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

Breaking the Chain of Mother-to-Child Transmission

Last year alone, 700,000 children under the age of 15 were newly infected with HIV.[1]  That means that between every sunrise and sunset, nearly 1,800 children contracted HIV – the overwhelming majority in the Global South. That same day, and every single one since, 1,400 died of an AIDS-related illness.[2] As you read this, children continue to suffer and die.

This is not only reprehensible, it is also reversible.

The key link in this deadly chain is the mother: more women of childbearing age are now living with HIV than ever before,[3] and over 90% of all HIV+ children contract the virus through mother-to-child transmission (MTCT), either during pregnancy, labor, delivery or breastfeeding. Clearly, preventing infections among prospective mothers is the single simplest solution to halting MTCT and depends upon a variety of stakeholders including public health authorities, international funding agencies, educational institutions, spiritual leaders, families and the women themselves.

Access to education has proven an especially powerful weapon against HIV – what the World Bank refers to as the ‘window of hope.’ Indeed, that window is wide open, with “studies around the globe show[ing] that HIV infection rates are at least twice as high among young people who do not finish primary school as those that do.”[4] Providing universal primary education and eliminating gender disparity in primary and secondary education – two of the UN Millennium Development Goals – could have far reaching impact on global infection rates for young women and girls.          

Nevertheless, perinatal and postpartum infections for the children of HIV+ women are not inevitable, as evidenced by low mother-to-child transmission rates in the industrialized world (of the 510,000 children under the age of 15 who died last year of AIDS-related illnesses, fewer than 300 were in high income countries, where MTCT only occurs in 1% to 2% of cases).[5] This has been achieved through early detection, indicating elective caesarean section delivery, highly active antiretroviral treatment (HAART) for mothers, prophylaxis for them and/or their babies and alternatives to breastfeeding.

Unfortunately, these strategies are not always practical in resource-scarce settings where public health systems may not have the infrastructure, human resources or technology required to lower MTCT rates. In these scenarios, viral load tests requiring specialized equipment are prohibitively expensive, proper surgery facilities for caesareans are often not available and breastfeeding substitutes - which often depend on clean drinking water – may not be feasible. Importantly, antiretrovirals (ARVs) are frequently scarce or are too costly; and rationing of these therapies has become the focus of global debate.  Without any of these preventative measures, 15-30% of children born to seropositive mothers will contract HIV. Among HIV+ mothers that breastfeed, this percentage increases to 20-45%.[6]

Since 1986, Cuba has pursued a comprehensive national program to prevent and detect MTCT and treat its consequences in children (see Spotlight: National Program for Detecting & Treating Mother-to-Child Transmission of HIV and Professional Literature: Vertical Transmission in Cuba). The Cuban strategy, based on a multi-disciplinary and inter-sectorial approach that combines an emphasis on prevention and early detection with intervention, has kept infection rates low: since 1986 through October 2005, 12% of children born to seropositive mothers have been infected with HIV, the lowest rate in the Caribbean. Providing 100% HAART coverage to those requiring it using locally-manufactured ARVs has been integral to achieving this low rate.

And yet, as Dr. Jorge Pérez, Director of the Pedro Kourí Institute of Tropical Medicine Hospital so eloquently put it: if it’s your child that’s diagnosed with HIV, it doesn’t matter how low the national rate is. For you it’s 100% (see Interview: Dr. Jorge Pérez). He has shared that pain with parents of seropositive children over two decades of working with people living with HIV/AIDS (PLWHA) in Cuba, and we are pleased to present for the first time in print an excerpt entitled The First Children from his forthcoming book Confesiones a un Médico.  

Nevertheless, infection rates could be lower still. To achieve this requires nimble, innovative responses, particularly focused on education and prevention (see Interview: Mariela Castro and Headline: HIV/AIDS Education Across Cuba). To this end, in 2000, the National Center for Prevention of STIs and HIV/AIDS launched the Women’s AIDS Prevention Project, with the aim of targeting women - who are 20% of HIV+ Cubans. This includes training seropositive women as health promoters, bringing the message to where young women congregate (like in Project Beauty Salon, where hairdressers are trained as promoters of HIV prevention), and emphasizing gender-specific approaches (Professional Literature: Gender, Vulnerability and their Relation to HIV/AIDS).

Our coverage is especially robust on the international front this issue with a pair of articles resulting from our correspondent’s visit to Cuban hospitals in Pakistan, where over 2,300 Cuban medical professionals have been volunteering in quake-affected areas (Top Story: Cuban Doctors Offering Massive Relief in Pakistan and International Cooperation Report: Touring Cuban Field Hospitals in Post-Quake Pakistan).

In The Fight Against AIDS in Cuba and Haiti, Drs. Arachu Castro and Paul Farmer advance the argument against market-driven public health resource allocation that dooms so many HIV+ children in the Global South.  We are reminded that until stakeholders find the will to make available comprehensive prevention and testing programs, universal primary education, potable drinking water, HAART and pediatric-appropriate medicines, 1,400 children a day will continue to perish.  A loss neither their mothers nor the world should have to bear.

The Editors 


Notes & References

  1. UNAIDS, AIDS Epidemic Update, December 2005.
  2. UNICEF, Children: The Missing Face of AIDS, 2005.
  3. In 2005, 17.5 million women between the ages of 15 and 49 were living with HIV (46% of the global total), a million more than two years prior. (UNAIDS, AIDS Epidemic Update, December 2005). Disturbingly, HIV infection rates for women 15-24 years old is increasing in every region across the globe – in Sub-Saharan Africa and the Caribbean, 3 out of 4 in this HIV+ age group are women. (The Global Coalition on Women & AIDS, Educate Girls, Fight AIDS, 2005).
  4. The Global Coalition on Women & AIDS, Educate Girls, Fight AIDS, 2005.
  5. UNICEF, Children: The Missing Face of AIDS, 2005.
  6. De Cock, KM et al. Prevention of mother-to-child HIV Transmission in resource-poor countries: translating research into policy and practice. JAMA, 2000, 283(9):1175-1182. 
 
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