Pediatric HIV/AIDS Scenario In Manipur

By Dr. L Ranbir *

HIV/AIDS has been recognized as an unstoppable epidemic in Manipur for more than 11 years. First reported in February 1990 and primarily affecting the young male IDUs in the beginning of the epidemic, HIV/ AIDS has already invaded many Manipuri families through heterosexual and vertical transmission, resulting in waves of subepidemics among women of child-bearing age and children.

Now. we have an epidemic affecting the general population and HIV/AIDS is emerging as a serious public health problem in general and a threat to child health and survival in particular.

In Manipur, an increasing number of young woman of child-bearing age are getting infected with HIV mainly through heterosexual route, a small percentage through both heterosexual and IDU, and transfusion of infected blood (before 1995). The seroprevalence rate of HIV among antenatal mothers in Manipur is around 2.5% and 80% of them acquired the infection from their husbands[1]. As a result, infants bom to these women are increasingly infected with HIV.

Pediatric HIV infection in Manipur was first reported to the Manipur State AIDS Control Society (MACS) in January 1994 and the first pediatric AIDS case in February 1995. As of October 2001, 286 HIV infected children, 168 males and 118 females below 10 yr of age and 895 individuals, 764 males and 131 females between the age group of 10 to 20 years constituting 2.86% and 9.78% respectively of the total 12,239 HIV/AIDS have been reported to the MACS[2].

The exact number of infected children who had developed AIDS and died of the disease is not known. In fact, these HIV infected children represent only a fraction of the total seropositive pediatric population in Manipur with most severe clinical manifestations.

Considering under-diagnosis,under-reporting and delay in reporting, it is estimated thai thousands of children have already been infected with HIV since the beginning of the epidemic. Based on the total population (2.4 million)[3] recorded birth rate (18.6)[4], seroprevalence rate among ante-natal mothers (2.5%)[1] of Manipur and vertical transmission rate of 30%, it can be calculated that around 1,116 infants are born to HIV infected mothers every year and approximately 334 babies become infected.

So, it can be estimated that almost each day, an infant infected with HIV is born almost in Manipur. All the infected children till now have acquired their infection through vertical route. Although we have a small sub-population of children with thalassemia, there is no report of their being infected with HIV through blood transfusion.

As the pediatric HIV/AIDS sub-epidemic in Manipur progresses, the natural history and outcome of the HIV infected children have become more clear. However, the natural history, clinical profile and the outcome have been modified by various factors including antiretroviral therapy (ART). For descriptive purpose, children with HIV/AIDS can be grouped under three categories 1). Children with minimum treatment,
2). Children treated for HIV associated disease, but without ART
3). Children treated with ART and for 01.

The clinical markers of pediatric HIV/AIDS are almost the same as those observed in any other developing countries. Rapid progressors become symptomatic by 3-4 months with mainly oropharyngeal and esophageal candidiasis, PCP, recurrent respirator)' tract infections and diarrheal diseases, marked hepatosplenomegaly, wasting syndrome and encephalopathy. The outcome of the rapid progressors is very poor.

Untreated, these children die within first few months of diagnosis. Treated without ART, but with PCP chemoprophylaxis, most will develop multi-system diseases and die within 2 years. Few children who are treated with ART survive through the third year.

Slow progressors become symptomatic at a variable period after 1 year. The important clinical markers are respiratory tract infections, diarrheal diseases - which are recurrent persistent and severe, hepatosplenomegaly, generalized dermatitis with or without bacterial or fungal infections, malnutrition, growth failure and opportunistic infections like tuberculosis and multi-dermatomal heroes zoster.

As the child survives longer, gastrointestinal symptoms and dermatological problems become more severe. The risk of getting tuberculous infection also increases and P. marneffei infection, which is endemic in the South-East Asia, is emerging as one of the common AIDS defining opportunistic infections in children.

Without treatment, most of these children die around 5 years of age due to severe bacterial infections and OI. Slow progressors without ART but with nutritional and treatment of common childhood diseases and opportunistic infections survive up to 8 yrs in most of the cases. The long term outcome of few children who are treated with ART, are still not-known.

Long-term survivors present with minimum signs and symptoms. Important among them are growth failure, lymphadenophathy, parotitis and most have anorexia not explainable by other causes and dusky skin color. Most of them are still surviving at 10 years with minimum health problems. The various factors affecting the outcome of the HIV infected children in Manipur are the stage of the HIV disease, the quality of the caregivers, family factors like financial, educational status and social support system, and affordability, adherence and maintenance of ART.

HIV/AIDS is a family disease, As the clinical disease occurs within months in infected infants and children, pediatric AIDS is often the first evidence of heterosexually transmitted HIV infection at the family level, leading to serious social, legal and domestic consequences. As there is no effective cure and vaccine, all these HIV infected children will die of AIDS resulting in the rise in the infant and under five mortality rates in Manipur.

Besides, there will be a growing population of orphans who are taken care of by extended family system, which will be a great burden to the society at large. As the young parent die of AIDS, leaving behind sick children, the responsibility of care and support of these children fall on the grandparent who are physically and financially ill-equipped. Their despair and frustration under such a situation have become evident.

However, because of the strong tradition of joint family system in Manipur, all are not lost for these sick children as they are often looked after by the members of the joint family.

The management of these children, on the part of the medical fraternity has become a formidable challenge because of the complicated amichronic nature of the disease and the social stigma attached to it. In this part of the country neither we have the armory to fight this disease, nor have we the experience to cope up with the chronic multi-system disease, financial and other family problems with which they come to us.

Although it is a known fact that HIV/AIDS is spreading very rapidly in this part of the country, the special care and support much needed by these HIV infected children, are not being addressed in time.

In conclusion, pediatric HIV/AIDS is emerging as one of the top killer diseases in children in Manipur and will be a major pediatric health problem in the years to come. We also have a growing population of orphans, which will be a great burden to the society at large,

The epidemic has progressed too far without the knowledge of most of us. There is still no governmental policy and program to address the special needs of the pediatric HIV/AIDS. We have been ignoring it for too long, and we now need to recognize it as a common threat.

The time has come for all the pediatricians in the country to give greater attention to this growing subepidemic and recommend remedial steps for the prevention of the disease and for the care of the HIV infected children.

References

• Status Report, Manipur State AIDS Control Society, Imphal, Manipur; National AIDS Control Programme, Manipur, 2000-2001
• Manipur AIDS Control Society, Lamphelphat, Imphal, Epidemiological Analysis of HIV/AIDS in Manipur, Monthly Update, September 2001, 1-4.
• Directorate of Economics and Statistics, Government of Manipur, Miscellaneous (Population of India by state/UT, according to Provisional Results of 2001 Census), Statistical Abstracts of Manipur - 2001, 2001, p, 214.
• Directorate of Economics and Statistics, Government of Manipur, Vital Sta tistics, Statistical Abstracts of Manipur - 2001, 2&9I, p. 40.
• National Child Survival mid Safe Motherhood Programme, Training Module. Plan and Implement, MCH Division, Ministry of Health and Family Welfare, Government of India, Mew Delhi, January 1994, p6.