The UN’s Pursuit of an AIDS Goal Puts Women and Children at Risk

The UN’s Pursuit of an AIDS Goal Puts Women and Children at Risk

FRIDAY, 3 December 2010

FOR IMMEDIATE RELEASE

A set of reports issued by UN agencies in time for World AIDS Day 2010 announced advances in programs aimed at “preventing mother-to-child transmission of HIV (PMTCT).” But the assertions of progress for women set out in the UNAIDS Report on the Global AIDS Epidemic 2010 and UNICEF’s Children and AIDS: 5th Stocktaking Report do not hold up under scrutiny. And claiming that full success can be achieved by 2015 is as misleading as the program’s very name, which points a finger of blame at infected mothers. One simple step toward respect for mothers’ rights would be a change of names, to “prevention of vertical transmission.” Other steps are far more urgently required.

The UN announced this week that “53 per cent of women in need received antiretrovirals for PMTCT.” Relying on partial data that make true comparisons across years nearly impossible, the reports compared the 2010 percentage with a 15 percent marker reached in 2005. Media packets did not mention that this year’s total included women who were prescribed only single-dose nevirapine. That quick fix is no longer recommended by the World Health Organization (WHO) because it falls so short of acceptable standards of care, but worse, because it puts mothers and babies at risk.

About a third of women who are given a single dose of nevirapine during childbirth will develop resistance to that class of drugs. Later, when their HIV disease progresses and they need treatment to stay alive, the antiretroviral regimens used in most developing countries may not work. Over 50 percent of the babies exposed to single-dose nevirapine will also develop drug-resistant HIV.

Even the pharmaceutical company that patented nevirapine has since discouraged its use in single doses to prevent vertical transmission. But it was still prescribed to many program beneficiaries, and that was still described by the UN as a 2010 success story. Of the four countries in sub-Saharan Africa applauded for achieving the UN’s 80 percent coverage goal, three — Namibia, South Africa and Swaziland — reached the target in part by prescribing single-dose nevirapine; in Namibia, 48 percent of women enrolled in the program received it. In Ethiopia and India, single-dose nevirapine was prescribed to all the women treated, and yet both countries earned a tick on the UN ledger that marks progress toward “virtual elimination of mother-to-child transmission.”

AIDS-Free World’s own stocktaking leads us to conclusions starkly at odds with the UN’s assessment. The truth can be found by poring over this week’s and other recent UN reports, and cobbling together pieces of fact scattered across hundreds of inside pages. They tell a different story than the one presented this week, about a program with five characteristics that the public, the media and HIV-positive women should know:

First, in the UN reports, progress toward ending mother-to-child transmission is not measured by counting the babies protected from HIV. It is estimated by counting the women given drugs to prevent transmission, and then calculating the likelihood that the drugs succeeded. So far, no real data exists that establishes how many infant lives have actually been saved. The claim that an “HIV-free generation” is within reach is based on guesswork, not evidence.

Second, the figures said to represent beneficiaries of “PMTCT” services include not only pregnant positive women who received appropriate antiretroviral drugs (ARVs) and infant feeding counseling and support, but also women who were given nothing more than single-dose nevirapine. Since that drug application is known to endanger the lives of women and children, it should be discontinued, not counted as an achievement.

Third, the vast majority of women offered single-dose nevirapine are deprived of their rights to informed consent. They are told that taking the drug will give their babies half a chance, but they are not informed that drug resistance may jeopardize their own chance of survival. Women have the right to decide for themselves whether that life-threatening risk is worth taking.

Fourth, the UN knows that interventions available in wealthy countries and many other places worldwide can be 99 percent effective. Prescribing effective ARVs, providing correct infant feeding information and addressing the health needs of pregnant women with HIV protects infants from contracting the virus and keeps their mothers alive. Achievement of those goals is neither too complex nor too expensive to consider, if the intent is health equity, not efficiency. But the UN has not pressed hard to ensure that a 99 percent success rate is made available to all. Instead it settles for cheap and easy approaches, which yield low success rates and ignore both babies’ and mothers’ rights to the highest attainable standards of health.

Fifth, UNICEF, the WHO, and UNAIDS appear to have abandoned efforts to support safe breastfeeding. For poor women with limited access to clinics, newly designed Mother-Baby Packs contain take-home ARVs for mothers and babies that extend only about six weeks past childbirth. The drug regimens provided do not last through the 12-month recommended breastfeeding period — and the packs contain no information about exclusive breastfeeding. This runs counter to guidelines revised by WHO in 2010. The health agency now concurs with research showing that HIV-positive women can breastfeed exclusively for six months without risk of transmitting HIV, provided they are given the right information, or ARVs, or ideally, both. Deprived of that guidance and support, mothers face a 15 percent risk that their babies will contract the virus through breastfeeding before reaching age one. The new Mother-Baby Packs do nothing to help mothers avert the risk of HIV transmission during the WHO and UNICEF recommended breastfeeding period.

World AIDS Day announcements strongly implied that success is evident in the number of babies saved from HIV infection. Of all the countries lauded, not one measured its progress by determining whether the babies born to mothers given prophylactic ARVs are now free of the virus, HIV-positive, dead or alive.

Using pass/fail grading systems, countries are said to have achieved the ultimate UN goal for prevention of “mother-to-child transmission” by administering some form of ARV to 80 percent of HIV-positive pregnant women. Equal weight is given to countries that provide the most effective drug regimens and services for both mothers and babies, and to countries that continue to use single-dose nevirapine; that take no steps to prevent nevirapine resistance; that do not provide the continued ARV regimens that protect babies born HIV-negative from contracting the virus later through breastfeeding; that offer no infant feeding information; and that discharge new mothers without first assessing whether they need ARVs for their own health.

Ironically, ensuring that babies remain free of HIV and keeping infected mothers alive and healthy through and well beyond childbirth is easier than any other HIV prevention. Children most likely to contract HIV can be singled out with absolute certainty: their mothers test HIV-positive while pregnant. It is possible to calculate within a few percentage points the best ways to reduce that risk. Needless to say, preventing HIV in a child is only half a success — unless the woman, too, is clinically assessed and treated, a child protected from HIV is placed on a path toward orphanhood.

The UN has focused its attention this year squarely on vertical transmission, since a prevention triumph is more likely there than anywhere else. After decades of inadequate achievement on AIDS, the agencies are desperate to achieve one goal. But if they stay on the current course, the UN will be unfurling its “mission accomplished” banner over the graves of women and children.