Chetan on HIV in Malawi, Letter from Africa

Sorry for months of radio silence. I figured there was nothing new to write about or take pictures of until recently.

The prevention of mother to child transmission of HIV infection is one of the most important aspects of any comprehensive HIV treatment program, but its also the most difficult. Babies get HIV from their mothers in three ways: during pregnancy, at the time of delivery, and during breastfeeding. In America , if a woman is receiving antiretroviral drugs and does not breastfeed, her chance of having an infected baby is around 1%. In Africa , it's a different story altogether. Healthy pregnant women work until they deliver and then they go back to work. They generally don't access antenatal care, particularly in Malawi where there is a long tradition of midwifery and home deliveries.

The picture is of an HIV infected woman who I see in our mobile clinic. Her name is Magret (phoenetic for Margaret) and she is in her early 20s and married with two children. (She's better off than many of her peers that are divorced and live alone with the children). Every time she comes, she brings her baby, Stefano, who is about one year old and still breastfeeding. You don't have to be a doctor to see that Stefano is sick. He is chronically ill and not gaining weight probably from a combination of HIV and malnutrition. In a cruel twist of fate, though Magret has HIV, she is not receiving antiretroviral drugs at this time because she's not sick enough to warrant it. When we spoke about the risks of HIV transmission with breastfeeding, her response to me was "If I don't breastfeed the baby, then what will he eat?"

The risk of HIV transmission with breastfeeding is 10-16%, and it seems to be greatest within the first 4-6 months of life. Though 1.7 million babies develop HIV each year due to breastfeeding, almost that many would die if not breastfed - mostly from diarrhea and malnutrition. For some, it is better to have an HIV infected baby than a dead baby.

I spend all day doling out life saving drugs, yet it is obvious that this is only part of the solution to AIDS in Africa . We can give people medicine, but if they don't have clean water or food to eat, they will still die. Because of improved public health measures (childhood immunizations, obstetric care, etc.) the population of Malawi has doubled in the last thirty years despite HIV! However, food production has not kept pace. Every year, there is the threat of drought and with it famine.

There are non-governmental organizations (NGOs) and U.N. affiliated groups working in Malawi on everything from family planning to teaching farming methods and donating fertilizer. However, cooperation is sorely lacking. They all have their own agendas, which include producing pretty annual reports for donors. For its part, the government of Malawi is trying to bring all involved parties together as part of a concerted process, but it is difficult. Understandably, NGOs are reluctant to sacrifice autonomy to a third party, particularly a government fraught with corruption. For me, it's a new source of frustration to add to an already long list!

All the frustrations have been tempered, however, by the love and support I've received from you all (especially the care packages!). Based on how often I have been emailing, I think this will be the last time before I come back to the US and move to Boston in June. Thanks again for being part of my MSF experience, and I look forward to catching up with everyone in person soon.

 

Chetan