November 12, 1998
I. S. Gilada, India
HIV continues to hit India "below the belt" pushing us in the third phase,
affecting a large number of housewives -- more than 1.5% in Mumbai and 0.5% in
rest of India. Perinatal transmission contributes little in the gross HIV
infections, but the incidence of paediatric AIDS is increasing.
has some activists for the cause of trees, animals and human rights but there is
dearth of "Child-Rights" activists, as the foetus does not even cry
and continues to be a neglected lot. In a country ridden with poverty,
illiteracy, double standards and multiple scandals, poor health care seeking
behaviour and limited medico-social support to women, it is an uphill task to
provide "positive health" to women and prevention of HIV is a major
challenge. IHO-Wadia intervention model to reduce the impact of perinatal
transmission is a beginning to pursue "Right to AIDS-Free Life" for
infants. To prevent perinatal HIV transmission is our prime responsibility,
National AIDS Control Organisation (NACO); which is the single responsible body
in preventing millions of children being infected with HIV in due course is not
only insensitive and callous in this regard, but has been raking unnecessary
controversy by planning the "AZT Trial on Pregnant Women." Spending
millions and wasting time on re-inventing the wheel on the time-tested modality
which has been proved for reducing mother to child HIV transmission from 50 to
95% with different models, will surely put annually some 100,000 children to
risk of HIV. While the NACO delegations have gone to USA, Uganda and Thailand to
look at those models, they did not bother to see IHO-Wadia model. The two
important conferences on "Prevention of Perinatal HIV Transmission" in
last two weeks one at Mumbai on October 30-31 and at Chennai on November 6-7,
had no representation from NACO.
against AIDS against all odds for 13 years and on evaluating multi-pronged
approaches from street-corner meetings to the World Congress, IHO has been
spearheading the community mobilisation against AIDS. Safe-Motherhood project
was initiated in 1992 as a collaborative effort of IHO and Wadia Hospital,
without any official support but with a clear foresight and fullest community
mobilisation better nutrition, treatment with ACTG-O76 and avoiding future
education of all ANC attendees at a large Women's Hospital using effective
counselling in groups of 10-15 followed by a system of negative consent;
systematised HIV screening of almost 12,000 women each year;
test by "pooling", identify infected one, retest positive woman
and encourage spouse testing;
with less than 20 weeks gestation given choice to decide fate of pregnancy;
with gestation beyond 20 weeks given choice of modified ACTG-076 protocol:
ZDV 400 mg/day x 8 wk to mother, 10mg/kg x 6 wk
to infants; Caesarian Section, Modified BF; and
are followed quarterly till 18 months and tested for HIV at 9 and 18 months
all only six women went for second and two for third pregnancy, rest opted
barrier contraception. None committed suicide and only 3 opted for divorce. The
largest, innovative, cost-efficient and replicable model of perinatal HIV
intervention for busy hospital settings in Asia has emerged.
has now been replicated elsewhere. In orthodox society to achieve behaviour
modification is hard; for which one needs knowledge of local customs, beliefs,
languages, experience and practices. For evolving cost-effective, socially
acceptable, harm-minimisation strategy, we need sensitisation and aggressive
promotion. ZDV given to infected women in low doses commensurate to average
weight for a shorter duration has been equally efficient in preventing perinatal
transmission. Due care should be taken as regards selection, drug resistance,
toxicity, orphans, cost, counselling/care, discrimination, option of MTP,
patients on ART, expensive tests, management of other diseases and ethical
I. S. Gilada, Secretary General
Health Organisation(NGO); Municipal School Bldg,J.J.Hospital Compd,
How refreshing it was to read
Dr. Gilada's posting of November 12 on SEA-AIDS
and learn of his experience with reducing mother-to-child HIV transmission at
Wadia Hospital (described as a larger women's hospital) in India, which
began six years ago. You stressed among other issues that programs like
yours need to consider costs and must be practical if they are going to
reach many people. Specifically, you mentioned several key components that
I would like to reiterate and address (my comments follow each point).
[the program was started] without any official support with clear
foresight and fullest community mobilization.
It is encouraging to see what a non-governmental organization (NGO)
can do on its own, even when government support is not yet forthcoming.
Such independence leads to greater experimentation, which may not occur
if the government intrudes too early, especially in these changing times.
While government agencies debate what needs to be done next, you have moved
forward and now have something useful to share with others.
counseling in groups of 10-15 followed by a system of negative
consent. HIV screening of almost 12,000 women each year.
I gather by "negative consent" that you mean they have the option of
not continuing with the testing process, but must say so. Others would
refer to this as routine testing, similar to routine measuring of blood
pressure, anemia and the like. You recognize that individual pretest counseling
is expensive when faced with the task of screening 12,000 women per year.
Thus you have come up with a working alternative that greatly reduces the
cost, and perhaps is sufficiently effective at informing the women of what
is to come.
3) ELISA test by "pooling,"
identifying infected individuals, and retesting
Assembling the blood in pools so that one ELISA is done for a batch
of 5-10 specimens is an important cost savings, especially useful when
the prevalence is low. If the pool or batch is positive, then the individual
specimens making up the pool are tested separately to find out who is or
is not infected. UNAIDS and others have been recommending such pooling
for a long time, and it is nice to see that progressive groups like yours
have adopted this procedure.
4) Encourage spouse testing
This important step is often overlooked in pregnant women testing
if husbands do not exist or are unimportant. Programs that test and educate
pregnant women offer good opportunities to also test husbands, vital if
the disease is to be discovered and addressed. By ignoring spouse testing,
health programs give out the message that couples cannot be trusted to
share such intimate matters with each other. We need to overcome such attitudes
if the barriers to testing are to be eliminated, as you apparently are
5) Seropositives with less than 20 weeks gestation are given the choice
of deciding the fate of their pregnancy
In the early stages of pregnancy, you are sharing the information with
the women and encouraging them to decide for themselves if they want or
do not want to have an abortion. Thus it is the woman that chooses, rather
than the medical care provider.
6) Seropositives with gestation beyond 20 weeks are given the choice
of a modified ACTG-076 protocolzidovudine (AZT) 400 mg/day x 8 wk to mother,
10mg/kg x 6 wk to infants; caesarian section, modified breast-feeding
Based on recent research findings in the New England J of Medicine (339
(20), November 12, 1998), even lower doses of AZT seem to be effective,
adding further flexibility and options to your treatment recommendations.
Finally, you stated that most of the HIV infected women opted for barrier
contraceptives and that only a handful again became pregnant. Furthermore
you pointed out in your setting that no one committed suicide and all but
three (who were divorced) kept their families in tact.
Perhaps others in
Asia have similar practical experiences that address the important issues
of cost and effectiveness of programs aimed at reducing mother-to-child
transmission. If so, please share them with us.