Accompanied by Waweru, an HIV counselor, a woman walks into a consultation room of the Médecins Sans Frontières ‘Blue House’ clinic in Nairobi. She is carrying a child, and looks weary. She has her hands full with a traditional woven bag–a ‘kiondo’–hanging from her shoulder and her three-year-old son, Titus, in her arms.
He is living with HIV/AIDS and is having treatment with antiretroviral (ARV) therapy, which slows the process of the disease and should allow him to live a normal life.
When Elizabeth is asked how Titus is doing, she takes a paper bag out of the kiondo. She pulls out Lamivudine and Zidovudine syrups, followed by a little plastic bag with big bright yellow Stocrin 200 mg capsules. She explains that the syrups are administered twice a day in equal amounts of 12.5ml each time. Titus takes one capsule of Effavirenz daily as well.
This is never easy with a small child when living in a cramped one-room shack. The procedure is challenging, and requires basic things such as clean water, which is not always available. Children who are a little older than Titus are prescribed tablets, taken once daily. Mothers have to break a tablet into two for accuracy. Most children are unable to swallow the half tablet so it is crushed up and mixed into food, one half in the morning and the other at bedtime the measurements must be precise or the treatment will fail. And of course, as the child grows, the dosage has to be constantly adjusted.
Clearly, reducing the risk of mother-to-child transmission of HIV/AIDS is preferable – but this too has its problems. The main way to prevent transmission in a developed country like Australia is to deliver via caesarean section, something which is rarely an option for women in sub-Saharan Africa. More commonly, a woman can be given drugs at about 28 weeks and again just before the birth, to reduce her viral load, and therefore the chance of transmitting the virus to the baby during birth. The baby is then given drugs immediately after birth.
However, even this scenario is not always possible.
“The first obstacle is that the vast majority of women don’t have access to antenatal care,” says MSF Australia’s Dr Myrto Schaefer.
“The second obstacle is that not all women with access to antenatal care have HIV testing. “The third obstacle is that most women don’t have access to any kind of services that offer an anti-retroviral treatment. The fourth obstacle is that the protocols are quite complex if you want to be effective and the fifth obstacle is that there is no good alternative to breast feeding in most African settings.”
In Sub-Saharan Africa nearly half of children who are born with HIV/AIDS will die before the age of two. “Then you have the child’s side. You want the child to be monitored once it’s born so you can find out whether your intervention has been successful or not. You want to diagnose the child as soon as possible to see whether the child has acquired HIV either during delivery and shortly after delivery in order to treat this child as soon as possible, because we know that in Sub-Saharan Africa about 50% of the children who are infected with HIV AIDS die before the age of two years."
Dr Schaefer is also acutely aware that around 30% of children who are born to HIV positive women die before the age of two even if they are not themselves infected, because the mother dies or gets sick and cannot take care of the child. “So it’s an issue of not only taking care of the child and trying to prevent the transmission from mother to child, it’s also important that we look at the woman as an individual and treat her HIV/AIDS in the best way for her,” she says. “As an organisation, MSF is always striving to balance what will work best for the patient with what is actually possible in the field. Accordingly, we must look at where the mother is in her treatment – giving her the wrong drug at the wrong time, or too early, can lead to resistance later on when she needs the drug most.”
Formula-feeding can greatly reduce the risk of transmission, and certainly in a Western setting this would be the protocol. But here again, the solution for a woman in Africa is not so simple. When a woman doesn’t have access to clean water, for example, or lives a long way from a health centre, breastfeeding for as long as possible can actually be better for the child, in spite of the risks.
“If you take an educated woman in Nairobi with access to clean water, you would certainly give her the option of formula feeding,” Dr Schaefer says. “But in rural Africa, say in Homa Bay in Kenya where we have a program on Lake Victoria, if that woman doesn’t really understand how to mix the food, or if she doesn’t have access to clean water, then the child is deprived of all the immune globulins that usually are transmitted with breast milk. That child might not have access to good vaccination services, so will be exposed to a high risk of dying from diseases other than HIV.”
In Kenya, 33 percent of children with HIV-positive mothers are born with the disease and 50 percent of suspected HIV-positive children are dead by the time they reach two years of age. And whichever the method of transmission, AIDS is a terribly efficient killer of children.
“Once they’re infected, children very often fall sick much earlier, much more seriously and die much faster than adults,” says Dr Schaefer.
“Even if they survive, if they are not taken care of them early enough their neurological development is going to be impaired. You do have more interest to identify them early to offer quality treatment to them early in order to be sure they have a healthy life later.”
Something of a departure from MSF’s traditional role as providers of emergency medical care, Dr Schaefer stresses working in HIV is “not the same as working in a refugee camp”.
“It’s not the same as working in a cholera epidemic, you can’t just go and implement a tried and tested intervention that will work for thousands of people.” But clearly something is working. In Matarae, in 2004, a pregnant HIV-positive woman came to the Blue House. She received treatment, and MSF was able to test her baby at 18 months of age. “When I was there, in May last year, this woman found that her child was not infected,” recounts Dr Schaefer. “I have this picture of the woman holding up her child and it’s a healthy child and that to me is a success story.”
