Inter Press Service - December 8, 1999
Teena Amrit Gill

This was hailed as good news, since most health care systems in developing countries could not afford long courses of AZT for pregnant women, as normally prescribed in northern countries.

The new trials with short courses were considered a way to achieve similar results at lower cost.

But now, two years later, doubts are beginning to surface around in medical and activist circles over the wisdom of using such a short, monotherapy course of AZT on pregnant mothers.

In Thailand too, despite widespread use of the short regimen AZT therapy for HIV-positive mothers, some voices of concern are beginning to be heard regarding the safety of the treatment for the mothers involved.

A course of AZT, also known as zidovudine, for the pregnant women is known to reduce HIV transmission to as much as 10 percent from the earlier rates of transmission of 25-30 percent.

The main reason for using the short regimen is financial, as it costs just 80 U.S. dollars against nearly 1,000 dollars for the longer course. But activists say this regimen has been adopted without enough precautions about the possible harmful toxic effects of the drug.

"Other than financial reasons, we also tend to use the shorter regimen because in northern Thailand women tend to come to antenatal clinics only later in their pregnancy," says Dr. Marc Lallemant, director of the Perinatal Prevention Trial, Thailand.

"Therefore it is more practical to give them the drug during the latter part of their pregnancy," he explains.

The trial is being conducted jointly by the U.S.' Harvard University, the Thai Ministry of Public Health and the Institute for Research and Development (IRD) in France amongst others.

However, the use of monotherapy AZT, and its testing on Thai women before its risks have been assessed, has raised a number of questions, not just in Thailand but across the world

"Why is it," asks a medical student who did not want to be named, "that AZT is mostly given to pregnant HIV positive women in the West as a multiple therapy drug, and over long periods, while here it is used alone and for such a short period?"

While research on the possible long term toxicity of using AZT on both mother and child is ongoing, activists and some medical professionals say the Thai government has been too hasty in the use of the drug without any plans to monitor its possible side effects on either mother or infant.

"At the moment it is not routine to see what the side effects of the drug are on the mother," says Piyada Kunawararak, chief of the Ministry of Public Health's Communicable Disease Control Centres Promotion and Implementation Section.

In Chiang Mai "it is not routine to see what the side effects of the drug are on the mother," Piyada stresses.

By the end of the decade it is estimated that more than 100,000 children under the age of 15 will have lost their mothers to AIDS. By 2005, this figure will more than double, to almost 232,000. Close to one million Thais are known to have HIV/AIDS.

According to Thailand's National Economic and Social Development Board (NESDB) by 2000, 63,000 children will be infected with HIV and 47,000 will die of AIDS. Between 5,000 to 8,000 newborn children are infected with HIV every year in Thailand, or 10 percent of the new infections in the country.

At present AZT is freely available in all government hospitals and health centres in the six most highly affected provinces, in upper Northern Thailand, and is in the process of being provided across the entire country.

The short course available to pregnant women is administered for about a month before delivery, and is then given to the newborn child over a period of one week.

This is despite the fact that clinical trials in Thailand by Harvard University together with others including the Thai Ministry of Public Health, have stopped using this very short regimen.

"We immediately stopped using the shortest treatment amongst our four different treatment arms," says Dr Marc Lallemant from the French Institute of Research and Development, also participating in the trial, "because transmission rates were far too high."

Despite this, the Ministry of Public Health is continuing with the current regimen. With over 85 percent of women in Thailand attending antenatal clinics, the coverage is expected to be extremely wide and successful.

Since Thailand's economic crisis in mid-1997 funding has completely dried up for the treatment of HIV/AIDS patients, unless they are participants in research programmes. But there is no shortage of funds for pregnant seropositive women.

"There is obviously an overall policy to prevent as many newborn children from being born HIV positive as possible," says an academic working on HIV/AIDS-related issues.

"Not only because the costs of taking care of these infants is even higher than those of giving them and their mothers AZT but also because it is already often too late to prevent the pregnancy," he adds.

Few are however informed about recent medical research on AZT.

American studies have warned that the long-term toxicities of in-utero exposure to antiretroviral agents for the mother and infant are not yet known. However, they note that "zidovudine has clearly been shown to have genotoxic effects in mice, monkeys, and humans, and has also been associated with carcinogenic effects in mice and monkeys".

It is also known that many women tested HIV positive in the first trimester of their pregnancy, are often told to abort their child by medical staff.

Since a large percent of pregnant women, especially in northern Thailand where the epidemic is most pronounced, only attend antenatal clinics toward the end of their pregnancy, the only remaining choice available for them is usually AZT. More than 80 percent of women in Bangkok hospitals are estimated have abortions when they learn about their seropositive status.

In cities like Chiang Mai and Chiang Rai in northern Thailand, 30 to 40 percent of women go in for abortions, which are illegal and often carried out secretly and in unsanitary conditions.

Very few know there is a 70 percent chance that their child will not be infected with HIV.

Given the options HIV-positive women have, says a research student, "it is not surprising that many would choose to take AZT despite possible risks, which most are probably not even informed about."

However, as activists especially in Africa are arguing, there must be more attention paid to possible risks. And if one of these is the actual shortening of the women's own lifespans, then what are the options available to their early orphaned children.

In Thailand, the state has virtually washed its hands off the responsibility of HIV/AIDS since the onset of the economic crisis in mid-1997, other than providing AZT to seropositive pregnant women. No other drugs both anti-retroviral or for opportunistic infections are available.

Counselling is ad hoc. Once the AZT treatment is complete the women and their children, most of whom are very poor, are left to fend for themselves.

Though the Ministry of Labour and Social Welfare still gives 500 to 1,000 Baht (13-26 U.S. dollars) monthly to those living with the virus, this is seen as almost a joke.

Laughs a NGO worker here: "The money is only given to those in the third stage of AIDS, which is when the person is almost dead. And then they are expected to go and collect the money on their own. It's absolutely ridiculous." (END/IPS/ap-hd-he/tag/js/99)
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