By Sean Healy
Part one of a three part series
The clinic is small and unassuming - three little rooms in a self-contained, yellow-painted annexe under a spreading mango tree in the grounds of Chamanculo Maternity Hospital. Not exactly the place you associate with life-and-death struggles. And yet this clinic is the site of one - the desperate attempt to stem the mother-to-child transmission of HIV.
The hospital is one of only a handful in Maputo, the capital of Mozambique. HIV infection among pregnant women is chillingly high here: 17% according to some estimates, 4% higher than the rate in the overall population, and more than double what it was only six years ago. What is worse, HIV infection can easily be passed from mother to child: transmission will occur during pregnancy, delivery or breast-feeding in 25-40% of cases.
Birgit St=FCmpfl, a German midwife who runs Médecins Sans Frontières' Chamanculo clinic for prevention of mother-to-child transmission (PMTCT), sighs. "We've only been open for two months and already I can see how tough it is going to be," she said.
The good news is that there is a medical solution. If the mother is administered a single dose of a particular drug, nevirapine, immediately before delivery, and if the baby is also administered a small dose of nevirapine inside its first 72 hours of life, the chances of transmission can be reduced by as much as 50%. If this is then combined with a program to encourage HIV+ mothers to use safe feeding techniques (either exclusively breast milk or exclusively formula milk), maybe a generation of Mozambican babies can be saved from childhood infection.
St=FCmpfl is on her second mission with Médecins Sans Frontières, after a previous stint on the Thai-Burma border. She is well aware of the possible benefits but also the difficulties the project faces.
The clinic runs two kinds of services: first, a voluntary testing and counselling service aimed primarily at the mothers who come through the hospital, and second, for those who test positive, the PMTCT program proper - including; prevention counselling to try to stop new infection during pregnancy; early treatment of opportunistic infections; the administration of nevirapine to mother and child; and the provision of formula milk, free of charge.
Soon, it will also be linked to a new MSF program using anti-retroviral medicines to treat HIV+ people.
Improving links with local facilities
The links with the maternity hospital are good and getting stronger. Every morning, the 80-odd mothers who gather for ante-natal consultations in the maternity hospital hear a short presentation about the clinic and the PMTCT program. A more detailed education program, for groups of 20 mothers, is about to start in the next month.
Birgit also hopes to run more training programs for the hospital staff, who deliver on average 450 babies each month and are desperately under-resourced. Other hospitals are also starting to refer pregnant mothers to the clinic. In the two months since it opened, 50 mothers have been tested with 20% found to be HIV+; 24 women are presently in the PMTCT program.
So far so good. But 'solutions' are never that easy to implement.
"Take feeding as an example," explained Birgit. "Nevirapine is great because it's so simple. But it's no use if we don't tell the mothers that breast milk and mixed feeding can transmit the virus and encourage them to switch to exclusively artificial milk."
For a midwife, this is very hard to accept.
"I never thought I would come to a country to promote artificial feeding - and yet that's what I have to do if I want to stem mother-to-child infection."
For the mothers, it can be even harder to accept. Exclusive breast feeding - meaning no other liquids or solids for six months - has a low chance of transmitting the virus. But exclusive feeding is very rare in Mozambique. Nearly all mothers will combine breast milk with other foods or liquids; and mixed feeding has a high likelihood of transmission and is exactly the type of feeding that Birgit advises mothers against doing.
But exclusively artificial feeding is possibly even rarer and is associated with illness and bad mothering. If a relative sees her with formula, it might raise some dangerous questions.
"It is almost impossible for a mother to artificially feed if she hasn't disclosed her HIV status to her closest family. But most women are afraid to disclose, they're afraid they'll be thrown out of the house," Birgit said.
Mothers also need to support and advice on feeding, as improperly prepared artificial milk can harm the baby. But in many cases, it is not even the mother who is making decisions about what and how to feed the child - it is the grandmother, or even the husband's mother, who might not be sympathetic.
There are also economic pressures.
"One woman came back early saying she had no more formula," Birgit remembered. "When I confronted her, she admitted that her husband had sold it at the market. Each tin costs US$5 and they're poor; how can you blame them?"
But for all the hard stories, Birgit says there are an equal amount of positive stories; of mothers who enter the program and find hope in it; of babies who do not contract the virus because of the program.
Beatriz Mangate, the clinic's receptionist, found out a year ago that she had the virus, when she was already pregnant with her second child. She was put on the PMTCT program, received nevirapine and started artificial feeding. It is still too early to know if her baby daughter is HIV+ or not - but Birgit says the baby is healthy and has every chance of being free of the virus.
"I don't have this emphasis that I'm here to save the world," Birgit said. "I have to turn a blind eye to so many dilemmas here. But what keeps me is the positive tested mothers, seeing HIV + people, women, assuming a positive life. That is something incredible, exciting, encouraging, powerful. We have to start somewhere, find a way somehow."