Will all children be born free of HIV, syphilis and hepatitis-B by 2030 ?

Shobha Shukla / Bobby Ramakant *

Despite knowing how to prevent vertical transmission (from mother to the baby) of HIV, syphilis and hepatitis-B infections, we are failing with every child who is born with either of these preventable infections. We have the science-backed tools to ensure that all children are born free of these three infections. Failing to deploy them with utmost effectiveness is highly unacceptable.

All governments have committed to achieving the 17 United Nations Sustainable Development Goals (SDGs) and their 169 targets. The promise to end AIDS, end viral hepatitis and other communicable diseases, like syphilis. are part of the SDGs too. Strong evidence since years has repeatedly proven that it is possible to ensure that all children born to parent(s) with HIV, hepatitis-B or syphilis, can be born free of these three infections.

No excuse for inaction

To spur progress towards ensuring that all children are born free of these 3 infections, UNICEF, WHO and UNAIDS have recently launched a roadmap for the triple elimination of mother-to-child transmission of HIV, syphilis and hepatitis-B in Asia and the Pacific region for 2024–2030. The roadmap builds on the existing WHO Regional Framework for the Triple Elimination of Mother-to-Child Transmission of HIV, Hepatitis B and Syphilis in Asia and the Pacific 2018–2030.

Earlier, WHO Global Strategy for Women’s, Children’s and Adolescents’ Health (2016–2030) had set an ambitious goal of ending all preventable maternal, newborn, and child deaths, including stillbirths, by 2030.

Similarly, in 2022, the World Health Assembly had endorsed the three interlinked "Global health sector Strategies on HIV, viral hepatitis, and sexually transmitted infections for 2022–2030" to eliminate vertical transmission of HIV, syphilis, and hepatitis-B viruses.

Importance of ensuring children be born free of 3 infections

According to the WHO and the latest roadmap, all 3 infections of HIV, syphilis and hepatitis-B, can be transmitted from women to their newborns during pregnancy and childbirth. In addition, HIV can be transmitted during breastfeeding too.

These infections can lead to adverse pregnancy outcomes and potential long-term consequences for both mother and child. Without science-based interventions, vertical transmission rate for HIV can be up to 45%, leading to high morbidity and mortality among HIV-exposed infants.

Similarly, 70% to 90% of infants born to women positive for hepatitis-B infection may become chronically infected with hepatitis B if not vaccinated and treated.

Syphilis during pregnancy can result in congenital anomalies, a high risk of stillbirth, premature births, low birth weight and early infant deaths.

68 months left to meet the target

With just less than six years left to meet the targets, governments need to invest more in robust policies and tailored programmes to meet these goals of ensuring every child is born free of HIV, hepatitis-B and syphilis, This includes:
- Antenatal screening for HIV, syphilis and hepatitis-B for women and their male partners.
- Treatment and care services for women and their male partners with HIV, hepatitis-B and syphilis.
- Safe delivery and infant feeding options.
- Hepatitis-B vaccination and immunoglobulins, and HIV prophylaxis for children and adolescents.

Likewise, ensuring close collaborations and integration within and across reproductive, maternal, newborn, child, and adolescent health services and immunisation and disease-specific programmes is crucial. This will help improve the accessibility of health services for women, children, and their families, leading to better outcomes, more efficient resource use, and sustainable mechanisms.

Asia Pacific is home to 9% of children with HIV globally

According to the latest data of UNAIDS, globally there were 1.4 million children living with HIV (aged between 0-14 years) in 2023. Let us all remind ourselves that medicines like zidovudine was first used in rich nations over 30 years ago (in 1994) to reduce HIV risk of the unborn child of HIV positive parent(s).

Today we have far more effective treatment regimens available to ensure children are born free of HIV - and both mother and the child live healthy and normal lives.

In Asia Pacific region, there are 120,000 children (aged between 0-14 years) who are living with HIV. Indonesia comprises 26% of the regional total of new HIV infections among children, followed by India (23%) and Papua New Guinea (8%).

Since 2010, new HIV infections among children have declined by 62% in Asia Pacific region- from 300,000 in 2010 to 120,000 in 2023. Although progress in reducing new HIV infections is greatest among children, progress has stalled in recent years, said Eamonn Murphy, UNAIDS Director for Asia Pacific, and Central Asia and Eastern European regions.

Vaccine-preventable hepatitis-B rings alarm bells

According to a 2023 WHO report, two-thirds of undiagnosed and untreated hepatitis B-infected population lives in the Western Pacific and South-East Asia region of the WHO. Vaccination for hepatitis-B is considered effective in preventing infection and the chronic consequences of the disease, such as cirrhosis and liver cancer.

Prevalence of chronic hepatitis-B among the general population in the Western Pacific region is one of the highest in the world. In 2019, an estimated 5.92% of the adult population in this region was infected with hepatitis-B - 116 million people chronically infected – with 470,000 deaths. In the South-East Asia region, there were 260,000 hepatitis-B cases in 2019, with 180,000 deaths.

Deadly divide between the rich and not-so-rich nations

In most high- and upper-middle-income Asia-Pacific countries, almost all children aged one year had received the recommended hepatitis-B vaccination in 2021, meeting the WHO minimum threshold of 95% to avoid vaccine-preventable disease outbreaks.

In contrast, the average vaccination rate in lower-middle and low-income Asia-Pacific countries for vaccine-preventable diseases was around 75%, which is insufficient to ensure the interruption of disease transmission and protection of the population.

Despite poor quality data, STI burden is alarming

The overall availability and quality of data on sexually transmitted infections (STIs) remain weak in both the Western Pacific and Southeast Asia regions. However, what we do know is alarming enough: the number of syphilis cases was over 1.1 million in the Western Pacific and 350,000 in the Southeast Asia region in 2020. Syphilis is preventable and treatable, so this is another unacceptable situation.

It is time for accountability

When world's first therapy was rolled out in the rich nations in 1994 to reduce the risk of vertical transmission of HIV, an Indian non-profit too began the historic rollout in 1994 - eight years before the government programme stepped up to do so (from 2002 onwards).

“This roadmap gives hope. We can do better. Not only rich nations began rolling out zidovudine based treatments to reduce risk of vertical transmission of HIV 30 years ago in 1994, but even Indian Health Organisation (now renamed as People's Health Organisation) had initiated this therapy in Mumbai in 1994 itself under IHO-Wadia Model of Prevention of Mother-To-Child Transmission of HIV (PMTCT). India took another 8 years to begin a government-led programme to prevent vertical transmission of HIV from 2002 onwards," said Dr Ishwar Gilada, Focal point (Chair) of International AIDS Society (IAS) Asia Pacific and Governing Council member of IAS.

"We can and must ensure every child born to HIV positive pregnant women is HIV free - because we have the proven tools and approaches to do so - there is no excuse for any further delay. If this is achieved at our Mumbai-based Unison Medicare and Research Centre for past one decade - of 220 children born HIV free to HIV positive mothers - why not for rest of India?" rightly asks Dr Gilada.

"Likewise for hepatitis-B - as it is vaccine preventable and the vaccine costs a pittance - less than INR 100 for complete immunisation - there is zero-excuse for inaction. People are tested for hepatitis-B infection at multiple points (such as blood banks, indoor patients in hospitals, antenatal clinics, STIs clinics, HIV centres, pre-surgery, pre-immigration, etc) as part of Triple-H ( HIV, hepatitis-B and hepatitis-C ) response, but unfortunately hepatitis-B vaccine is not even advised, leave alone provided, to those who test negative for hepatitis-B. It is important programmatic convergence if all countries in Asia Pacific region can ensure all children born are free of the 3 infections: HIV, hepatitis-B and syphilis,” said Dr Gilada, who is also the Emeritus President of AIDS Society of India (ASI) and longest-serving HIV medical expert in India.

Dr Gilada had established India's 1st HIV clinic in government-run JJ Hospital in 1986 and then later established India’s first HIV comprehensive medical care centre (Unison Medicare and Research Centre) in 1994.

Community engagement is critical in private sector too

Feminist movement and HIV response historically have shown the defining roles communities play in shaping people-centred and rights-based responses.

But community engagement is missing or suboptimal in private sector, says Pooja Mishra of National Coalition of People Living with HIV in India (NCPI Plus). Communities can help spur demand generation for the services related to Triple-H (HIV, hepatitis-B and hepatitis-C virus). Pooja complemented that public services related to prevention of vertical transmission of HIV are good in some places. NCPI Plus and partners continue to advocate for improving people-centred services.

30 children contract HIV every day in Asia Pacific

UNAIDS estimates that services to prevent vertical transmission of HIV have averted nearly 72,000 new HIV infections among children in the region since 2015. Yet in 2023, approximately 10,000 children were newly infected.

“Around 30 children contract HIV every day in this region,” said Eamonn Murphy of UNAIDS. “No child should begin life with a disease we can prevent, and no family should miss out on the information, services and support to give their children an HIV-free start.”

In most countries where antenatal data were available for all three diseases, hepatitis-B was the most prevalent infection, with rates sometimes several times greater than HIV or syphilis.

“Unfortunately, health is a huge privilege. Poor people do not have access to information and we are still facing a lack of equity in the healthcare system. Women living with HIV face stigma and discrimination including gender-based violence and gender-based inequalities,” explained Aya Oktariani, National Coordinator of Iktan Perempuan Positif Indonesia (the Indonesia Positive Women Network or IPPI).

IPPI shows how community-led services can strengthen services to prevent vertical transmission of HIV. Their Mother Club ensures women living with HIV access treatment and maternal health services while ensuring their babies receive HIV prophylaxis and early infant diagnosis.

Thailand eliminated vertical transmission of HIV and syphilis in 2016

Thailand was the first country in Asia Pacific to eliminate vertical transmission of HIV and syphilis in 2016. Thailand had begun rollout of treatment to reduce the risk of vertical transmission of HIV in 1996, two years after the rich nations began the rollout.

Malaysia, Sri Lanka and Maldives too have eliminated vertical transmission of HIV and syphilis in 2018-2019. Some more countries are either on track or close to being on track to do so, such as Bhutan, Cambodia, China, and Mongolia.

All countries in Asia Pacific region and globally must ensure that no child is born with either of the three preventable infections. It is high time to prioritise people's health and wellbeing and walk the talk to deliver on the promises and human rights.