POSTING 34: RESPONSE TO MEETING STATEMENT 


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Frerichs, R.R. Response to AZT/MCT -- UNAIDS Meeting Statement.

SEA-AIDS Network, April 13, 1998.

Posted in response to:

SEA-AIDS, April 9, 1998

From Joe Thomas, Hong Kong

Those who are following the discussion on promoting the use of AZT monotherapy in the developing countries please take note of the following report and the researchers concern that monotherapy continued to be administered to pregnant HIV-1-positive women, despite the existence of more effective, alternative therapies. They note that treatment with an antiretroviral therapy that does not completely curb viral replication, does not prevent vertical transmission to the child, and could limit the patient's future therapy options as a result of drug-resistant mutations.

What a pity that this report was not published by CDC, in MMWR. So that it would have attracted a much need priority in public health policy. Like the half- baked research report on the benefit on the administration of AZT during pregnancy for the women in developing countries. (appeared in MMWR, March 6, 1998. Vol. 47, No. 8). Which forced the global AIDS Leaders to move pretty fast, to come up with (matching to the MMWR report) a half- baked public health policy for the developing countries.


Fischer, Conrad; Rosenwald, Victoria; Harewood, Lisa; et al. "Antiretrovirals During Pregnancy in HIV-1-Positive Women in New York City (Research Letter)" Lancet (04/04/98) Vol. 351, No. 9108, P. 1029. 

Researchers at New York University School of Medicine conducted a survey of obstetric healthcare providers in July 1997 to assess the use of antiretroviral therapy in HIV-1-infected pregnant women in New York City.

Represented in the survey were 221 prenatal patients seen during the year, including 150 who were personally supervised by the respondent; antiretroviral therapy was accepted on average, in 96 percent of reported cases.

Zidovudine monotherapy was initially recommended for 42 percent of antiretroviral-naive patients, combination therapy was advised for 25 percent and the remaining participants were given individually tailored treatments. Thirty-nine percent of patients were reported to have utilized combination therapy by the third trimester, while three of 13 institutions reported using ZDV monotherapy for all patients throughout the pregnancy and two of the 13 said they used combination therapy for all patients.

Researchers expressed concern that ZDV monotherapy continued to be administered to a majority of pregnant HIV-1-positive women (61 percent), despite the existence of more effective, alternative therapies. They note that treatment with an antiretroviral therapy that does not completely curb viral replication, does not prevent vertical transmission to the child, and could limit the patient's future therapy options as a result of drug-resistant mutations.


Dr. Joe Thomas

Community Research Program on AIDS,

The Chinese University of Hong Kong

B,7/B. Prince of Wales Hospital

Shatin, N.T., HONG KONG.

R.R. Frerichs Posting

The use of zidovudine (better known as AZT) monotherapy in pregnant women to prevent secondary transmission to their offsprings has been criticized by Dr. Joe Thomas and others. In his April 9 posting, Dr. Thomas referred to the research undertaking of CDC and Thai scientists on the merits of low-dose AZT as "half-baked," and chided UNAIDS for promoting "half-baked public health policy for the developing countries." While opinions may vary on what comes out of the kitchen, policy research should be easier to digest.

The findings of the Thai study are widely available (Morbidity and Mortality Weekly Report 47(8)151-154, 1998), and should be reviewed by those interested in preventing mother-to-child HIV transmission.

While UNAIDS has been troubled over testing issues -- not knowing how best to detect HIV among the many pregnant women who now carry the virus -- the organization is correct in supporting the Thai study and encouraging the use of low-dose AZT prevention therapy, when economic circumstances warrant such an approach.

Dr. Thomas also presented a research letter that appeared in last week's Lancet (Lancet 351(9108)1029, April 4, 1998) by Fischer et al. that described treatment patterns in New York, the largest city in the wealthiest country in the world, and related their findings to settings where bread, rice, and clean water are day to day concerns. The normative treatment in the United States for HIV infection now is combination therapy or HAART (highly active antiretroviral therapy).

Other wealthy countries also now feature such treatment. A recent study by Mouton and colleagues in France (AIDS 11(12), F101-5,1997) showed a clear benefit to early HAART with a drop in hospitalization days by 41%, new AIDS cases by 41% and deaths by 69%. The cost of such therapy, however, is very high.

Contained in the research letter in Dr. Thomas' April 9 posting, was the sentence, "Researchers expressed concern that ZDV monotherapy continued to be administered to a majority of pregnant HIV-1-positive women (61 percent), despite the existence of more effective, alternative therapies." Dr. Thomas used this letter to justify his concerns with AZT use in developing countries. The focus of the letter, however, was on New York, where money is available for more comprehensive therapy, not on other locals where treatment alternatives are more limited. Combination therapy or HAART which should be available in wealthy New York would likely not be available in the foreseeable future for use to prevent mother-to-child transmission in developing countries. With this in mind, the practical solution for public health officials in high-HIV-prevalence countries is to use low-dose AZT therapy with HIV-infected pregnant women, following the guidelines being established by UNAIDS and others.

Finally, let me conclude with a section of a email message I sent last week to Dr. Thomas (we are friendly colleagues from earlier days), commenting about the negative effect that our on-going SEA-AIDS dialog may have on policy.


- RR Frerichs to J Thomas (6 Apr 1998)

...As you know, there is much reluctance out there to address HIV in an open manner. To do so means dealing with self and soul, and for many that is a trying undertaking. So what would I like to see happen in these discussions? If we assume that HIV infected pregnant women should be advised about ways to prevent further transmission, then the first step should be to detect the problem. Coming up with good detection schemes that are cost-effective and acceptable requires much discussion and planning. In doing so, people have to be willing to consider the consequences of no detection as an alternative (or what I view as inaction). 

The second step should be to inform pregnant women about the meaning of HIV and if infected, to understand the need for treatment, possible cessation of breastfeeding and what will come next.

The third step should be to initiate treatment, followed by a fourth step of continued assistance and care, both for child and mother. Once HIV is diagnosed, it cannot be avoided. Thus if an unstated objective is avoidance of the problem, then the best thing to do is avoid testing or at least make testing difficult to obtain. 

Yet avoidance becomes hard on the conscience if people accept that AZT is effective at saving offsprings. Such avoidance would seem unethical,and certainly uncaring. On the other hand, if AZT is not effective, or at least has questionable value, then it provides a welcome rationale for not testing, and for not having to inform women and their sexual partners that they are infected. I suspect that both of us do not want to see such lack of action be legitimized, thereby causing further harm. 


 

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