Treating mothers-to-be

Meanwhile, motivated by the crisis in sub-Saharan Africa, a team of experts who had developed comprehensive programs for HIV at Harlem Hospital in New York City developed what it called the MTCT-Plus Initiative at Columbia University’s Mailman School of Public Health. The team was led by Dr. Wafaa El-Sadr, university professor of epidemiology and medicine at Columbia. Its goal was to provide HIV care and treatment for families in poor countries, using prenatal care and prevention of mother-to-child transmission (PMTCT) as the entry point for HIV-positive people into HIV care programs. The idea was to link prevention and treatment programs, and combine HIV care and treatment with broader reproductive healthcare delivery.[7] The initiative formally launched on July 10, 2002 with the announcement of 12 demonstration sites in Africa and Asia. At the time, few in sub-Saharan Africa had access to treatment, and for most HIV was a death sentence.

The team wanted to bring recent US successes in HIV treatment and preventing MTCT to developing countries. "It became clear that the pediatric epidemic in the US had changed pretty dramatically," says Dr. Elaine Abrams, the initiative's deputy director for programs, director of the Family Care Center at Harlem Hospital, and associate professor of pediatrics at Columbia. "We had figured out how to prevent babies from acquiring HIV infection. We were seeing fewer and fewer new children with HIV, and we were effectively treating those who had HIV," she says.[8] The team planned to build on its experience in treating a poor population in the US, adds El-Sadr.[9] She recalls:

We believed that it was quite relevant to meeting the epidemic in Africa… that if we used the same principles that we applied when we’re working in a disenfranchised, highly impacted community in the US, that many of these same principles would be relevant to the work in Africa. There really are more similarities than differences between populations around the world in terms of their needs, in terms of their aspirations.

That meant treating patients holistically, including psychosocial needs, rather than just providing clinical care. “From day one, I felt that in Harlem we had to shape the response to the epidemic in a way that would be responsive to the needs of the families in the communities that we worked with,” says El-Sadr.


Dr. Elaine Abrams
© Mailman School of Public Health

PMTCT challenges. Mother-to-child transmission rates ranged from 15 to 45 percent. By 2003, antiretroviral treatments for pregnant women had been able to reduce transmission rates to below five percent for those fortunate enough to get the medication.[10] Getting treatment to women who needed it, however, was a major challenge. Less than five percent of HIV-positive pregnant women in Africa accessed PMTCT services in 2003, and an average of 1,600 infants were born with HIV infection every day.[11] "The prices of ART were pretty staggering, so who would pay for it? Cost and availability of drugs was the major impediment," says Abrams.

The standard first attempt to prevent MTCT was to give the mother a single dose of the antiretroviral drug nevirapine when she went into labor, and a single dose to the infant within 72 hours of delivery. The simplicity of giving single doses of a single drug made this approach appealing to poor countries. Moreover, WHO guidelines at the time called for giving mothers a more effective combination of ARTs—dubbed highly active antiretroviral therapy (HAART)—only if they qualified for treatment based on the criteria for all adults: Stage III or IV illness or CD4 counts below 200.[12] However, few people had access to such treatment.

As the crisis intensified, it became clear that preventing the spread of HIV had to involve a major effort to protect the next generation. Public health experts increasingly viewed prevention of mother-to-child transmission as an essential aspect of tackling HIV, especially in poorer settings. But healthcare systems in resource-constrained countries had minimal capacity to provide PMTCT services, even at the level of consistently providing HIV testing at prenatal care appointments. People living with HIV, including HIV-positive pregnant women, were stigmatized, which made it difficult for pregnant women to seek PMTCT services in their communities in the first place. Moreover, of HIV-positive women in treatment, pregnant and postpartum women were more likely to drop out of treatment than non-pregnant women, according to the WHO. Morning sickness, concern about the effect of drugs on the fetus, and the burden of caring for a newborn made it hard for the women to stay in treatment. Women also often lacked support from their male partners. In one study in Malawi, more HIV-positive pregnant women wanted to disclose their status to their spouses than actually did.[13]

ICAP’s MTCT-Plus Initiative was the first multi-country HIV treatment program. From its inception, it enrolled nearly 14,000 women and children in sub-Saharan Africa and Thailand in ongoing HIV care and/or treatment. Prenatal care was often the first point of contact in the health system for an HIV-positive woman in sub-Saharan Africa. "Women were coming into the ante-natal care clinic for an HIV test," says Abrams.  "If they were positive, they got, usually, a single dose of medicine to protect the baby—not terribly well, but it protected the baby." MTCT-Plus offered not only the opportunity to prevent HIV transmission from the woman to her baby, but enabled her to access treatment if she was eligible. In addition, women in the program were invited to bring in family members for HIV testing, and those found to be infected were offered similarly comprehensive care and, if eligible, antiretroviral treatment.

Treatment.At the same time, given the magnitude of the crisis and the need for hundreds of thousands, if not millions, of people to access treatment, not everyone was sold on the idea of trying to treat so many people, pregnant or otherwise, in low-income countries. International health experts debated whether treatment or prevention should take priority in poorer countries. The principal issues were the still-high cost of antiretroviral drugs, concern about patient inability to adhere to treatment (and the resulting risk of drug resistance), and the lack of facilities and systems to deliver such services to so many people.

In 2003, the World Health Organization and the joint United Nations Programme on HIV and AIDS (UNAIDS), the UN's lead HIV-AIDS entity, came down firmly on the side of treatment. They launched the “3 by 5” initiative, a plan to provide antiretroviral treatment to 3 million people living with HIV-AIDS in low- and middle-income countries by the end of 2005.[14] WHO positioned 3 by 5 as a step toward making universal access to HIV-AIDS treatment and prevention a human right.[15] Access to antiretroviral drugs was especially restricted in sub-Saharan Africa, and barely one percent of the 4.1 million people who needed HIV treatment were receiving it.[16]

The WHO criteria for who should receive ARTs were based on clinical staging, in this case a combination of its own disease stage rankings and the state of a patient’s immune system based on CD4 counts.[17] WHO recommended that an HIV-positive adult or adolescent start antiretroviral therapy if s/he had stage IV HIV disease, irrespective of CD4 count; stage III HIV disease with CD4 counts of less than 350; or stage I or II HIV disease with CD4 cell counts of less than 200. It was an emergency response aimed at treating people with advanced HIV disease. In January 2003, the US also started a push toward treatment, announcing the President's Emergency Plan for AIDS Relief (PEPFAR), which promised $15 billion over five years to support HIV programming in developing countries, principally in Africa.


[7] Myer et al., “Focus on women: linking HIV care and treatment with reproductive health services in the MTCT-Plus Initiative,” Reproductive Health Matters, 2005.

[8] Author’s interview with Dr. Elaine Abrams In New York City on April 29, 2014. All further quotes from Abrams, unless otherwise attributed, are from this interview.

[9] Author’s interview with Dr. Wafaa El-Sadr In New York City on May 14, 2014. All further quotes from El-Sadr, unless otherwise attributed, are from this interview.

[10] “Mother-to-child transmission of HIV,” WHO website. See: http://www.who.int/hiv/topics/mtct/en/

[11] Philipa Musoke, Recent advances in prevention of mother to child (PMTCT) of HIV, African Health Sciences, 2004. See: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2688329/

[12] CD4 cells, also known as T cells, were immune system cells that signaled the onset of infection so the body could defend against it. A healthy person had a CD4 count of 500-1,000 cells per cubic millimeter. AIDS compromised the immune system, driving down the cell count. WHO used a CD4 count of 200 or below to designate an HIV-positive person as having AIDS.

[13] Tadesse et al., “Likely stakeholders in the prevention of mother to child transmission of HIV/AIDS in Blantyre, Malawi,” Africa and Health Sciences, 2004. See: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2688327/

[14] WHO 3 by 5 Initiative website. See: http://www.who.int/3by5/en/

[15] Ibid.

[16]  “WHO Issues Global Alert after Grim Report on HIV/AIDS,” BMJ, 2003. See:  http://www.ncbi.nlm.nih.gov/pmc/articles/PMC200831/

[17]  Stage I: Asymptomatic

      Stage II: Weight loss of less than 10 percent of body weight, minor mucocutaneous manifestations (seborrheic dermatitis, prurigo, fungal nail infections, recurrent oral ulcerations, angular cheilitis), herpes zoster within the last five years and/or recurrent upper respiratory tract infections. Normal activity.

      Stage III: Weight loss of greater than 10 percent of body weight, unexplained chronic diarrhea for more than 1 month, unexplained prolonged fever for more than one month, oral candidiasis (thrush), oral hairy leucoplakia, pulmonary tuberculosis and/or severe bacterial infections. Bedridden less than half the time in the last month.

      Stage IV: HIV wasting syndrome; pneumocystis carinii pneumonia; toxoplasmosis of the brain; cryptosporidiosis with diarrhea for more than one month; cryptococcosis extrapulmonary; cytomegalovirus disease of an organ other than liver, spleen or lymph node (e.g. retinitis); herpes simplex virus infection; progressive multifocal leucoencephalopathy; any disseminated endemic mycosis; candidiasis of esophagus, trachea and/or bronchi; atypical mycobacteriosis; non-typhoid Salmonella septicemia; extrapulmonary tuberculosis; lymphoma, Kaposi's sarcoma and/or HIV encephalopathy. Bedridden more than half the time in the last month.