the care of children affected by AIDS. 2006. p. 15.
Mandal S, Bhattacharya RN, Chakraborty M, Pal PP, Roy SG, Mukherjee G. Evaluation of the prevention of parent to child transmission program in a rural tertiary care hospital of West Bengal, India. Indian J Community Med 2010;35:491-4.
Welty TK, Bulterys M, Welty ER, Tih PM, Ndikintum G, Nkuoh G, et al
. Integrating prevention of mother-to-child HIV transmission into routine antenatal care: The key to program expansion in Cameroon. J Acquir Immune Defic Syndr 2005;40:486-93.
[Figure 1], [Figure 2]
[Table 1], [Table 2]