San Francisco Chronicle - July 29, 2001
Tom Abate, Chronicle Staff Writer

"It was extremely sobering," Brune said during a crackling long-distance telephone interview, "when we're looking at a program to deliver state-of-the- art AIDS medicines, to realize that the local health authorities can't even provide basic sanitation."

Undaunted, the 31-year-old graduate student is helping change one tiny square in the tragic mosaic that is AIDS in Africa. While the world seems paralyzed by the magnitude of the crisis, she and Oakland pediatrician Daniel Robbins are focusing on mother-to-child transmission of AIDS in Zimbabwe.

"We're talking about 60,000 children a year in Zimbabwe alone," said Robbins. "If they do contract the disease, they'll never live to take their first step."

As a pediatrician, Robbins is attuned to the tragic frequency with which HIV-infected mothers pass on the disease during childbirth. During last year's International AIDS Conference in Durban, South Africa, he heard researchers describe how a pilot project in Uganda cut the rate of mother-to-child transmission of HIV in half by giving one dose of the drug Nevirapine to mothers during labor and another single dose to the infant after birth.

Now Robbins, who administers a small trust fund dedicated to Zimbabwe, is working with Brune to bring that two-pill regimen to the southern African country's 26 birthing clinics. Their objective is to save some of those 60,000 children who might otherwise never live long enough to take that first step. "For $20 a child, we think we can save half of them," Robbins said.

Brune joined the effort last November, when she heard Robbins discuss his plans during a career day at UC Berkeley's School of Public Health. Brune approached him to discuss a field internship.

"The topic really resonated with me," said Brune, who had once worked with crack babies at a clinic in St. Louis. "I felt like this was something I could do."

At the end of May, after months of preparations by fax and phone, Brune flew to Harare, Zimbabwe, to help Rosemary Nheta-Todd, an African public health expert hired by Robbins, get the program up and running in one clinic in Epworth, a squatter town about 8 miles from the capital.

"We were worried at first about the stigma attached to AIDS, that people would not normally want to know their HIV status," Nheta-Todd said in a telephone interview. "It is a very delicate issue to bring up when you're sitting down with a mother."

In fact, most of the estimated $20-per-child cost of the program derives from the need to train midwives and nurses how to broach the testing issue with expectant mothers. Other expenses include the cost of the HIV tests and the counseling required to explain the child's treatment option if the test comes back positive.

The drug itself will be free. Robbins said Nevirapine's manufacturer, the German drug firm Boehringer Ingelheim, has pledged to provide the $2 pills at no charge.

In addition to training, counseling and testing, the program will bear the expense of record keeping. Robbins said health authorities in Zimbabwe were initially reluctant to approve a national program, out of concern that the Nevirapine treatment was too new and experimental. Robbins promised that in addition to dispensing the pills, the program would track the results to make sure that the treatment saved half of the children born at risk of AIDS.

Brune arrived in Zimbabwe in time to help initiate the pilot program in Epworth. A report on its first month of operation contained both positive and negative signs. Of 221 women who visited the clinic for prenatal care, 84 women agreed to take an HIV test, a success rate of 38 percent.

"We think we've done pretty well so far," Nheta-Todd said. "The crucial thing will be how many of those tested come back for the results."

In that regard, the numbers were less encouraging. Fewer than 1 out of 3 women tested in the first month returned for the results by the time the report was written. They may have suspected the odds were bad -- about 40 percent of the women who agreed to take the test turned out to be HIV-positive.

Although the experience at Epworth may seem like a tiny, tentative start, Robbins was thrilled when the Elizabeth Glaser Pediatric AIDS Foundation, based in Santa Monica, recently agreed to help expand the pilot program nationwide, which could cost more than $1 million a year.

While the mother-and-child program is still getting under way, international AIDS fighters such as Stanford University's David Katzenstein are giving it an A for effort.

"Dan (Robbins) has done a masterful job of using the limited resources and solid reputation of the (Kapnek) Trust to work with a government that is financially and politically beleaguered," Katzenstein said. "The project is in its infancy, but it's a very important step."

Meanwhile, Brune continues to get an education in the realities of practicing medicine in a nation where a patient can die on the way to the hospital because the ambulance has run out of fuel.

"I wrestle with the demons that plague me," Brune wrote in a recent e-mail in which she confessed her sense of inadequacy, given how great is the need. "I listened with a lump in my throat as (nurse-midwife) Stella (Makunike) confided in me . . . what a thankless job nurse-midwiving is," Brune wrote. "(They) are dealing with human life daily, with blood and urine and feces, with body fluids and dangerous situations" -- and the only way to ensure a steady supply of gloves is to threaten to strike.

"I struggle with the fact that while we are hopefully saving the lives of hundreds of children, we do not yet have the resources at our disposal to provide so much as palliative treatment for their parents," Brune wrote, adding plaintively, "No easy answers yet." .

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