Sri Lanka Express

HIV, antenatal care in Sri Lanka:
a global health success

Photos courtesy Castle Street Hospital for Women
Sri Lanka's dedication to maternal and antenatal health is helping it to eliminate mother-to-child transmission of HIV, Sophie Cousins reports in The Lancet Infectious Diseases journal (November 2017 issue).

She writes:

The maternity ward at Castle Street Hospital for Women in Sri Lanka's capital, Colombo, is bustling with pregnant women. Some lie on metal gurneys trying to get some respite from the sticky heat, while others briskly walk the corridors in hope of inducing labour. In addition to all being pregnant, the women have something else in common: all have been tested for HIV.
“I haven't ever seen a case of HIV among pregnant women”, said gynaecologist Sanath Lanerolle, who delivers 300 babies a month at the hospital. “Women are aware of HIV. Literacy rates are very high and women have free access to antenatal care.”
HIV is rare in Sri Lanka, with a prevalence of less than 0·1% among the general population. This translates to approximately 4000 adults with HIV and fewer than 100 children, according to the National STD/AIDS Control Programme. Lanerolle is just one of dozens of frontline health-care workers who have never seen a case of HIV.


As a result, Sri Lanka—marred by a 26-year civil war and a devastating tsunami in 2004—will apply to WHO for validation of elimination of mother-to-child transmission (MTCT) of HIV and syphilis early next year. If confirmed, it will be the fifth country worldwide to eliminate MTCT of both diseases, and the second in Asia (after Thailand). The elimination of both diseases has been identified as a global public health priority by WHO, in line with Sustainable Development Goal 3.

Kapila Jayaratne (Family Health Bureau, Sri Lankan Ministry of Health) and Suchira Suranga (Family Planning Association of Sri Lanka) both attribute the country's progress to its strong maternal and child health programme, which dates back to the 1920s when the Health Unit System was introduced. The System provided institutional and home care for mothers and children, including trained assistance during birth and postnatal care.

The expansion of the Health Unit System, along with the development of its official Family Planning programme in 1965, quickly reduced maternal and child mortality. It also normalised institutional birth and improved health-seeking behaviour. “The system is geared to take good care of mothers,” said Razia Pendse, WHO's Sri Lanka director. “Almost 99% of women access antenatal care and more than 95% deliver in facilities. Once a mother is tested and is identified as HIV-positive, the system is well positioned to take care of that mother. Linkage to care is near 100%.”

In 2002, prevention of MTCT of HIV began in Sri Lanka, with the introduction of antiretroviral treatment for HIV-positive pregnant women. However, because of the low prevalence, screening for HIV was restricted to major maternity hospitals, said Sisira Liyanage, director of the National STD/AIDS Control Programme.

It wasn't until 2013 that universal antenatal screening for HIV became national policy, when it was integrated into routine syphilis screening that had been in place since 1952. But advocating for universal antenatal screening was difficult; not only because of HIV's low prevalence but also because of competing health priorities, like dengue and malaria (which was eliminated in Sri Lanka in 2016).
However, because almost 100% of women receive antenatal care and syphilis screening is widespread, the ministry decided to combine an HIV test with a syphilis test so that both could be done from the same sample. “Before the national policy was in place, only 5% of pregnant women were tested for HIV but by the end of 2016, we screened more than 90% of pregnant women and by the end of the year it will be more than 95%”, Liyanage said.

To qualify for HIV elimination, several criteria must be met, including 95% of pregnant women accessing antenatal care; 95% of pregnant women who access antenatal care being tested for HIV; and of those who are identified as positive, 95% must start treatment. In 2015, there was one case of MTCT of HIV among the 18 pregnant women who tested positive. Last year there were none, and so far this year, none have been recorded.

But although Sri Lanka has high literacy and a robust, easily accessible health system, HIV is still shrouded in stigma and discrimination. Last year, a 6-year-old boy from the northwest of the country made international headlines after he was refused entrance to school because of false rumours that he had HIV. The case reinforced the country's need to combat stigma.

“HIV has moved so far yet here, we're still so fearful”, said Hans Billimoria, an activist at Grassrooted Trust, a non-governmental organisation that focuses on educating young people. “Morality controls HIV. If you're promiscuous, you'll get AIDS and die. We can't use that line anymore.”

Liyanage said that the government was conducting sensitisation programmes for health-care workers across the country in a bid to reduce stigma. He stressed that finding the missing fraction of women who don't access antenatal care and linking them to the health system was crucial.

Despite these challenges, confidence is high that Sri Lanka will receive its validation next year, adding MTCT of HIV to its growing list of eliminated infectious diseases.