H.I.V. Efforts Leave Children Behind
AWENDO, Kenya — The stories the mothers tell when they gather periodically at the Awendo Health Centre in western Kenya are a catalog of small failures, missed opportunities and devastating consequences. What unites the group of women is their children: All have H.I.V.
It has been two decades since efforts to prevent the transmission of H.I.V., the virus that causes AIDS, from mother to child during pregnancy and birth began in earnest in sub-Saharan Africa. Yet some 130,000 babies are still becoming infected each year because of logistical problems, such as drug shortages, and more pernicious ones, such as the stigma that makes women afraid to seek tests or treatment.
Then, many of the children who contract the virus are failed a second time: While the effort to put adults on H.I.V. treatment has been a major success across the region, many children’s infections are undetected and untreated. Seventy-six percent of adults with H.I.V. are on treatment in sub-Saharan Africa, according to U.N.AIDS, a United Nations program. But just half of children are.
An estimated 99,000 children in sub-Saharan Africa died of AIDS-related causes in 2021. Another 2.4 million children and adolescents in the region are living with the virus, but just over half have been diagnosed. AIDS is the top cause of mortality for adolescents in 12 countries in East and Southern Africa.
Preventing a woman from passing H.I.V. to a child at birth is, in theory, relatively straightforward. The policy in every sub-Saharan African country with a high prevalence of H.I.V. stipulates that pregnant women who test positive but are not on treatment are to be given drugs to block transmission. Their babies should be given another drug for the first six weeks of life. In more than 90 percent of cases, this protocol is enough to prevent a child from becoming infected.
Progress at preventing mother-to-child transmission has been stagnant in several countries in the last five years, and the Covid pandemic set it back further, with disruptions to the supply of tests and drugs, clinic shutdowns, staff shortages and a shifting away of attention to the fight against AIDS.
Laurie Gulaid, UNICEF’s Nairobi-based regional adviser on H.I.V./AIDS, said the problem in Kenya and beyond was the gulf between written policy and what the government actually funds, prioritizes and puts into practice. “The intentions are good, but the infrastructure, the resources, the training, the staff — those aren’t there yet, not the way they need to be,” she said.
In Migori, a county that has one of the highest rates of H.I.V. prevalence in Kenya, many public clinics have not had H.I.V. tests to give pregnant women for several years. If women know they have H.I.V., then sometimes their babies are on antiretroviral medication. But sometimes those drugs are out of stock, too.
To start children on medication, health workers must know that they have the virus, and that is where the system breaks down, said Tom Kondiek, the pediatric clinical officer at the main public hospital in Migori. The children may be brought to a clinic over and over but never be tested because staff do not think of it for a child of 4 or 5, or because no tests are available.
Even when women are diagnosed, health systems often fail to think of their families, Ms. Gulaid of UNICEF said. In routine care, children are typically seen at 6 weeks old, but H.I.V. tests are included only for babies known to have been exposed. Other children may not be seen again unless they fall very sick, and it is not standard practice to test all children.
Nancy Adhiambo, a mother of five, learned she had H.I.V. during her third pregnancy. She started treatment but struggled to stay on the drugs as she moved around while leaving a chaotic relationship, and could not obtain medication consistently for her baby.
That little girl, now 8, was not tested for H.I.V. for years, even though she was often sick with pneumonia as a toddler. It was not until last year, when Ms. Adhiambo was living near a clinic in Migori and joined a tightknit mothers’ group, that she had all her children tested and learned that her third child was infected. So was her last-born, a 1-year-old.
These days, the older daughter’s H.I.V. is well controlled, and so is Ms. Adhiambo’s.
But when Ms. Adhiambo went to the pharmacy for the children’s drugs, she heard the same answer she had been given for weeks: The free pills were out of stock. She could not afford the ones that were for sale in town, she said, so she would divide her remaining tablets among the children.
“Poverty complicates things,” she said. “We can only hope for the best.”