Dr Alexander lamented that even today, only about an estimated 70% of pregnant women in India access antenatal care services nationally; less than 60% deliveries are institutional; and about 30% women do not know their HIV status. We indeed have a long way to go.
Test and treat infants
Other than strengthening PPTCT services, there is need to ensure early infant diagnosis in HIV exposed infants - those born to HIV positive mothers. With the rollout of PPTCT we now have many children born to HIV infected mothers, who may be HIV-negative because of PPTCT. The WHO recommends to screen these infants early on, as there is a high risk of death before the age of 2 years for infants with HIV. The WHO recommends that infants exposed to HIV should ideally undergo the 1st virological test for diagnosing HIV infection at 4 to 6 weeks of age. HIV exposed children should be given ART as post exposure prophylaxis soon after birth, without waiting to confirm HIV diagnosis. This is likely to eradicate the virus and perhaps lead to a functional cure, said Dr Ira Shah.
She shared that the only reliable way to diagnose HIV in infants, especially those less than 18 months of age, is to do a virological test. ELISA test at this early age is likely to give false positives and should be done only in children above 18 months for confirmation and in children above 6 months for screening.
A second confirmatory test should be performed on infants who test positive, but ART should not be delayed while waiting for results. They should again be tested at 6 months and 12 months. In case of breastfeeding infants, if the first HIV test is negative, a second test should be done after 4-6 weeks of stopping breastfeed. So there have to be 2 tests done before declaring an infant as HIV positive.
The tests done for early infant diagnosis of HIV are DNA PCR or an RNA PCR. These tests are done in centralised hospitals while samples are picked up from various ART centres, so Dr Ira Shah recommended the 'dried blood spots' method over liquid blood sample, as the former is easy to prepare, and does not require refrigeration.
Gaps to bridge
In India early infant diagnosis was introduced in a phased manner in 2010. But Dr Shah said that there are huge time gaps in diagnosis, confirmation and initiation of ART in HIV exposed infants in India. The median age at first sampling was found to be 4 months, instead of 4-6 weeks. There are also huge delays and loss to follow up between 1st and 2nd testing. Turn around time for final confirmatory result (2nd test result) could be as high as 270 days.
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