MSF offers prevention of mother-to-child transmission
In many places in sub-Saharan Africa, mothers do not have access to prenatal care. As a result, many are not tested for HIV/AIDS. Since those who are HIV-positive don’t know their status, they aren’t given treatment and this makes it more likely that they will pass on the virus to their child. Without access to treatment, transmission of the virus to the baby occurs in up to 40 percent of cases.
MSF provides Prevention-of-Mother-to-Child-Transmission (PMTCT) treatment in many of its projects in sub-Saharan Africa. The story that follows is about MSF providing PMTCT treatment in Zimbabwe.
“MSF is now treating close to 40,000 HIV-positive people in Zimbabwe, over 7,000 of whom are children. It is estimated that there are about 2 million HIV-infected people in the country.”
“Have you come for your results?”
“Are you ready for them, no matter what the results are?”
“Yes, I am ready.”
Mlala, the MSF nurse-counsellor, peers over her round steel-rimmed glasses at the eight-month-old pregnant woman sitting opposite her. Nobukhonsi, 17, sits quietly and composed like all the other young women who have come to take the HIV test. Today, 14 have come to the Urban Clinic in southern Zimbabwe’s rural district of Tsholotosho. MSF has been in the area since 2002, treating HIV patients and providing PMTCT? Prevention-of-Mother-to-Child-Transmission, in other words, trying to keep HIV-positive mothers from passing on the virus to their babies.
The room is quiet; in this rural town there are hardly any cars driving along the dirt roads. A donkey bays in the distance, and chickens are right outside the clinic door. The MSF PMTCT nurse-counselor Thandiwe Mlala, 59, has been testing and counselling pregnant women for three years now with MSF, but has decades of experience as a midwife. Sitting on the bench outside her door, the 14 women talk among themselves in low tones, as is typical of almost all Zimbabweans. They only laugh uproariously when Mlala comes outside to do the female condom demonstration, waving a wooden penis at them.
Many of them say as they come into the testing room that they are more afraid of the needle for the test than of the results. But Mlala holds their thumbs securely; quick prick, a drop of blood applied to three strips of paper?two for HIV and one for syphilis. Then it only takes ten minutes. Slowly, a small red line appears; all is still well.
Mlala turns in her chair to check the test strips. They are all lined up next to each other, labelled with numbers. Out of the 14, five have two lines. Two lines means HIV-positive.
Nobukhonsi’s strip has only one line. Mlala tells her and she tucks her head and smiles. She understands that she must come and check again before delivery and that it is best to practice safe sex until then and while she is breast-feeding. She gets up and when she gets outside bursts out in happy chatter. The next young woman, in a long flowered dress, comes in smiling, perhaps influenced by the good mood outside. But her test has two lines. She is HIV-positive. She is six months pregnant. The father of the child is in South Africa working, like almost 75 percent of the men of the town. They come back once a year at Christmastime. They often have unprotected sex with the women. Many women become pregnant, and almost three out of ten become HIV-positive.
MSF is now treating close to 40,000 HIV-positive people in Zimbabwe, over 7,000 of whom are children. It is estimated that there are about 2 million HIV-infected people in the country. The virus can be transmitted to the fetus during the pregnancy through the placenta, though there is a higher risk of infection during delivery when the baby comes into contact with the mother’s blood.
A combination of drugs called AZT and Nevirapine (and in some cases also lamivudine) can prevent this transmission during the pregnancy and at delivery. But even if the baby makes it through that, it can still get the virus through its mother’s milk.
The World Health Organization (WHO) recommends replacement feeding for a baby with an HIV-positive mother if it is acceptable, feasible, affordable, safe, and sustainable—referred to as AFASS conditions.
The best policy would be that an HIV-positive mother does not breastfeed her baby at all. But for women in Zimbabwe, and elsewhere, this policy poses some problems. They do not have the money to buy the alternative formula milk; in fact, even regular milk is a hard-to-find commodity in Zimbabwe these days. With the country having over 10 million percent inflation, a can of formula milk can go into the trillions while an average salary is now no more than 800 billion (approximately $8 US) per month. Half a liter of regular milk can fetch up to 350 billion.
But pregnant women in Zimbabwe have an even bigger problem: their husbands and their mother-in-laws; they are afraid to tell them they are HIV-positive. That was the case with Sherryl*, who tries to calm her 18-month old baby while he cries continuously and thrashes about in discomfort. Both Sherryl and her baby boy are HIV-positive. They are at Mpilo Hospital, in Bulawayo, Zimbabwe’s second largest city. The hospital is where children with HIV are treated, and it is understaffed and overcrowded. Outside the waiting room, there is a long line of caretakers and their children. Most of the kids are not brought in by their real parents because over 70 percent of the parents have already died. MSF helps treat almost 2,000 HIV-positive children at Mpilo Hospital—the biggest group of HIV-positive children treated in any MSF program.
Sherryl’s baby is already taking ARVs but now he probably also has tuberculosis (TB). He has a mass in his abdomen and has not urinated for a week; he’s not eating and is rapidly becoming acutely malnourished. HIV-positive babies’ most common illnesses are usually respiratory, such as TB or pneumonia, but also include skin diseases and malnutrition. They don’t grow like other children, though doctors are not quite sure why. A vertically-infected adolescent (one who received the virus from his or her mother) can be 19 years old but still look 12.
“I was afraid my husband was going to shout at me if he found out I got tested,” says Sherryl, not looking up. Because she did not test, she did not know she was HIV-positive, so she did not participate in the PMTCT program that MSF offers. Somewhere along the line, her baby became infected.
Although in both programs, MSF has a very good intake of HIV testing (almost 99 percent of mothers opt for the test after being pre-counselled), in Bulawayo´s overcrowded maternity clinics over half the women who deliver do not know if they are positive or not. This probably means that many mothers in this city do not come for prenatal care where the test is offered.
Part of the problem in Bulawayo’s clinics is that there are hardly any staff. “There is not a particular nurse doing the prenatal care,” explains Sithembinkosi Mazivisa or Maz, as everybody calls her, the MSF PMTCT counsellor in Bulawayo. “There is only one nurse for registration, for attending mothers, for booking, for follow-up, for post-natal care.” With Zimbabwe’s economical situation, nursing staff earn a maximum of $10 US a month. Many of them have left or are now leaving. The staff is shrinking, and the patients are growing.
“Part of the problem in Bulawayo’s clinics is that there are hardly any staff. With Zimbabwe’s economic situation, nursing staff earn a maximum of $10 US a month. Many of them have left or are now leaving. The staff is shrinking, and the patients are growing.”
Even when they know their status and take the preventive drugs during pregnancy and delivery, there is still a chance that they will infect their baby through breast-feeding. “They are afraid of their mother-in-laws,” says Mlala shaking her head. “I don’t know what to do with these mothers-in-law.” PMTCT mothers are encouraged to breast-feed the baby for six months and then abruptly stop it when beginning other types of feeding.
Other foods may affect the baby’s immature digestive system, making it easier for the virus to pass from the breast milk to the baby’s tissue.
But the mothers don’t tell their husband or anybody else that they are HIV-positive. “So the mother-in-law quizzes them, “Why are you not giving the breast to the baby?” says Mlala. MSF opted for the solution of giving Cabergoline, a tablet that stops the milk from one day to the next. This helps the mother avoid all the tricky questions and keeps the baby safe, but she is still not empowered to disclose her status. She still cannot stand up to the mother-in-law or her husband. Another problem arises with abrupt weaning, because then, in the middle of many economic problems, what will they do to find available alternatives?
“The problem is that the men are still not coming to be tested,” says Suzanne Mackh, an MSF nurse in Tsholotsho. MSF estimates that in Tsholotho only about 5 fathers to every 200 pregnant mothers will come in to be tested—about 2.5 percent. In Bulawayo only about 5 percent of the partners come to get tested. “They say the hospital is for women, not men,” says Mlala. And if the woman tries to tell him the result, “They put their heads down and don’t want to hear it,” she says the mothers tell her. The women are afraid to take their own treatment drugs, while the men wait until they are very ill to go to the hospital. Both usually end up dead, leaving over one million HIV-positive orphaned kids in Zimbabwe.
Out of the 1,000 babies delivered to HIV-positive mothers in one month in Bulawayo, only about 9 will be tested 18 months later to see for sure if the baby has been infected or not. Many could have died before that. The solution is early diagnosis, to be able to start treatment before the child’s immune system deteriorates and he or she develops opportunistic diseases, or even worse, before the child dies by two years of age, as 50 percent of children who are born HIV-positive do.
But if the kids are started on treatment when they need it, they can avoid many of the health problems common to HIV-positive kids, and they can have a normal growth rate.
Many of these HIV-positive children on ARVs continue to grow and live a positive life. “They should make a monument to the grandmothers,” says Florencia Romero, 34, MSF’s pediatrician in Bulawayo . After their own children die of HIV, the grandmothers bring in the grandchildren for their check-ups, make sure they get their treatment and provide for them.
• Read more about maternal-infant prevention
* name has been changed