The history of pediatric HIV sub-epidemic in Manipur is more than 10 years old. During this period we have seen the gradual transformation of the sub-epidemic from one affecting mainly the children of IDUs to one affecting the children of average Manipuri families whose parents are infected through heterosexual route. As of now, almost all the infected children have acquired HIV infection through vertical transmission from their infected mothers.

In Manipur, the first pediatric HIV infection was recognized in January 1994. Since than, an increasing number of children are infected through vertical transmission from their infected mothers. Since the beginning of the sub-epidemic, hundreds of children have died, thousands are still struggling for survival and many have been orphaned.

As of October 2004, 613 HIV infected children (347 males and 266 females) below 10 years and 1007 infected individuals (802 males and 205 females) between 10 to 20 years have been reported to the State AIDS Control Society, Manipur. In fact, these HIV infected children represent only a fraction of the total seropositive children subpopulation in Manipur with the most severe clinical manifestations as many cases of pediatric HIV infection are under-diagnosed and underreported.

So far, we have seen two waves of pediatric sub-epidemic. The first wave was seen during the early 1990s when there was an epidemic among IDUs. This epidemic was seen among the HIV infected children born to HIV infected women who were infected through heterosexual route from their infected IDU husbands.

A small proportion of HIV infected children in those days were children of women who had acquired HIV infection through blood transfusion before the mandatory screening for HIV was introduced in 1995. During this period, the HIV infection was confined mostly to the children of IDUs. The recognition of these infected children was not difficult in most cases as these children were brought at a very late stage of HIV disease and also the caregivers of these children themselves revealed the IDU and infective status of the parents.

The parents of these infected children were most often sick and as the limited financial resources of the families were utilized first for the IDUs and subsequently for the management of HIV associated illnesses of the parents, the care and support given to these unfortunate infected children were very poor. This was aggravated by the rapid progression of the HIV disease in children as compared to that of adults.

Most of the parents of these infected children also developed AIDS early because of their continuing high risk behavior and they died early in the course of HIV disease because of the common preventable prevailing diseases and OI. Although adult formulations of ARV became available sometime in mid 90s in India, most of the affected families could not afford to buy ARVs as the drugs were costly and not freely available.

Pediatric formulations of ARV drugs were also not available in 1990s. As a result, these HIV infected children suffered maximum both from the point of view of treatment and care and support, because their grandparents mainly spent most of their limited financial resources for the ailing parents. The outcomes of these children were also correspondingly poor.

This was because these children came in late stage of HIV disease and the doctors in early 90s did not have the required expertise in the clinical management as many of them were not trained in HIV/AIDS. This was compounded by the stigma and discrimination and also lack of awareness about their mode of transmission.

Almost all the rapid progressors of the first generation HIV infected children have died Most of the slow progressors from the socially disadvantaged families have also died mainly from common prevailing childhood diseases, malnutrition and OI.

Those slow progressors who are still surviving are mostly from economically stable families whose members are committed to the care and support of these children. Long term survivors of the first generation HIV infected children are still surviving with minimum health problems and they are now entering adolescence with uncertain future and a great risk to the society.

The second wave of pediatric sub-epidemic started in early 2000 when the HIV epidemic had spread to the general population where the young women of child bearing age were infected through heterosexual route by their sexual partners who are not IDUs. Unlike the first generation, these children are born to mothers who were infected through heterosexual route from their infected husbands who acquired their infection from FSWs.

The clinical profile of these infected children and outcome are to a certain extent different as compared to that of the first generation HIV infected children. This is mainly because of the intact financial resource and care and support given by their infected but asymptomatic parents. Most of the parents are unwary of their HIV status as they are seemingly in good health and do not have the severe clinical symptoms as compared to the first generation parents.

Therefore, pediatric AIDS is often the first evidence of heterosexually transmitted HIV infection in the family leading to serious social, legal and domestic consequences. Although these children are HIV infected they do not usually show the severe clinical symptoms because of their relatively good nutrition and prompt management of common illnesses. A high index of suspicion is required for the diagnosis of these children.

The present scenario is that we have a subpopulation of HIV infected children who are in different stages of HIV disease. This infected subpopulation of children consists of first generation long term survivors and slow progressors who are on ARV therapy and Ol chemoprophylaxis and those of the second generation who are mostly under-diagnosed.

We also have a growing population of AIDS orphans who are taken care of by their extended families with some support from NGOs and also by the various children homes situated at different districts of Manipur.

The need of the hour is care and support of these infected children and affected families for which we require the latest scientific knowledge about pediatric HIV disease and skill of proper diagnosis and management besides providing psycho-social support. This sounds easy to spell but will be very difficult to execute because of the chronic nature of the disease, limited financial resource and the associated stigma and discrimination.

So far, only few families could afford ARV treatment for these infected children. In most cases this is done at the cost of their basic needs of the daily living. There is little support from the government and nongovernmental organizations. The sub-epidemic has progressed very far without the knowledge of most of us.

We all need to realize this fact and join hands and plan to address the needs of these unfortunate innocent infected and affected children because they are going to the future parents of the state.

The future of these unfortunate children lies in those few hands who are committed to sacrifice their time, energy and expertise and always ready to say "we are here to render help".