Guest blog by Ann Akesson, MD, Medical Coordinator, Malawi, Médecins Sans Frontières/Doctors Without Borders (MSF)
On October 4 and 5, at the Global Fund Replenishment Meeting in New York, governments in some of the most affected countries will find out whether their planned HIV treatment programs will be funded, or whether they’ll have to greatly curtail current strategies.
A Global Fund that is not fully funded will have a tremendously negative impact on HIV/AIDS, tuberculosis, and malaria programs throughout the world. As the medical coordinator of a Médecins Sans Frontières/Doctors Without Borders (MSF) HIV prevention of mother-to-child transmission (PMTCT) program in Malawi, I know first-hand what kind of impact this will have on the mothers and babies where I work.
I’ve worked in the Thyolo district of Malawi since 2008. Here we’re treating approximately 2,700 pregnant women on different antiretroviral (ARV) regimens to protect their health and to prevent their babies from becoming infected.
But most HIV-positive women in Malawi don’t have access to preventive treatment, and few infants are tested for HIV infection. Without preventive treatment, 35% of all HIV-positive women will transmit the virus to their children. And an untreated infant is at extremely high risk of death: half of babies with HIV will die by age 2 if not treated.
Vertical transmission of HIV during pregnancy, childbirth, and breastfeeding has been virtually eliminated in North America and Europe. In the rest of the world, however, more than 400,000 infants acquire HIV from their mothers every year; approximately 90% of these infections occur in sub-Saharan Africa.
Yet with appropriate tools and strategies, effective PMTCT of HIV is possible. These strategies include a strong effective drug regimen for the pregnant woman and child, early initiation of treatment, and prophylaxis that continues during the breastfeeding period. Current World Health Organization (WHO) guidelines recommend that all adults with HIV, including pregnant women, start taking ARVs when their CD4 count falls below 350 cells/µL. This treatment, given to protect the health of pregnant women, is also effective in preventing HIV transmission to their babies.
For pregnant women with CD4 >350, the WHO recommends two different options, starting at week 14 of pregnancy. The first option involves a maternal regimen of AZT monotherapy and, if needed, additional ARVs at delivery, and one week postpartum. For the infant, nevirapine is recommended from birth until one week after all exposure to breast milk has ended. The second option recommends a triple medicine therapy for the mother until one week after breastfeeding has stopped, with prophylaxis to the infant for the first 6 weeks following birth.
ARV treatment or prophylaxis for mother and child means that HIV-positive mothers can breastfeed with limited risk of transmission to their children. Breastfeeding also reduces the risk of child malnutrition and infections such as pneumonia or diarrhea.
These recommendations help promote improved maternal and child health and survival. The risk of transmission can be reduced to <5% for mothers breastfeeding (from a background risk of 35%), and to <2% for non-breastfeeding mothers (from a background risk of 25%). More effective interventions in resource-limited settings make it possible for countries to virtually eliminate mother-to-child transmission and pediatric HIV/AIDS.
Malawi’s program will require funding to train PMTCT providers and purchase sufficient ARVs. Malawi has created a robust and feasible plan to support this and other progressive HIV programs and has submitted a Round 10 Global Fund application. Unfortunately, given the constrained budget of the Global Fund and discouraging financial predictions, MSF is concerned that Malawi may not receive adequate support. Without such funding, bold efforts to increase the number of pregnant HIV-positive women who receive PMTCT services will be lost.
Working to prevent infants from contracting HIV and improving the health of HIV-positive women is an extremely rewarding experience. We see mothers who have been worried about their children for months, and we are able to tell them that because they stuck to their medicine, their child is HIV-free. There really is no way to describe the look on a mother’s face when you can give her that kind of news. As a medical provider, my concern is that this type of progress will not continue in the rest of Malawi or other developing countries without a commitment to long-term funding.