Reduction in Perinatal Transmission of HIV
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Source: procaare@usa.healthnet.org
The trials which attempted to prove that a short course of AZT is ef-
fective in reducing perinatal HIV transmission (PHT) generated a lot of
negative comment for a variety of reasons. And the successful conclu-
sion of the trial in Thailand does not appear to have changed this
situation much. Despite Glaxo-Wellcome's offer of price reductions on
AZT for this purpose, most commentators note that the regimen is still
out of reach to a large proportion of the affected women. Others note
that without a solution to transmission via mothers' milk, the benefits
of perinatal intervention will be lost. Still others focus on the costs
(not only financial) connected with universal testing of pregnant women
to identify in advance those who infected so that they can be provided
treatment. And finally there are some who are rightly concerned with
the possibly conflicting rights of mother and child.
While there is no doubt that all of these concerns are very valid, it
does seem to me that they do miss the point: that we have made some
headway in the continuing battle against the virus and its effect on
those living in developing countries. I have never felt that we are go-
ing to see the breakthroughs that the American culture always seem to
demand. Progress will continue to be made with a patient, step-by-step
approach.
We now have a regimen which can be offered much more widely than the
previous 076 regimen, one that itself was a significant step forward.
To argue that it is unacceptable because it cannot be made available to
all or even most infected pregnant women is to miss the point that it
will be available to more than before, and that efforts by all involved
can continue to eat away at the larger population who initially will
not be included. We do not argue against the use of TMP/SMX for PCP
prophylaxis because there are many PLWHAs for whom it is not available.
I accept that there are concerns over counselling and testing of preg-
nant women. But I do not see why it has to be that the successful re-
sult of these trials mandates universal testing. Start with those who
have already been identified as infected, slowly move towards testing
of those who, either because they are informed or because of wider
availability of counselling, believe they may be at risk, and slowly
develop this so that a higher proportion of infected women are identi-
fied. This will miss many, but less that it does today. Is that not
worthwhile? Conversely, I would in no way condone universal testing in
the conditions which admit in most places today; in many cases the
costs (economic and emotional) will far outweigh the benefits - I think
this is already being seen in some countries that have rushed to imple-
ment it. In others, it is clearly unlikely at least in the short term
that adequate counselling can be provided to support the testing, or
that sufficient AZT can be provided to treat all those identified.
Concerns over breastfeeding are real and must be addressed; they are
extremely complicated and will require additional research and much
discussion. But again, let's try to be positive. If we can avoid the
perinatal infection, let's do all we can to prevent later infection
from breastfeeding.
I agree that it is unreasonable to expect many developing countries to
place priority upon PHT. given these challenges and all the other de-
mands placed upon their stretched healthcare systems. The strength of
our world is that we don't always have to rely on government action,
only that governments should provide a supportive environment. I know
that individuals and NGOS are now gearing up to respond to the opportu-
nity that these trial results offer, and they will be seeking - and
finding - creative ways to reduce the number of babies who are infected
by HIV at birth. Don't let's complicate their work with unreasonable
conditions. The world isn't fair; although better governments try to
use the principle of fairness in their policies, NGOs shouldn't be lim-
ited by this. They get stuck in and help whoever they can.
Am I idealistic? Perhaps! But I would like some of the naysayers to try
to take a more positive view of these developments and make sure that
they are not erecting barriers to those whose creative thinking can
make a difference, even though it be small.
There may be some (even sometimes I myself!) who will ask how I square
support for this intervention in PHT with my opposition to the UNAIDS
program of providing antiretrovirals in four developing countries.
Mostly I persuade myself that the circumstances behind this program are
very different, but I would be willing to debate this separately. The
benefit of being a volunteer is that one can sometimes follow one's
heart!
Chris
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Chris W. Green
Jakarta, Indonesia
Tel: +62-21-846-3029
Fax: +62-21-846-1247
mailto:chrisg@rad.net.id
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