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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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