The Jakarta Post
The number of HIV/AIDS cases in Indonesia continues to rise. Since the United Nations millennium development goals were launched in 2000, the world has made tremendous gains in reducing new human immunodeficiency virus (HIV) infections and helping HIV/AIDS patients to live longer and healthier lives.
With the 2016 UN Sustainable Development Goals, the UN aimed to end the global HIV/AIDS epidemic by 2030. This includes zero infections, zero deaths and zero discrimination. The Joint UN Program on HIV/AIDS (UNAIDS) urges HIV/AIDS to be addressed seriously because of its huge impact on increasing mortality, emerging socioeconomic problems and declining global productivity.
Indonesia’s Health Ministry records show that the number of HIV/AIDS cases in children has been increasing significantly since 2010. HIV-infected children may not have AIDS, so those who receive antiretroviral therapy (ART) early can grow and develop well.
Children are largely infected with HIV through mothers during pregnancy (5 to 10 percent), birth (10 to 20 percent) and breastfeeding (5 to 20 percent). Meanwhile less than 10 percent of children are infected through contaminated needles, blood transfusions, or sexual violence from HIV-infected adults. To end this HIV infection, the World Health Organization (WHO) has implemented strategies focusing on primary prevention of HIV in women of childbearing age, prevention of unintended pregnancies in women living with HIV, prevention of HIV transmission from an HIV-infected woman to her infant and provision of appropriate treatment and support to women and children living with HIV.
What Indonesians should learn is that preventive action is far more important than a merely curative one. Our neighbor Thailand was the first Asian country recognized by WHO for its target for eliminating mother-to-child HIV transmission. The key is the high rate of antenatal care (ANC) provision. Voluntary HIV testing with same-day results is offered during the first clinic visit, followed by re-testing later in pregnancy for HIV-negative women. For HIV-infected pregnant women, ART is provided as soon as possible.
Such treatment is available at a very low cost, thanks to Thai legislative changes that have allowed the non-commercial production of generic ART. Counseling services at antenatal clinics also promote dual methods of contraception to prevent unintended pregnancy in women with HIV. These are the fruits of the early and concerted efforts of all sectors of Thai society — something Indonesia must emulate.
In fact, the same approach had been applied by the Indonesian government regarding voluntary HIV testing for pregnant women. The government’s recommendation for pregnant women to undergo voluntary HIV testing is regulated in a 2013 Health Ministry circular on prevention of mother-to-child HIV transmission. Unlike Thailand, however, this voluntary HIV testing in Indonesia still faces many obstacles.
The first and foremost obstacle is the difficult access to antenatal services for most pregnant women in Indonesia. Only 80 percent of pregnant women go to ANC providers, leaving millions of expectant mothers unmonitored. This is related to the lack of knowledge about the importance of ANC, as well as unequal access to healthcare providers, a chronic unresolved problem. So how can all the pregnant women be tested, if they do not even undergo ANC?
The government should promote the importance of ANC and ensure all pregnant women have access to ANC. The ANC should be included within the Puskesmas Keliling (mobile community health center) program, to reach as many pregnant women as possible.
Second and worse, medical personnel are generally still hesitant to offer HIV testing to pregnant women, assuming they will refuse. Even if they are willing to, their husbands are often reluctant to allow them. There is also concern regarding the protection of women’s privacy and their risk of becoming stigmatized for having undergone HIV testing.
Apparently, the strategies required by each country vary depending on local conditions. In Indonesia, HIV testing being voluntary instead of mandatory makes many think it unnecessary. Thus, the government should make HIV testing for pregnant women mandatory. This policy would not be a panacea for the continuing pandemic of perinatally transmitted HIV, given the lack of access to ANC. However, whenever feasible, governments and other healthcare providers should consider HIV testing to be mandatory for all pregnant women.
In addition, HIV-infected mothers should obtain enough information about the pluses and minuses of formula and breast milk consumption. Breast milk is a vector for HIV after birth. According to WHO, HIV-infected mothers who choose to feed the baby with formula milk should meet the criteria of it being acceptable, feasible, affordable, sustainable and safe. If families cannot get formula milk with the above criteria, mothers may still breastfeed their babies as long as they employ proper breastfeeding techniques and continue to take ART. This education should be done by healthcare providers, especially those in community health centers and Posyandu (integrated health service posts).
For a long time, efforts to make all children HIV-free have run into many obstacles. We have had numerous lessons in the importance of working together to safeguard children. Since children are the country’s future, how the country responds to the problems they face indicates how highly the country values its future.
The writer is a physician at Permata Depok Hospital, West Java, and a Master of public health in sociomedical sciences candidate at the Columbia University Mailman School of Public Health, New York.