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Effectiveness of Anti-Retroviral Drugs in
Prevention of Mother to Child Transmission in Africa
September 24, 2007
Introduction: The Status of HIV and Transmission
In the past year, one of the largest killers amongst the human community has been AIDS. Regardless of reform in political or social action, AIDS is killing as many people each year in sub-Saharan Africa as the number of people who died in the 2004 Indian Ocean Tsunami. AIDS, acquired immunodeficiency syndrome, a disease caused by the infection of the human immunodeficiency virus (HIV) has killed 2.9 million adults and children in the past year alone, while the incidence of new cases over the course of 2006 was about 4.3 million with a prevalence of 39.5 million within the year. (UNAIDS, 2006) Within the past 25 years since its discovery, great developments have been made in the diagnosis and treatment of the virus. The Center for Disease Control has defined the diagnosis of HIV as having a CD4+ T-lymphocyte count of less than 200 per microliter for those ages 13 and above. (Castro et al., 1992) Treatments via anti-retroviral drugs and other cocktails are used and tested in the prevention of the spread of the virus; however, with an incidence rate greater than the death rate for those infected, the prevalence is only getting higher and promoting the spread of the virus by a variety of means from sexual intercourse to illicit drug use.
Home to more than 60% of the prevalence, sub-Saharan Africa ranks as the highest infected population in the world with the pandemic becoming harder and harder to handle everyday. (UNAIDS, 2006) In less than two years, sub-Saharan Africa has already seen an approximate increase of about 1.5 million infections in their prevalence statistics. Overwhelmed by the increase in prevalence, the African population has lost control of the pandemic due to a variety of reasons. According to the CDC, most transmission occurs from sexual contact with an infected person, by sharing needles, or from mother to child before or during birth or through breast-feeding after birth. (CDC, 2007) Although condom use is promoted and other options such as safe needle exchange programs have been implemented, those programs only touch part of the problem. The programs for the prevention of mother to child transmission (PMTCT) addresses the other part of the problem of infants with HIV, orphans with HIV, and a higher strain on the economic structure as there are more children than adults in the community. However, a barrier to the implementation of the PMTCT programs has been the inaccessibility of antenatal care for many women in rural areas, and therefore the PMTCT programs cannot reach full potential without the women coming in for help. US and other non-governmental aid is poured into the region in hopes of developing the programs; however, the question still remains in how to get mothers to come to clinics and overcome the social stigma associated with the disease.
reports “In Lesotho, transmission rates from mother to child are still as high as 37 percent; in Zimbabwe, 100 babies become HIV infected every day.” (Silverton, 2007)
The Botswana Press Agency reports statistics “FRANCISTOWN (Botswana) - About 96 percent of babies whose mothers enroll in the Prevention of Mother to Child Transmission (PMTCT) programme are born HIV free.” (Botswanas PMTCT programme a model for Africa, 2007)
Treatment for the Prevention of Mother to Child Transmission
According to UNAIDS, HIV positive rates of 10–30% are average for pregnant women in sub-Saharan Africa and even higher rates are possible. ([http://www.unaids.org/en/Issues/]). In the battle against the transmission from mother to child, nevirapine is the most common drug used because of its inexpensive costs and simplicity because there are only two doses needed one for the mother while in labor and one for the child soon after birth. (Bulterys et al., 2002) In the developed world, incidence rates of perinatal transmission of the virus has now dipped below 2% through the use of antiretroviral drugs and other behavior modification, especially limited or no breastfeeding for the new born babies. (Bulterys et al., 2002) However, in developing nations such as those of sub-Saharan Africa the PMTCT programs become harder to implement because of behavioral barriers and social barriers to the delivery of health care to the diverse populations.
Another News Network reports
“We have a plan to scale up pediatric ART [antiretroviral therapy] through PMTCT but, even now, when people are in the camps, we have a problem of follow-up” (Uganda: Lack of Rural Health Services Keeps HIV-Positive IDPs in Camps, 2007)
Before considering the behavioral and social ramifications of seeking treatment, the rationale of the treatment needs to be examined first. Nevirapine is a non-nucleoside reverse transcriptase inhibitor (NNRTI), which operates by inhibiting the reverse transcriptase of the HIV-1 strand. HIV-2 has a different conformation and therefore cannot fit in the bonding site for the NNRTI and therefore the drug is ineffective against the less prevalent second strand. Inhibition of the reverse transcriptase prevents the virus from infecting and replicating as the RNA is not transcribed to DNA because the nevirapine blocks the pathway. One problem with the treatment is that resistance is quickly built against the drug if the viral replication is not completely suppressed. (Proudfoot et al., 1995) Initially Boehringer Ingelheim Pharmaceuticals presented the drug as a prototype in 1992 while the company continued further investigation in the effectiveness of the simple preventative drug. (Grob et al., 1992) Then in 1995, Boehringer released the drug for FDA approval and submitted their paper to one of the most prestigious peer-reviewed chemistry journals, the Journal of Medicinal Chemistry. The Food and Drug Administration also offered its approval along with the Centers for Disease Control showing that even non-biased government agencies supported the treatment for the prevention of perinatal transmission. Therefore, the drug and its long-term use since its release are good indications of the effectiveness of the drug.
Effectiveness of the Treatment with Respect to Patient Behavior
Although the drug has proven to be an effective treatment option, the problem then arises within the patient population. Weak economic structure, along side a poor healthcare infrastructure provides difficult conditions for the distribution and administration of the drug. Although the drug has shown data of reducing vertical transmission rates from 35-40% to 5-10%, the reduction in risk is only if mothers seek help during antenatal care and labor. (CDC, 2004) Although the regimen is simple, only trained health-care staff can administer the drugs. The first dose, which is taken during labor pains, is usually given to the mother after the last checkup during antenatal treatment, but the mother must return to the health care facility to deliver the baby so that the healthcare workers can give nevirapine to the neonate. The high possibility of developing resistance has led to the implementation of this system because if the drug is incorrectly administered it can cut chances of the child ever having a chance without the disease. (Bulterys et al., 2002)
A couple of alternative procedures for the passing on of medication have been created for the spread of the treatment. The first is training traditional local birth attendants in the use and administration of the drug because they are often the only point of contact between mothers giving birth and any health care. Usually there is a stigma associated with HIV in sub-Saharan Africa, which discourages many people, including pregnant mothers, to seek help and counseling to deal with the disease. Instead, the mothers do not seek antenatal care and birth at home, which increases the chances of complications and is a risk factor for transmission. Even though, the services are free, other costs such as transport and food are barriers for the women to seek treatment. Therefore, Bulterys points out that health professionals need to begin teaching the local birth attendants how to test for HIV and administer the drugs, so that the women who come to them can receive adequate care. The other obstacle is providing alternatives to breast-feeding. Although, the nevirapine may be administered successfully, the risk of transmission increases again as many women cannot afford baby formula or other alternatives to breast-feeding to care for the neonates. Consequently, the women resort to breast-feeding and increase the risks of transmission. In response, different NGO’s have implemented systems of encouraging breast-feeding for a limited period, usually three months, and have accepted the costs of such a decision. However, they recognize that the breast-feeding must stop there and alternative forms of nutrition must be used afterwards, when the baby has developed a better digestive system. (Bulterys et al., 2002)
These alternatives to adjust for the behavior of the sub-Saharan African population provide hope to the vision of the end of HIV/AIDS spreading across the continent.
The spread of HIV/AIDS throughout the world and more specifically in sub-Saharan Africa is grabbing more and more attention from governments and organizations in hopes of changing the outcome of a continual spread of the pandemic. However, social stigma and a weak economic system are promoting the spread as people avoid getting tested and even more cannot get tested because visiting the clinics is too expensive. Treatment in most sub-Saharan African countries is now free, but other costs still prevent people from attaining treatment. The United States has attempted to help through plans, but with respect to other budgets, the amount devoted to such a large pandemic is menial and not nearly enough. Many African leaders are now frustrated with the games the developed world plays with their people and their economy as their indebtedness rises.
The Guerilla News Network reports
South African President Thabo Mbeki accused the U.S. of using Africans as “guinea pigs.”
Botswanas PMTCT programme a model for Africa. (2007). Retrieved September 19, 2007, from http://www.gov.bw/cgi-bin/news.cgi?d=20070911&i=Botswanas_PMTCT_programme_a_model_for_Africa
Bulterys, M., Fowler, M. G., Shaffer, N., Tih, P. M., Greenberg, A. E., Karita, E., et al. (2002). Role of traditional birth attendants in preventing perinatal transmission of HIV. British Medical Journal, 324(7331), 222-225.
Castro, K. G., Ward, J. W., Slutsker, L., Buehler, J. W., Jaffe, H. W., & Berkelman, R. L. (1992). 1993 Revised Classification System for HIV Infection and Expanded Surveillance Case Definition for AIDS Among Adolescents and Adults CDC.
CDC. (2004). Introduction of routine HIV testing in prenatal care--Botswana, 2004. Morbidity and Mortality Weekly Report, 53(46), 1083-1086.
CDC. (2007). How HIV is transmitted. Retrieved September 19, 2007, from http://www.cdc.gov/hiv/resources/factsheets/transmission.htm
Grob, P., Wu, J., Cohen, K., Ingraham, R., Shih, C., Hargrave, K., et al. (1992). Nonnucleoside inhibitors of HIV-1 reverse transcriptase: nevirapine as a prototype drug. AIDS Research and Human retroviruses, 8(2), 145-152.
Proudfoot, J., Hargrave, K., Kapadia, S., Patel, U., Grozinger, K., McNeil, D., et al. (1995). Novel non-nucleoside inhibitors of human immunodeficiency virus type 1 (HIV-1) reverse transcriptase. 4. 2-Substituted dipyridodiazepinones as potent inhibitors of both wild-type and cysteine-181 HIV-1 reverse transcriptase enzymes. Journal of Medicinal Chemistry, 38(24), 4830-4838.
Scheff, L. (2004, December 20). Stepping over bodies on the way to market. Retrieved September 19, 2007, from http://www.gnn.tv/articles/article.php?id=1011
Silverton, K. (2007, September 19, 2007). New hope for the children of Lesotho, from http://news.bbc.co.uk/2/hi/programmes/breakfast/6692619.stm
Uganda: Lack of Rural Health Services Keeps HIV-Positive IDPs in Camps. (2007). Retrieved September 19, 2007, from http://allafrica.com/stories/200708290858.html
UNAIDS. (2006). UNAIDS/WHO AIDS Epidemic Update. Retrieved September 19, 2007, from http://www.unaids.org/en/HIV_data/epi2006/default.asp
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