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Saving the babies: A victory in Africa

Mark R. Dybul, the US global AIDS coordinator, said Botswana's results were 'extremely impressive.' Mark R. Dybul, the US global AIDS coordinator, said Botswana's results were "extremely impressive." (STEFAN ZAKLIN/European Pressphoto Agency)

WASHINGTON -- The southern Africa country of Botswana has reduced the rate of HIV transmission rate from mother to child to less than 4 percent, providing fresh evidence that several hundred thousand babies in the developing world can be saved annually from acquiring the deadly virus.

The success in Botswana recorded this year, according to specialists, is due to political support and several policy decisions, including the testing of all pregnant women for HIV unless they refuse; providing HIV test results in 20 minutes to the expectant mothers; and for those woman who are HIV-positive, giving dual drug treatment -- four weeks of AZT, and then a single dose of nevirapine at birth to mother and child.

It represents the first time that a developing country with a high prevalence of HIV has lowered transmission rates to levels approaching those in rich nations. In the United States and Europe, fewer than 2 percent of babies born to HIV-positive pregnant women have the virus. Parts of Thailand and the Western Cape Province in South Africa also have recorded extremely low HIV transmission rates.

The challenge for Botswana is especially pressing: 34 percent of its pregnant women, roughly 14,000 people, are HIV-positive.

Ambassador Mark R. Dybul, the US global AIDS coordinator, said Botswana's results were "extremely impressive. That's getting down to what we've be able to do in the United States and Europe. It's a great model of how you can do it" in Africa. The US government is encouraging other countries to adopt parts of the Botswana model; already, Cameroon, Kenya, and Zambia, among others, have started testing all pregnant women for HIV, unless the women specifically decline the test.

With no interventions, the risk for an HIV-positive woman to pass on the virus to her baby is 30 to 35 percent. With a single dose of nevirapine, that risk is cut roughly in half.

In the cases where a mother passes HIV to her child, roughly two-thirds occur during birth and one-third during breast-feeding. Botswana provides free infant formula for one year in hopes of lessening HIV transmission, but many specialists argue that HIV-positive mothers should breast-feed because mother's milk protects babies from a host of infectious diseases.

On the basic question of protecting children at birth, though, there's no debate about the lack of services. UNICEF estimates that just 11 percent of HIV-infected pregnant women have access to medicine that would prevent the transmission of the virus. Worldwide, roughly 500,000 babies annually contract the virus from their mother -- the vast majority in Africa -- totaling 12 percent of the new HIV infections last year, according to UNAIDS.

A 2006 study in the KwaZulu-Natal province of South Africa, a nation that boasts the strongest economy in sub-Saharan Africa, found a 20.6 percent HIV transmission rate from mother to child. Researchers blamed the high transmission rate on low rates of HIV testing and poor prevention and support services for pregnant women.

Dr. Catherine M. Wilfert, scientific director of the Elizabeth Glaser Pediatric AIDS Foundation's prevention of mother-to-child transmission program, said one major reason for the difference between Botswana and KwaZulu-Natal is that Botswana's government made stopping HIV transmission at birth a priority and the South African province did not.

"Botswana has had the political will to roll out a national program," said Wilfert, whose organization supports programs stopping HIV transmission from mother to child in 17 countries, which does not include Botswana. "There are not many African nations that have done likewise."

Wilfert said researchers have known about the benefits of using AZT in preventing transmission since 1994, and nevirapine since 1999, "so we have long had the knowledge to put these things in place. It's the logistic issues and the political commitment that are probably the challenges for countries."

Success didn't come quickly in Botswana. For a few years after the program's inception in 2001, high rates of pregnant women did not test for HIV. In 2004, President Festus Mogae announced that anyone seeking care at a health facility would receive an HIV test -- unless they refused outright. That decision pushed testing rates up to more than 90 percent.

In 2005, the government also changed the way it tested babies for HIV, choosing a method developed in South Africa that used dried blood spots. Using DNA technologies, the babies' dried blood was tested for the HIV virus. Prior HIV tests for babies checked for antibodies, which fight off the virus. But mothers naturally pass on antibodies to the baby and remain detectable up to 18 months after birth, making such tests inconclusive as to whether the baby has the virus or the mother's antibodies. Waiting until 18 months for a foolproof test, though, can be foolhardy: As many as half of the HIV-positive babies will have died by then.

In a pilot project using the dried blood spots to test for HIV, the government found that 7 percent of 1,917 infants born to HIV-infected mothers had the virus in 2005. Satisfied that the tests were accurate, the government last year offered it nationwide. A follow-up study from November 2006 to February found that just 51 of 1,300 babies tested were HIV-positive, or 3.9 percent.

The new tests have lifted spirits of everyone involved, as health workers and families can learn the baby's HIV status as early as six weeks after birth, Dr. Tracy Creek, a medical epidemiologist at the US Centers for Disease Control and Prevention, said by phone from Gaborone, Botswana's capital.

"The testing is serving as a powerful morale booster for everybody -- for health workers, who are finally seeing their work succeeding, and for the mothers, who almost all are being rewarded with a [HIV]-negative baby," Creek said. "With the dramatic increases in HIV funding around the world, this can be done anywhere."

Dr. William Jimbo, chief of the prevention of mother-to-child transmission program for BOTUSA, a joint collaboration between CDC and the government of Botswana, cautioned that such programs need time to set up and money to train workers and buy laboratory equipment.

Wilfert, the Elizabeth Glaser Foundation doctor, agreed, but said it could be done.

"Other countries should say, 'Look what they did, we can do that, too,' " she said.

John Donnelly can be reached at donnelly@globe.com.

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