I am getting married next month, and I am so eager because I know I will have children. That is what I have always wanted. But I am also afraid of AIDS. What if one of us has HIV? (Anastasia, 19)
My partner is unconcerned about my serostatus. I have told him over and over again I have the virus. But he never believed me and insisted on having a baby. Now my child is dying of AIDS. (Christine, 34)
Anastasia and Christine,* both from Tanzania, are at two very different stages of their lives, yet share a concern that is nearly universal for African women: motherhood.
*Both names have been changed to ensure confidentiality.
Throughout the continent, most women want to have children, who are considered essential to self-fulfillment and family happiness. A childless woman can become an object of pity -- vulnerable to abuse or abandonment by her male partner--for whom only the most tenuous social role exists.
But now the desire for children competes with a new concern: fear that a newborn may be infected with HIV. The virus that causes AIDS can be passed from mother to child, either in utero, in the birth canal, or postpartum through breast milk. It's estimated that by the year 2000, as many as 10 million children worldwide could be infected with HIV--most through mother-child transmission--and more than 90 percent of them will live in developing countries.
In Africa, perinatal transmission occurs in an estimated 30 percent of births to HIV-infected women. With seropositivity rates among women of reproductive age as high as 30 percent in some regions of Tanzania, the next decade may see growing levels of mother-child transmission that could overwhelm health resources and threaten recent national improvements in child survival rates.
Strategies to prevent perinatal transmission of HIV continue to be developed, yet the cost of implementing them can be a serious roadblock for developing countries. Throughout the 1980s, in fact, many believed that maternal prevention was the only affordable response for poorer countries. Now, public health experts and physicians are seeking ways to make new developments in perinatal transmission prevention available to women in the developing world.
Education, Testing and Counseling
Perhaps the most fundamental barrier to stemming mother-child transmission in countries like Tanzania is the difficulty in getting accurate basic information about HIV to women, particularly those outside of urban areas. Unless they're specifically designed to address women's needs, even widely circulated HIV prevention messages often bypass women.
"Many women are still ignorant about the disease, even though AIDS awareness nationally is high," said Dr. Xavier Karlenza of WAMATA, a nongovernmental organization based in Dar es Salaam, Tanzania's capital.
Testing and counseling women who are HIV-positive would give them the knowledge to make decisions about whether and how to give birth, helping them understand how to lower the odds that their babies might also become positive. Unfortunately, testing is very expensive, and medical personnel generally test only women who exhibit symptoms of HIV infection, when and if they seek treatment at clinics. Counseling programs are rare in Tanzania and much of sub-Saharan Africa, particularly in rural areas. Some nongovernmental organizations and medical facilities offer maternal counseling, but it is not widespread enough to serve all the women who need it.
Structural problems also limit action that HIV-positive women can take, once they know their status and are aware of the risks of maternal transmission. Abortion is illegal in Tanzania and many other African countries. Women who choose to terminate their pregnancies must either have enough money to go discreetly to private doctors or be able to convince a doctor to rule the procedure medically necessary in order to get a free or inexpensive abortion at a public clinic. Contraception to avoid further pregnancies can be difficult to get and sometimes prohibitively expensive for poor women.
Dealing with Denial
But even for women who have access to testing and counseling, knowledge is not always power. Financial dependence on men and traditional gender roles may deprive HIV-positive women of the ability to make decisions about childbearing and health.
Christine is a mother of three who lives on the outskirts of Dar es Salaam. Unemployed, she is involved in her second relationship since her husband died of AIDS in 1988.
"I was diagnosed HIV-positive three years ago, but because I still look healthy I've found it so difficult to convince my lover that I have the virus," she said while breastfeeding her 18-month-old daughter, who also tests positive. "I regret that I became pregnant, but what could I have done, when this man insisted on having a child with me to cement our relationship?"
Christine's concerns about transmission of HIV were not enough to override her boyfriend's insistence that she become pregnant. His denial of the risks involved for Christine and their child--and of the need to use condoms both as protection for himself and as contraception--displays a widespread problem for counselors in Tanzania.
"Denial compels people not to acknowledge their vulnerability," said Dr. Karlenza. "Even after counseling, accepting change in life-style and sexual behavior must come from within a person."
Women determined to give birth may also avoid the truth about perinatal transmission. Asha Mruma, a counselor from the city of Arusha, encounters a great deal of denial from some of the HIV-positive women she tries to help. One woman she counseled several times was adamant that no harm could come to a child she conceived.
"All she wanted was to have a baby," said Mruma. "She did not want to see the danger of possible infection of her child after delivery simply because she was feeling well and strong."
Because women's status and role in African societies are so closely linked to the powerful cultural imperative of motherhood, denial will continue to be a barrier to preventing mother-child transmission. Improving and increasing basic HIV education to the public--particularly the message that just because you look healthy doesn't mean that you're not infected--is one solution to the popular misconceptions that feed denial about HIV infection.
Breastfeeding
A critical and much contested issue that has preoccupied counselors and public health professionals is whether to advise women in developing countries against breastfeeding because of the risk of HIV transmission through breast milk.
Estimates of likelihood of HIV transmission from breast milk range widely, from as low as 16 percent to as high as 60 percent. It's difficult to assess risk from breast milk because testing does not clearly reveal whether the virus was transmitted prenatally, during the birth itself, or later through breastfeeding. Recent research has shown that the chance of transmission through breast milk rises if the mother contracts the virus after rather than before she becomes pregnant, possibly because the rate of virus replication is higher in the early stages of infection. Other studies have examined the possibility that prolonged breastfeeding lasting more than a year may be riskier than shorter-term breastfeeding.
Breastfeeding has long been promoted in the developing world because it dramatically reduces infant morbidity and mortality. Breast milk contains important nutrients and immune factors not found in baby formula. And in parts of the world where clean, safe water is not available for mixing formula, breast milk saves children from many infectious diseases and malnutrition. Breastfeeding also benefits poor families.
"In many developing countries, where annual incomes are so low, the cost of infant formula is prohibitive," said Dr. Andrea Ruff of the Johns Hopkins School of Public Health. "The overall health and well-being of families would be compromised if they had to buy formula, and the infants themselves might be fed less in order to make the formula go further."
The World Health Organization advises pregnant women in regions of the world where infectious diseases and malnutrition are primary causes of death forinfants to continue to breastfeed, regardless of their status. In regions where this is not the case, infected women are advised against breastfeeding.Counselors in Tanzania encourage their clients to breastfeed, no matter what their status is.
Zidovudine (AZT)
This antiretroviral drug has been shown by the AIDS Clinical Trials Group to reduce perinatal transmission by two-thirds if given to women before, during and after delivery. Because of these dramatic findings, the U.S. Public Health Service created new guidelines for health workers recommending AZT for HIV-positive pregnant women in the United States.
Unfortunately, AZT is far too expensive for widespread use in Tanzania and other developing countries. But researchers are planning clinical trials in Thailand, Côte d'Ivoire and Haiti to test the efficacy of less costly short-term regimens during different stages of pregnancy and delivery.
"We're interested in finding out whether a shorter course of AZT during labor itself will lower the risk of transmission," said Dr. Ruff of Johns Hopkins, which will conduct the Haiti study in early 1996. "We'll also investigate whether a shorter course during the first couple of weeks of breastfeeding, when the infant ingests the colostrum loaded with the mother's antibodies, might also be effective."
Another antiretroviral drug, nevirapine, rapidly lowers the viral load and is also being investigated for use by pregnant women. It could be produced and administered at less cost than AZT, although its manufacturer does not appear to be interested in producing the drug for developing country use.
Cost-conscious Interventions
The most affordable interventions are those that can be delivered to all pregnant women without the need for expensive testing. A 1994 study from Malawi shows greater risk of perinatal transmission in women with Vitamin A deficiency, although it is not yet known whether Vitamin A actually prevents transmission. Vitamin supplementation against disease is already part of the health promotion strategy in many developing countries.
Vaginal lavage--cleaning the birth canal--is a simple method of lowering HIV transmission risks during birth. Some concerns include the possibility that certain chemical cleansing agents may damage the fetus and irritate the mother's genital mucosa and should be avoided.
Mother-child HIV transmission is a serious threat to the future of developing countries where the epidemic is severe. As HIV/AIDS researchers continue to study perinatal transmission and discover new ways to prevent it, public health specialists and policy makers must also find ways to make new knowledge and treatments available and affordable for women and health care systems in developing countries.
-- Halima Shariff, AIDSCAP/Tanzania
Halima Shariff is an AIDSCAP program officer based in Tanzania.
