Failing Women and Children
By Stephen Lewis and Paula Donovan
June 1, 2009
The world's policymakers have been cooking the statistical books on HIV services to mothers and babies. AIDS-Free World's co-directors Stephen Lewis and Paula Donovan wrote the preface to Failing Women, Failing Children: HIV, Vertical Transmission and Women's Health, the International Treatment Preparedness Campaign's report, "Missing the Target 7," based on research in six countries. The report was launched in May 2009 and received instant attention.
A year ago, researchers and activists set out to understand why the world is missing the target on a goal it set back in 2001: slash the rate of HIV infections from mothers to babies by half. We found that the global institutions in charge have been cooking the statistical books. Despite the success they've proclaimed - One-third of the way there, and closing in on the goal! - they're nowhere near the target. They haven't even been aiming for it.
On paper, the global programme called "Prevention of Mother-to-Child Transmission" is a model of sound design and human rights principles. Its four prongs, guided by ten sound principles, cover the gamut from prevention to counseling to treatment.
In practice, the programme is a shameful example of double standards.
We remember well the elation in the mid-90s at our former offices in UNICEF headquarters, when results emerged from clinical trials in Uganda and Thailand. The risk of vertical transmission - passage of the virus from one generation to the next -- could be slashed, thanks to simple, relatively low-cost drug regimens for mothers and infants. An 11-country pilot project was spearheaded by UNICEF and assisted by the World Health Organization, and the good news/bad news rollercoaster ride began.
The first low point came with the pilot projects' title: "Prevention of Mother-to-Child Transmission", or PMTCT - a name that implies that mothers are the source of the virus, rather than the latest link in a long chain of transmission.
Finally in 2000, more good news: the pharmaceutical company Boehringer Ingelheim announced that for the next five years, any developing country could request free supplies of its anti-retroviral drug nevirapine - a single dose of which, administered during labour to an HIV-positive woman and immediately after birth to her baby, was then believed to cut by half the risk of transmission (now we know that it's actually two-fifths). Buoyed by the possibilities, the world's governments made a commitment in 2001 to reduce infant infections by 20% by 2005, and 50% by 2010.
Suddenly, silence. Over the next several years, in report after report issued by UNAIDS, the global Prevention of Mother-to-Child Transmission programme barely got an honorable mention. By 2003, 95% of the pregnant women in sub-Saharan Africa, the pandemic's epicenter, were not receiving any services at all to prevent vertical transmission. Like so many other programmes targeting women, everyone and no one at the UN seemed to be in charge. UNICEF went back and forth on infant feeding. Wealthy nations were bringing their transmission rates down to negligible levels. But for poor women in developing countries, coverage stalled at 9% as rates of pediatric infection soared. Scale-up was slow, uptake was low, and no one seemed to know why. Experts offered reasons: women refuse testing; women don't return for test results; women given drugs don't take them as instructed. The problems, it seemed, were caused by the women.
In the meantime, researchers were concluding that for most of the world's babies born to mothers with HIV, the best guarantee of HIV-free survival at a year and a half was a diet of nothing but breastmilk for the first six months. But most women didn't breastfeed exclusively. The UN's ardor for explaining breastfeeding to women diminished as the issue became more complex: babies needed to be fed all breastmilk, or all breastmilk replacements (formula); a mix of the two could kill them. Before a mother chose not to breastfeed, she'd first need to assess whether breastmilk substitutes met five criteria: acceptable, feasible, affordable, safe and sustainable. And then the most difficult risk of all to weigh: without the nutrients and immunities in mother's milk, the baby could die of other causes. Before long, in developing countries that encouraged women with HIV to avoid breastfeeding and provided formula, many babies did die.