E-drug: Reduction in Perinatal Transmission of HIV
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The trials which attempted to prove that a short course of AZT is
effective in reducing perinatal HIV transmission (PHT) generated a lot
of negative comment for a variety of reasons. And the successful
conclusion 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
going 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
pregnant women. But I do not see why it has to be that the successful
result 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
identified. 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
implement 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
demands 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 opportunity 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 limited by this. They get stuck in and help
whoever they can.
Am I ideallistic? 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 (chrisg@rad.net.id)
Jakarta, Indonesia
Tel: +62-21 846-3029 Fax: +62-21 846-1247
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