September 30, 2009
Kenya 2009 © Colette Kerr
Nurse Colette Kerr returned to the United States in July after eight months with Doctors Without Borders/Médecins Sans Frontières (MSF) in Busia, a rural district in western Kenya, where MSF runs an HIV/AIDS project. Kerr oversaw the prevention of mother-to-child transmission (PMTCT) program for pregnant women and new mothers. MSF offers PMTCT interventions in over 50 projects, with 8,700 HIV-positive pregnant women having received preventive treatment and 8,800 babies having received post-exposure treatment in 2008.
Treatment providers continue to struggle to prevent newborn infections amid complex protocols and high numbers of patients who do not return for follow-up treatment. Despite the challenges, PMTCT programs such as MSF’s dramatically increase a child’s chances of being HIV-free and deliver essential support to HIV-positive mothers. Here, Kerr describes her experience in Busia.
When new patients come to the clinic for antenatal care, each receives a handful of tests—for malaria, for malnutrition—and then we ask, “Do you want to be tested for HIV?”
Kenya 2009 © Colette Kerr
The virus can be transmitted from an HIV-positive woman to her fetus or infant at three stages: during pregnancy, through the placenta; during delivery, when the baby comes into contact with the mother’s blood; or during breastfeeding. In the US and Europe, transmission rates are generally below two percent thanks to the widespread availability of antenatal care and HIV screening. Plus, antiretroviral drugs (ARVs) and infant feeding formula are easily accessible. In much of Africa, however, most women simply do not have access to these measures.
Before testing, we explain that we can give medicine to help them live a long time with HIV and to prevent transmission to the baby. On hearing this, they almost always get tested. So we prick their fingers for a blood sample and wait 15 minutes. If two red lines appear on a patient’s test strip, she is HIV-positive.
Bringing Care Closer to Patients
The people waiting at the clinic, like many others in Busia, earn their living by fishing, farming, or bartering. They have little income for transportation or health care. Without antenatal care, women miss the opportunity to be screened for HIV in a place where 15 to 20 percent of the population is living with the virus. If women don’t know their HIV status, they won’t receive ARVs, which can help keep them healthy throughout their pregnancy and prevent them passing HIV to their babies.
MSF and the government have pursued a decentralized approach in order to make treatment adherence less of a hardship for the women. Since MSF began providing HIV/AIDS treatment at the Busia district hospital in 2003, the program has branched out to 10 rural health centers and into home-based care. Tiny, two-room government clinics in remote places provide PMTCT without electricity, labs, or pharmacists. MSF provides support with drug supplies, the transport of samples to labs, and sufficient staffing. In MSF’s program here, transmission of the virus to the baby occurs in less than seven percent of cases. Without any intervention, about 20 percent of babies born to HIV-positive mothers will be infected at birth, and more will be infected later through breastfeeding.
During a pregnant woman’s initial visit, a local nurse and a nurse acting as a mentor answer the patient’s questions and provide support. In follow-up appointments we administer ARVs and demonstrate safe feeding practices. Counseling patients on how to disclose their status to partners and families is critical. If a woman fears that attending clinics and taking two pills a day will expose her as HIV-positive, which can carry harsh consequences, she might default. Some husbands reject wives who test positive, though few of these husbands get tested themselves.
I think of one patient whose first child had died, and she didn’t know why. When she came to the clinic during her second pregnancy and tested HIV-positive, she joined the PMTCT program. But she feared telling her husband and family. She kept it a secret. The second baby got sick right away and tested positive. It wasn’t until then, for the sake of the baby, that she told her husband. She had to explain why the baby needed weekly hospital visits. Even though transmission wasn’t prevented, early diagnosis meant that we were able to start treatment before the child’s immune system deteriorated, before he developed opportunistic diseases or, even worse, before he died by the age of two as happens to half of all children born HIV-positive. Her husband didn’t leave her, but it was tough. He did not get tested.
A Lasting Impact
We give newborns antiretroviral syrup at birth and a follow-up dose within the first month to further reduce the risk of transmission. Ideally an HIV-positive mother does not breastfeed. But in Busia formula milk is not widely available, safe, or affordable and there is fear that abstaining from breastfeeding could expose a woman’s status. MSF encourages HIV-positive mothers to breastfeed exclusively for six months and then abruptly stop when beginning other types of feeding. Other kinds of food may damage the lining of the baby's stomach and intestines, making it easier for HIV in breast milk to pass into the baby’s tissues.
To help confront some of the practical challenges and stigmas, MSF runs monthly peer support groups at the clinics. These meetings serve as a venue for patients to see that they aren’t alone and that PMTCT is feasible for women like themselves.
I remember one woman who had nearly graduated from the program. She had been devastated to learn that she is HIV-positive. In the months that followed, she absorbed all the information she could; she was so devoted to the pregnancy. She had twins. One died at birth and the other weighed less than five pounds. She came to the clinic every week for check-ups and supplemental food to make sure she had good milk. The baby got sick a few times, but when I last saw him, at five months old, he was growing strong and healthy.
At seven months we run a test to confirm a baby’s status. If it is positive, we immediately enroll the child in the HIV/AIDS program and start administering drugs. If the baby is negative, we tell the mother that she doesn’t need to bring her baby anymore and we enroll her in the program.
When I organize the lab results from the babies born to our HIV-positive mothers, the positives crush me, but each negative result feels like a graduation party. I just think, “All the woman’s hard work, all the things she had to sacrifice—it worked.” It’s the only reward I need. And in the end, the program counts for much more than good test results. The awareness-raising activities demystify HIV and help chip away at the stigma for the whole community. And mothers receive the tools they need to live positively, receive treatment, and provide the best care for their babies regardless of HIV status.
© 2013 Doctors Without Borders/Médecins Sans Frontières (MSF)