HIV in Cuba:
Prevention of Mother-to-Child Transmission
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Vertical Transmission in Cuba

Gender, Vulnerability and their Relation to HIV/AIDS

 

CUBAN PROFESSIONAL LITERATURE - REVIEW ARTICLE

Vertical Transmission in Cuba

Ida González Núñez MD, PhD
Manuel Díaz Jidy MD
Jorge Pérez Ávila MD, MS

 Vertical Transmission (VT) is the route by which more than 90% of children and adolescents under 15 years of age are infected by HIV worldwide; in developing countries the percentage is almost 100%. It is estimated that in 2003 around 630,000 nursing infants throughout the world acquired HIV, a great majority during the gestational period and delivery or due to breast feeding. Likewise, around 490,000 children died last year from AIDS-related causes.[1]

The mother-to-child HIV transmission rate in Cuba as of October 25, 2005 was 12.1% (26/214), a low rate when compared to other developing countries. Of the 26 infected children, 15 were girls and 11 boys. This includes all children of seropositive mothers, independent of whether they or their mothers received prophylactic treatment with AZT.  To prevent transmission, AZT has been included in the National Vertical Transmission Prevention and Control Program since January 1, 1997.
 
Unlike Cuba, where 100% of HIV+ pregnant women receive antiretroviral (ARV) treatment, progress in most of the developing world towards increasing access to ARV treatments has been very slow, so that only 10% of pregnant women have access to antiretrovirals.[2] In Burkina Faso, Ethiopia, Malawi, Nigeria and South Africa, less than 1% of the women infected with HIV who gave birth in 2003 had access to VT-preventative treatment. In Cambodia, Myanmar and Vietnam coverage is below 3%.[3]

To reduce the effects of this problem, since 1999, UNICEF[4] has spearheaded the creation of international projects to reduce VT in low and middle-income countries. Between April 1999 and July 2002, projects supported by UNICEF and other associated organizations treated almost 600,000 pregnant women in prenatal care centers and provided ARV treatment to 12,000 seropositive women after counseling and HIV testing.
       
In low and middle income countries, the probability that an HIV+ breastfeeding mother will transmit the virus to her retrovirus negative child is at least 30%.[3] On the other hand, in industrialized countries, HIV transmission to nursing babies is rare thanks to ARV prophylaxis, delivery by caesarean section, and the use of breastfeeding alternatives.[4-6]
  
In Cuba up to October 25, 2005, 214 children (101 girls and 113 boys) have been screened at the Pedro Kourí Institute of Tropical Medicine (IPK, according to its acronym in Spanish).

This includes all children born to HIV+ mothers, whether they had ARV prophylactic treatment or not. Of these, 26 children were HIV+ and 17 of them developed AIDS (nine died, 13 receive HAART and four are asymptomatic). There were 121 children NOT INFECTED with HIV: 64 girls and 57 boys, while 67 are still being studied (22 girls and 45 boys). These results were achieved thanks to the application of the HIV/AIDS prevention and control program,[7] which includes the proscription of breastfeeding since 1986, caesarean section since 1989, and AZT prophylaxis since 1997 (Figure 1; Tables 1, 2, 3, 4, and 5).

Figure 1: Cuban Children of HIV/AIDS Seropositive Mothers, January 1, 1986 to October 25, 2005

Table 1:   Cuban HIV/AIDS Seropositive Children,
January 1, 1986 to October 25, 2005

Age

Female

Male

Total

%

< 12 months

3

2

5

19.2

12-23 months

2

2

4

15.4

 2-4 years

6

3

9

34.6

5-14 years

2

4

6

23.0

15-18 years

2

-

2

7.7

TOTAL

15

11

26

100

Source: Pedro Kourí Institute of Tropical Medicine

Table 2: Living Cuban Children Infected with HIV/AIDS,
January 1, 1986 to October 25, 2005

Age

Female

Male

Total

%

12-23 months

1

1

2

11.8

2-4 years

5

2

7

41.1

5-14 years

2

4

6

35.3

15-18 years

2

-

2

11.8

TOTAL

10

7

17

100

Source: Pedro Kourí Institute of Tropical Medicine

Table 3: HIV/AIDS Mortality in Cuban Children,
January 1, 1986 to October 25, 2005

Age

Female

Male

Total

%

< 12 months

3

2

5

55.5

12-23 months

1

1

2

22.2

 2-4 years

1

-

1

11.1

5-14 years

-

1

1

11.1

TOTAL

5

4

9

100

Source: Pedro Kourí Institute of Tropical Medicine

Table 4: HIV/AIDS Negative Children of HIV/AIDS
Seropositive Mothers, January 1, 1986 to October 25, 2005

Age

Female

Male

Total

%

23 months

1

 1

2

  1.7

 2-4 years

24

25

49

40.4

5-14 years

35

31

66

55.0

15-18 years

  4

-

  4

  3.3

Total

64

57

121

100

Source: Pedro Kourí Institute of Tropical Medicine

Table 5: Children of HIV/AIDS Seropositive Mothers Under Study, January 1, 1986 to October 25, 2005

Age

Female

Male

Total

%

< 12 months

13

28

41

61.2

12-23 months

 9

16

25

37.3

 2-4 years

-

 1

   1

  1.5

Total

22

45

67

100

Source: Pedro Kourí Institute of Tropical Medicine           

Of the 26 infected children, nine have died (34.6%) as shown in Table 3; five of these were nursing infants, two of them were under 2 years of age, one was 3 years and 3 months old, and one was 8 years and 10 months old. However, since the use of ARV in children was approved by the FDA (Food and Drug Administration), Cuba, along with other countries, has adopted these guidelines as a model, dramatically changing the course of HIV infection, reducing viral replication, and extending life.[8]

According to the literature, at least one quarter of HIV-infected newborns die before their first birthday and 60% before their second. In general, the majority die before they are 5 years old.[9] In our experience however, 55.5% of the cases (5/9) died in their first year, 77% (7/9) before reaching their second birthday, and in general, 88.8% (8/9) before they reached  five.

The nine patients who died developed the first pattern of evolution and showed severe opportunistic infections, leading to their death. They started with early clinical symptoms and severe disease, such as PCP (Pneumocystis carinii or Pneumocystis jirovecii pneumonia), currently known as AIDS markers. Only the life of one child could be extended to 8 years and 10 months because of the antiretroviral therapy he was given.

Prospective studies have demonstrated that mean survival is 96 months,[10-13] with evidence of early immunological impairment.[14-16] Since the application of HAART in Cuba after July 2002, the survival dynamic has changed for HIV/AIDS-infected children. The life of 47% (8/17) of the children has been extended to over 5 years. Of these children, two girls are over 15, and two girls and four boys are between 5 and 14. This is associated with the follow-up, control, and treatment established by the program (Table 2).

HIV diagnosis must be done as soon as possible on any newborn child of an HIV+ mother, and treatment started early to avoid an increase in viral replication and subsequent immunological impairment.[17]

With the success of HAART and media coverage about different methods to diminish VT (ARV treatment, caesarean section, treatment of newborns, etc), the interest of HIV-infected people in having children has grown, both in couples where both people are infected and in couples with only one seropositive individual.[18]

At the beginning of the epidemic in Cuba, from one to three children were born annually to HIV+ mothers. Since 1993, the number of births has been growing due to the increase in the number of infected women of childbearing age. In 1997, when the use of AZT in pregnant HIV+ women was included in the National Program for AIDS Prevention and Control, births decreased. In 1998 only three children were born to HIV+ mothers. In spite of education and prophylactic treatment to decrease VT, some HIV+ women refused the medication and others preferred to voluntarily interrupt their pregnancy.

Since 1999, perception of the problem has changed due to beneficial results from the national program and the number of births started increasing from 11 to 20 births per year. In 2004, 36 children were born, and as of October 2005, 32 children have been born. This increase was also influenced by the higher incidence of pregnancies that reach term with the use of AZT treatment in women of reproductive age, and more recently, by the use of HAART for preventing VT in pregnant women with AIDS (Figure 2). Also, the greatest number of births in the country takes place in the capital, where the most seropositive people are found (Figure 3).

Figure 2: Annual Number of Children Born to HIV/AIDS Seropositive Mothers, January 1, 1986 to October 25, 2005


Source: Pedro Kourí Institute of Tropical Medicine.
*Note: No children were born to seropositive mothers in 1987

Figure 3: Geographical Distribution of Cuban Children of HIV/AIDS Seropositive Mothers by Province, January 1, 1986 to October 25, 2005


Source: Pedro Kourí Institute of Tropical Medicine

The program has also identified some difficulties that constitute predisposing factors for VT such as: late inclusion of pregnant women in the program, delays in test results and delivery of HIV serology of pregnant women to family doctors, and non-adherence of pregnant women to treatment

The fact that the Cuban health system guarantees HIV+ parents free medical care and treatment in addition to social and economic support, increases the life expectancy of HIV+ mothers and in a certain way diminishes orphanhood. Of the 26 HIV+ children, six that are alive and receiving HAART treatment were breastfed by their mothers because they were detected late; among them, one girl is motherless and another, fatherless. None of the nine children who died were breastfed by their mothers. At the time of death, only one child was motherless (Tables 6, 7, & 8).

Table 6: Double Orphans, January 1, 1986 to October 25, 2005

Age

Female

Male

Total

%

5-14 years

5

1

6

100

Total

5

1

6

100

Source: Pedro Kourí Institute of Tropical Medicine

Table 7: Motherless Children, January 1, 1986 to October 25, 2005

Age

Female

Male

Total

%

12-23 months

-

1

1

  5.3

2-4 years

2

1

3

15.8

5-14 years

9

3

12

 63.1

15-18 years

3

-

  3

 15.8

Total

14

5

19

100

Source: Pedro Kourí Institute of Tropical Medicine

Table 8: Fatherless Children, January 1, 1986 to October 25, 2005

Age

Female

Male

Total

%

<12 months

 2

-

  2

  8.7

2-4 years

 2

-

  2

  8.7

5-14 years

11

7

18

78.2

15-18 years

 1

-

 1

  4.3

Total

16

7

23

100

Source: Pedro Kourí Institute of Tropical Medicine

According to Dr. Peter Piot,[19] Executive Director of UNAIDS, speaking at the 14th International AIDS Conference in Barcelona, Spain on July 7-12, 2002, “AIDS has created an orphan crisis.” At that time there were 13.4 million children under 15 that had lost their father or mother or both because of HIV. In the same way, Carol Bellamy,[19]  Executive Director of UNICEF, describes this “as the biggest problem posed by the HIV epidemic and the most long lasting. Even if the cure for HIV is found tomorrow, the number of orphans would continue to increase for a decade,” she added.

National sensitivity towards people at risk, including mothers and children through the Maternal-Child Health Program, enables Cuba to have excellent social and health indicators. Childhood mortality ranges from 6 to 6.5 per 1000 live births.[20]

 REFERENCES

  1. AIDS Epidemic Update. Geneva: UNAIDS; 2003.
  2. ONUSIDA. Informe sobre la epidemia mundial de SIDA 2004: Cuarto informe anual. Ginebra: ONUSIDA; 2004.
  3. ONUSIDA. Informe sobre los progresos realizados en la respuesta mundial a la  epidemia de VIH/SIDA, 2003. Ginebra.
    Available at: http://www.unaids.org/html/pub/topics/ungass2003/ungass_report_2003_sp_pdf.pdf.
  4. UNICEF. La transmisión del VIH de madre a hijo: Hoja de datos del UNICEF.  Ginebra: UNICEF; 2002.
  5. Dabis F, Ekpini ER. HIV-1/AIDS and maternal and child health in Africa. Lancet 2002; 359:2097–104.
  6. OMS. Saving mothers, saving families: The MTCT-plus initiative: Perspectives and practice in antiretroviral treatment - case study. Geneva: 2003. Available at:  http://www.who.int/hiv/pub/prev_care/pub40/en/.
  7.   Plan estratégico nacional ITS/VIH/SIDA, 2001-2006. Ciudad de La Habana: MINSAP; 1997. 
  8. Ramos Amador JT. Infección por VIH en Pediatría: Aspectos generales. In: González-García J, Moreno Guillén S, Rubio García R, editors. Infección por VIH 2000. Madrid: Doyma; 2001. pp. 11-46.
  9. Dabis F, Ekpini ER. HIV-1/AIDS and maternal and child health in Africa. Lancet 2002; 359:2097–104.
  10. Bulterys M, Fowler MG. Prevention of HIV infection in children. Pediatr Clin North Am  2000;47:241-60.
  11. Scarlatti G. Pediatric HIV infection. Lancet 1996; 348: 863-8.
  12. Barnhart HX, Caldwell MB, Thomas P, Mascola L, Ortiz I, Hsu  HW, et al. Natural history of human immunodeficiency virus disease in perinatally infected children: an analysis from the  Pediatric Spectrum of Disease Project. Pediatrics 1996; 97: 710-6.
  13. Tovo PA, De Martino M, Gabiano C, and the Italian Register for HIV infection in children. Prognostic factors and survival in children with human immunodeficiency  virus type-1 infection. Lancet 1992, 339:1249-53. 
  14. McIntyre J, Gray G. What can we do to reduce mother to child transmission of HIV? BMJ 2002; 324:218-21.
  15. Blanche S, Newell ML, Mayaux MJ, Dunn DT, Teglas JP, Rouzioux C, et al. Morbidity and mortality in European children vertically infected by HIV-1: The French Pediatric HIV Infection Study Group and European Collaborative Study. J Acquir Inmune Defic Syndr Hum Retrovirol 1997; 14:442-50.
  16. Resino S, Gurbindo MD, Bellón JM, Sánchez-Ramión S, Muñoz-Fernández MA. Predictive markers of clinical outcome in vertically HIV-1 infected infants, a prospective longitudinal study. Pediatr Res 2000; 47:509-16.
  17. Manual práctico de la infección por VIH en el niño. 2da. ed. Barcelona: Prous Science; 2000.
  18. Iribarren JA, Ramos JT, Guerra L, Coll O, De José MI, Domingo P, et. al. Prevención de la transmisión vertical y tratamiento de la infección por VIH en la mujer embarazada. En: González-García J, Moreno Guillén S, Rubio García R, editors. Infección por VIH  2001: Madrid: Doyma; 2002. pp. 119-67.
  19. Piot P, Bellamy C. Mesa redonda sobre Orfandad celebrada durante la 14th Conferencia Internacional sobre SIDA [CD-ROM]. Barcelona, España, 7-12 de Julio del 2002.
  20. Anuario estadístico de salud 2004.Ciudad de la Habana: MINSAP; 2004. 

THE AUTHORS

       Ida González Núñez MD, PhD, is Full Professor, 2nd Degree Specialist in Pediatrics, and Junior Researcher.
       Manuel Díaz Jidy MD, is Professor and Researcher, 2nd Degree Specialist in Internal Medicine.
       Jorge Pérez Ávila MD, MS, is Professor and Researcher and Master in Clinical Pharmacology.

All work at the Pedro Kourí Institute of Tropical Medicine.

 
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