Pain for a purpose
Rocking her baby, Maggie winces as the nurse pricks the heel of her six-month-old baby. The baby screams as the nurse firmly squeezes out drops of blood on to circles drawn on a special blotting paper. The blood is insufficient, so the nurse has to prick the baby's heel again.
Previously, an HIV test for babies was only possible at 18 months of age and most women, like Maggie, who had not participated in the prevention of mother-to-child transmission (PMTCT) of HIV programme, would not have brought their children for testing at all or would have done so only when they were too sick to save. HIV develops fast in infants, and without treatment, a third of infected children will die of AIDS before they are one year old, according to the World Health Organization (WHO).
However, today in Malawi, an HIV test following counselling has become part of routine ante-natal care. And since 2008, the dry blood test for HIV, which allows a baby to be tested one week after birth, is gradually being scaled up. UNICEF, along with other partners, has supported the training of nurses in PMTCT and dry blood testing.
As Maggie's case shows, the links between HIV diagnosis and care and PMTCT services have also been strengthened. Maggie's HIV status was not determined at the ante-natal clinic but when she was diagnosed with tuberculosis, which she is still being treated for. It was the nurse treating her for tuberculosis who recommended that she test her baby for HIV.
Mary Wiseman, a midwife who coordinates the PMTCT programme at the Ndirande Health Centre, says so many women want to test for HIV, and also to test their babies, that the staff are faced with a heavy workload. Yet, she adds, “It is a great job now, because most of the babies we see are now surviving. In the past, they would be dead by now.”
Nurse Wiseman explains the process with enthusiasm. “It begins with counselling, which can last 30 minutes, or however long is needed.” She is clearly dedicated to her work. Pregnant women who test positive for HIV are offered daily zidovudine (AZT) from 14 weeks into the pregnancy and are counselled about aspects of the programme, including infant feeding. Most HIV-positive mothers choose to exclusively breastfeed as they cannot afford artificial milk.
Monitoring the health of HIV-positive pregnant women as well as their children is crucial. A Health Surveillance Assistant (HSA) visits the homes to counsel about infant feeding. “If they do not come to the clinic, we follow them up in their homes,” says Agnes Katete, an HSA at the health centre. “I make sure they have tested their babies and encourage them to stop breastfeeding at six months. I advise them about the food they should then give their babies.”
Since 2008, Nurse Wiseman says that out of 143 babies born to women who participated in the PMTCT programme at Ndirande, 136 tested HIVnegative. The seven who tested HIV-positive are now on anti-retroviral treatment (ART). The main problem with the dried blood test is lack of transport. If the test fails to reach the nearest hospital for analysis within 48 hours, the blood sample has to be destroyed and the baby tested again. “This happens sometimes,” says Nurse Wiseman.
Nationally, most babies are not even tested, even though AIDS is one of the main causes of Malawi's high infant mortality rate of 72 per 1,000 live births (2006). Despite having declined in recent years, this is still one of the highest in the world. The statistics are grim. There are an estimated 102,000 children living with HIV, of whom about 30,000 need anti-retroviral treatment to survive. At the end of 2008, about 24,000 children were on ART. Only 40% of HIV-positive pregnant women attending antenatal clinics were accessing antiretroviral treatment. Almost 17,000 HIV infections among newborns each year are passed on from their mothers.
Although it has reduced, stigma and fear continue to hinder programmes to prevent mothers from passing HIV to their babies and to test their infant. “Men especially need to be more involved,” says Nurse Wiseman. “Most men refuse to test, and some women do not even reveal their status to their husbands.”
However, gradually women are beginning to change their attitudes, like 28- year-old Mary Nyozani, who found out she was HIV-positive when she was pregnant. She takes particular care with her appearance and talks confidently as she plays with her bubbly two-year old daughter, Cecilia. Her baby tested negative with the dry blood test. “I was prepared for either result, negative or positive. I would accept the condition,” says Nyozani serenely. “The counselling I received here has been very helpful. I know my future is good. I feel healthy.”
And as for Maggie, she says, “My husband has been supportive and I am no longer worried. My baby, she looks healthy. I think she will turn out HIV-negative.” Maggie should know within the week.