Many people think it's the single greatest victory in AIDS: Giving the drug AZT to pregnant women halves the chance that they will pass on the virus to their newborns. It's being hailed as a vaccine for babiesand scientists, industry leaders, and activists have gone to extraordinary lengths to make it affordable in the Third World, where 90 percent of all infected people live.
Researchers devised a special "short-course" regimen that lowered the cost of AZT by prescribing it only during the last few weeks of pregnancy. Glaxo Wellcome, the maker of AZT, has offered to slash the price for developing nations by up to 70 percent, a price the company says earns no profit.
So it came as a shock when South Africaone of the wealthiest nations on the continentannounced in October that it will not make AZT available to pregnant women. South Africa has even put on ice pilot programs designed to test the feasibility and cost-effectiveness of the regimen. "The government cannot afford it," explains Vincent Hlongwane, spokesperson to health minister Nkosazana Zuma. "That doesn't mean we don't care about those children, those women," he insists. But the government has launched a broad-based AIDS awareness campaign, and "the money available would best be utilized for those campaigns."
The decision not to fund AZT received unanimous support from South Africa's nine regional health officers, but it has sparked strong protest from many local doctors and AIDS activists, who insist that the issue is not money but priorities. "It's completely unacceptable," declares Morna Cornell, director of the South Africa AIDS Consortium, which represents about 70 HIV organizations. She says that the government could provide AZT for less than one percent of its health budget. And she points to a study by a group of leading South African researchers showing that providing the drug to infected mothers will actually save money in the long run by averting the cost of caring for babies who would have developed AIDS. "We don't dispute that at all," concedes Hlongwane. "This decison is not based on cost-containment or cost-effectiveness. It's purely a question of affordability." Such reasoning spurred an economist to write a commentary in the Johannesburg Mail & Guardian castigating the AZT decision as "economically illiterate and shockingly ill-informed."
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Whatever its merits, South Africa's decision is certainly dismaying. Just this summer, the World AIDS Conference in Geneva featured the theme "Bridging the Gap" between rich and poor countries, and various pilot programs were announced to deliver AIDS drugs to developing nations. But this latest news shows how daunting the challenge of delivering anti-HIV medicine is.
South Africa may indeed be wealthier than its neighbors, but as Hlongwane points out, "Large sections of our population still do not have access to clean water, proper housing, or electricity. More than 48 percent of the population is functionally illiterate. More than 38 percent are without jobs." So even while officials at the United Nations AIDS program, UNAIDS, are scrambling for some way to enable South Africa to provide the drug, they worry about a domino effect. Isabelle DeVincenzi is coordinating an 11-nation UNAIDS program to test the real-world feasibility of the AZT regimens. "Our biggest anxiety," she says, is that "other countries might say, 'South Africa is not going to do it so why should we?'"
Meanwhile, infected women are "desperate," Cornell says, because "they know theres something that can reduce by 50 percent the chance their babies will get the virus." Indeed, pregnant HIV-positive women in Soweto staged their first AIDS protest rally last Saturday, demanding that the government reverse its AZT decision.
According to the latest UNAIDS estimate, South Africa has the world's fastest growing epidemic. More than 13 percent of all adults in that country are infected with the virus, and among pregnant women, the rate is even higher. In some areas, over a third of all pregnant women are infected with HIV.
But reducing mother-to-child transmission is far more complex than merely getting AZT pills to pregnant women. Indeed, with Glaxo having lowered the price, the main cost is the counseling required to make sure pregnant women understand their complicated options. Moreover, the issue is tangled by factors ranging from the social politics of breast-feeding, to HIV stigma, to the health minister's stubborn personality and troubled AIDS history.
While AZT can halve mother-to-child transmission, breast-feeding can also transmit the virus, diminishing the gains from giving AZT during pregnancy. But providing infant formula has risks, too. Mother's milk contains important immune-system antibodies that can help babies ward off diseases such as diarrhea and other infant killers. Formula doesn't confer these benefits, and if it is prepared with contaminated water, it can actually endanger babies.
These public-health concerns are inflamed by politics. In the 1970s, infant-formula manufacturers such as Nestlé were accused of profiteering at the expense of Third World babies. Ever since, African health care professionals have strongly urged women to breast-feed, and it is not yet clear that the risks of contracting HIV outweigh the dangers of using formula.
Finally, infected mothers might stick to breast-feeding to avoid the stigma of HIV. Breast-feeding is culturally important in most of Africa, so using formula might raise questions and flag mothers as HIV positive. In Soweto, studies show that fewer than 15 percent of infected mothers refuse formula, but it is not known how rural South African women will react. In other African countries, such as the Ivory Coast, women have resisted formula in much greater numbers.
These questions could have been answered by South Africa's pilot studies, say local researchers. But the government has put those studies on hold.
The AZT decision will only intensify the conflict between AIDS activists and health minister Zuma, a complicated figure known for being intelligent and committedbut also headstrong. "We've had an enormously difficult relationship with the minister," says AIDS Consortium director Cornell. "It's been one pitched battle with her after another."
Zuma crafted a well-regarded AIDS plan early in her tenure, but she has since made two high-profile blunders. The first was a lavish, multimillion-dollar musical, Sarafina II, that was supposed to impart HIV prevention information. However, it was roundly condemned for sending mixed messages, and it was astronomically expensive, consuming one-fifth of the governmnent's AIDS budget. Zuma tried to avoid responsibility by claiming the musical had been funded by the European Union, but that was not true. Later, Zuma championed a drug called Virodene as a treatment for AIDS, even though it had not been rigorously tested and despite the fact that most of South Africas medical establishment decried it as worthless.
Zuma also possesses a famous stubborn streak, and according to several people who have worked with her, she digs in her heels hardest when challenged. But UNAIDS and Glaxo insist the door is still open, and the very people who will bear the brunt of Zuma's decisionblack South African women, especially those who are poorare the people she has spent her life fighting for. A staunch ANC member who has Nelson Mandela's absolute loyalty, she made her name working to improve community health.
So it's people like Florence Ngobeni who just might change her mind. A Soweto woman who lost a daughter to AIDS last year and now works as an HIV counselor, Ngobeni is organizing other women to rally against the ministry of healths decision. "I'm very angry and very ashamed of my government," she says. She worries about women who will have to suffer what she didthe loss of a childeven though that can now be prevented. And she worries for herself, too. "If the government says no to something like this that's affordable, what about me when I get sick? Will I get treatment? Im not even talking about antiretrovirals," she says. "What about simple things like diarrhea. Will they treat me?"
Other women apparently feel the same way. Almost 60 showed up to a meeting organized by Ngobeni, twice as many as she had expected. Pregnant, HIV-infected women have not been vocal activists, like gay men. Often poor and worried about the reaction of their husbands and family, they face a myriad of difficulties. But this decision may have galvanized some of them. "For the first time in my life," says Ngobeni, "I see HIV-positive women standing up to these problems."
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