Wall Street Journal - September 26, 2003
Michael Waldholz

At an aging hospital on the edge of the rough-and-tumble Soweto section of Johannesburg in South Africa, two determined doctors using a proven drug have managed to reduce mother-to-child HIV transmission by almost two-thirds.

The success story of the program, called Preventing Mother-to-Child Transmission, or PMTCT, is not just about money -- though that's an important part of it. It's also about the will of the doctors to improve their patients' plight.

Unfortunately, it is the lack of both adequate financial resources and single-minded determination that seems to be missing in all too many sub-Saharan African countries. The UN report describes, with a spate of sad statistics, how international efforts are failing to stem the rampaging epidemic that has already claimed 15 million lives in the past 15 years.

Those figures are especially disturbing, as they come two years after a loud and widely-embraced call for action by a special week-long session of UN in June, 2001. (See the report1.)

The report notes that world-wide spending to battle AIDS will reach $5 billion this year, double the amount of three years ago. Yet, the report also points out that the amount is still only half of what existing health programs in the most severely distressed areas could consume right now.

Most troubling, many goals that more than 100 UN member nations agreed to meet by this year, such as simply setting up national HIV/AIDS prevention and treatment programs, aren't being met, a clear indication that many nations ravaged by HIV/AIDS have yet to make fighting it a top priority.

Also, a pledge made by the nations at the UN session to treat three million people with drugs by 2005, an effort that will require the will and huge amounts of cash, will fall far short of its target, the report predicts.

The local response by nations with high infection rates and the financial support from rich industrialized countries "has been pathetically low," said Paul De Lay, an official of UNAIDS, the UN agency that oversees action against the disease. Repeating a refrain he has said many times before, UNAIDS' longtime executive director Peter Piot this week called the failure to meet the UN goals "a dramatic wake-up call to the world."

The dismal response noted in the report and the sheer scope of the global HIV problem can sometimes make fighting the virus seem hopeless. That is why the small successes that can be used as models to build on elsewhere continue to be worth identifying.

One of the best examples is Soweto's PMTCT program based in the 3,000-bed Chris Hani Baragwanath Hospital, possibly the world's largest medical center. Bara (as it is often called by locals) is the main source of primary care for many of the millions of mostly poor Soweto residents.

Since 1996, it has turned a promising experiment in preventing newborn infections into a standard of care many African nations would do well to replicate.

The PMTCT program works by administering a single dose of an anti-AIDS drug, Viramune, to women just prior to delivery. Another smaller dose is then given to newborns.

Crucial to the program's success is that Viramune is being made available for free by its manufacturer, the German drug giant, Boehringer-Ingelheim Gmbh. The company has promised to make similar donations to any country that sets up programs like the one at Bara. But many sub-Sahara nations haven't made this issue a priority yet, or say they don't have the funds to pay for counseling services, medical providers and tests for pregnant women.

"A dramatic increase in resources -- in personnel and money -- would allow us to set up many more programs throughout Africa," says Kate Carr, president and CEO of the Elizabeth Glaser Pediatric AIDS Foundation of Los Angeles, which helps fund the Bara program at the hospital and in 13 related clinics in Soweto at a cost of about $400,000 a year. Ms. Carr says the foundation now has received 120 funding requests that would cost about $35 million to support, a sum beyond the pediatric AIDS Foundation's resources.

But the Bara success also highlights a host of other hurdles beyond money.

One is local leadership. The program was essentially the brain child of two Bara dynamos: Glenda Gray, a young and spunky pediatrician, and James McIntyre, a middle-aged obstetrician. By the mid-1990s, the two colleagues were being overwhelmed by sick and dying mothers and their newly-infected offspring, not to mention a host of tough-to-treat social ills plaguing these orphaned children.

By 1998, several studies in the U.S. and elsewhere showed that small doses of anti-AIDS drugs could block the spread of the virus from mother to child. Indeed, the treatment, now standard in many rich nations, has meant that fewer than 200 children are being born infected with HIV in the U.S. each year, down from 1,500 to 1,750 infected a year prior to 1996.

Soon after the drug's effectiveness was proven in the U.S. and elsewhere, Drs. Gray and McIntyre created a test site at Bara that within a few months showed that: 1) an easy-to-use, low dose of the drug reduced transmission; 2) many women were able to use the drug successfully even if they delivered their children at home; and 3) as word spread about the drug's effectiveness and availability, many women overcame the stigma of being infected that previously kept them from getting tested at all.

At the same time, the doctors paid attention to problematic local practices. For example, many mothers whose newborns were protected from virus by the drug were later infected through breast feeding. The Bara team persuaded many women to use formula, even though that goes against local practice.

Their initial study was especially profound because the two doctors were able to run it despite strong resistance from the South African government, which, until recently, has argued against buying large quantities of anti-AIDS medicines, calling them potentially toxic and too expensive.

"Glenda and James have produced an enormously effective program that is gaining a lot of attention in other parts of Africa," says Larry Phillips, a Boehringer-Ingelheim executive in charge of the company's AIDS business.

Mr. Phillips says the company will ship about 166,000 doses of the drug this year for PMTCT programs. But he figures the number could be many times higher if more communities would set up programs.

The challenges in Soweto aren't over. New data shows that more than 90% of 16,0000 women seeking pre-natal care in Soweto over the past two years are now agreeing to be tested. Yet only about half those found to be HIV positive are accepting treatment, a figure suggesting the Bara team still has an uphill battle to wage.

Still, the Bush administration says it will spend $15 billion over the next five years helping fight HIV/AIDS in Africa and other poor nations.

So far very little of that money has been released, largely because officials are uncertain where to spend it. With 2,000 newborns being infected each day, according to UNAIDS, backing programs like the one at Bara -- run by doctors similarly determined -- would be a good place to start.

Write to Michael Waldholz at mike.waldholz@wsj.com

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