PROCAARE: Reducing perinatal transmission

[procaare@usa.healthnet.org]

The AIDS Coordination Bureau, the resource centre for a number of Dutch NGOs
that support AIDS programmes in developing countries, recently organized a
workshop on linking prevention and care. In discussing programmes that target
women, measures to reduce perinatal transmission were addressed. A number of
questions for further debate emerged; we would be interested in the views and
answers of others. Responses can be sent to: acb@kit.nl  Thanks in advance.
Maria de Bruyn

1.  How can advocacy be undertaken to ensure that women's interests are being
adequately addressed in ZDV-pregnancy interventions? Are these questions being
researched?

-  What side-effects do pregnant women living with HIV suffer from short-term
ZDV administration (e.g., worsening of anaemia)?

-  What is the effect on women's health status when ZDV administration is
suddenly stopped after delivery, i.e., during a period when their bodies are
recuperating from childbirth?

-  What is the effect of short-term ZDV administration on progression of HIV
infection in women living with HIV? If short-term ZDV administration worsens
women's prognosis and they die sooner, does this mean that the problem of
orphan care will be increased further?

-  What side effects might the children who have received ZDV suffer?

-  If women receive ZDV during pregnancy, do they risk resistance to future
antiretroviral therapies that might become available in future? (This is
perhaps not so relevant for women in Africa and Asia but in some Latin American
countries measures are being taken to ensure that all persons living with HIV
get access to antiretroviral drugs.)


2. If short-term ZDV administration is successful in reducing transmission,
will all pregnant women in the trial countries (let alone all other developing
countries) be given access to the needed drugs? Oyewale Tomori, Zimbabwe,
noted: "I think if these trials succeed in bringing the cost of treating AIDS
patients down to one-tenth of the current costs, say $80-100,the African
patient and citizen making less than $1 a day can still not afford the
treatment. Neither will his government, spending less than $3 on health per
person per year, be in a position to provide the required support to correctly
administer the drug. Rather, the new regimen will be affordable to the patient
in America or Europe, where an AZT drug trial, if it includes a placebo group,
will not be tolerated."

-  Should some measures to reduce perinatal transmission be employed with all
pregnant women and new mothers (e.g., promoting alternatives to breastfeeding
and vitamin A supplementation) or only those who are HIV-positive, given the
costs that may be involved? 

-  If the latter option is chosen, does this mean that all antenatal clinic
attenders should be encouraged to undergo HIV testing? Will it be possible to
train all physicians and midwives in voluntary counselling and testing; will
the health-care infrastructure be able to handle such an intervention in terms
of manpower and logistics?

- If so, can the women's confidentiality be ensured? (Some even question
whether confidentiality should be an issue at all.)

-  Can the women involved be assured of receiving all the antenatal and
postnatal care that they need?


3.  How can donors and their partners ensure that women living with HIV/AIDS
are involved in health-care programmes so that they, too, have a voice in
setting up guidelines for interventions to reduce perinatal transmission (e.g.,
promotion of breast-feeding alternatives)?
                      
The questions regarding placebos may now no longer require debate since some of
the institutions carrying out the placebo-controlled trials have decided to
drop the placebo segment (e.g., in the Ethiopian study). The other issues
remain highly relevant, however; it is a question of whether the women
participating in the trials are seen only as "vectors for transmission" or also
as persons requiring good care.

From: "ACB / Maria de Bruyn" <ACB@kit.nl>

KEYWORDS: PERINATAL TRANSMISSION, ZIDOVUDINE, AZT, PRENATAL CARE
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