'Best-Kept Secret' For HIV-Free Africa

By Craig Timberg
Washington Post Foreign Service
Sunday, December 16, 2007; A26

NDORI, Kenya -- Giving antiretroviral drugs to pregnant women has long been celebrated as one of the few successful tactics in the war against AIDS in Africa. A single pill for a woman in labor, followed by a sip of syrup for her newborn baby, cuts HIV transmission rates by more than half, potentially saving the lives of millions of children.

But despite sustained financial and political support for the effort, studies show that only about one in 10 infected African mothers has access to the drugs.

As these programs falter across the continent, researchers increasingly agree that far more cases of pediatric AIDS could be prevented with a cheaper, easier and more effective alternative: birth control.

"It tends to be the best-kept secret in HIV prevention," said Ward Cates, head of research for Family Health International, a nongovernmental organization based in North Carolina that has extensive experience in Africa.

The group has found that programs providing antiretroviral drugs to pregnant women prevented 101,000 cases of pediatric HIV between 1999 and 2006. Contraception, meanwhile, averts the births of 173,000 infected babies each year, the group says.

Improving birth control availability in Africa, where usage rates are the lowest in the world, could prevent tens of thousands of more infections more reliably and less expensively than antiretroviral drugs, Cates said. Surveys among women who know they have HIV show most do not want to become pregnant again because they fear infecting their babies and leaving even healthy offspring as orphans.

Yet as research has mounted about the importance of contraception in controlling pediatric HIV, U.S. and other international funding for birth control programs has declined. The budget President Bush has proposed for this year is less than one-third the amount spent in 1995, when adjusted for inflation, according to statistics compiled by Washington-based Population Action International, which lobbies for better family planning programs worldwide.

The shift has contributed to the stagnation of contraceptive access in some areas and outright declines in western Kenya, where programs funded by international donors once helped women resist strong cultural pressure to have many children. Women here say they have little choice other than to risk giving birth to children doomed to develop AIDS.

Lilian Akoth Juma, 27, who has wide cheekbones, short braids and eyes wearied by seven hard years of widowhood, said she did not want to have more babies after learning she had HIV in 2004.

"I wanted to be done," Juma recalled as she sat in her dark, dirt-floored hut while infant son Javan suckled and his twin brother napped nearby. With their birth in April, Juma now has six children, not an unusual number in western Kenya, where many women live in deeply traditional villages nestled in the hills rising from the rocky shores of Lake Victoria.

Juma's attempts at family planning were frustrated by a combination of poverty, limited access to birth control and medical problems that made it unsafe for her to use contraceptive pills or injections, she said.

The man who, in accordance with local tradition, inherited her after her husband died refused to use condoms, she said. And she lacked the means and the knowledge, she said, to travel to a regional hospital where she might have found access to IUDs, contraceptive implants or surgical sterilization -- all once staples of U.S.-funded family planning programs here.

The United Nations estimated last month that of the 2.5 million children in the world with HIV, nearly 90 percent live in sub-Saharan Africa and that the overwhelming majority of those acquired the infection from their mothers. Raising these children, most of whom will die young after long periods of sickness, is not easy, especially for a mother also carrying the virus.

Sharon Awino, a scrawny 2-year-old who looks half her age, cannot walk or talk because of AIDS. Her mother, Susan Akoth, a slender, sad-eyed 18-year-old, said Sharon wakes up several times every night. A recent fever, accompanied by dehydration and loss of appetite, put the child in the hospital for three days.

"It's hard because she keeps on getting sick," Akoth said. "At night, I don't sleep."

The U.S. Agency for International Development once described Kenya as having "the most spectacular decline in fertility ever recorded in Africa."

The shift was driven in part by international funding that helped pay for radio programs, contraceptive devices and legions of community health workers who canvassed villages offering pills and counseling on how to find other services in the region's cities.

But U.S. support for family planning began to drop in 1996, the first budget year after Republicans took control of Congress. European donors also shifted their money away from contraception and toward other programs.

The U.S. money that did arrive was subjected to new restrictions when Bush, shortly after taking office in January 2001, banned funding to groups that provided or promoted abortion. Two of the largest distributors of contraception here, Family Health Options Kenya and Marie Stopes Kenya, did not provide abortions, which are illegal in Kenya, but were subsidiaries of London-based parent organizations whose members helped provide them in other countries. Together, the two groups closed five family planning clinics after losing U.S. funding.

Surveys conducted in recent years have shown significant shortages of contraceptives and the capacity to deliver them safely across Kenya. Birthrates are rising again, and the United Nations has nearly doubled its long-term projections for Kenya's population, from 44 million to 83 million by 2050.

"When the U.S. money got stuck somewhere, the program collapsed," said Geoffrey Luttah, head of the Family Health Options Kenya clinic in Kisumu, the region's biggest city. "We are only reaching very few people who can afford to come to the facility. So the area covered became very narrow. We are denying contraceptives to many people."

In 2003, when Bush created the President's Emergency Plan for AIDS Relief, or PEPFAR, some administration scientists lobbied for reinvigorating international family planning efforts. Four of them posted a study that year showing that even a modest expansion of contraceptive programs could prevent nearly three times the number of child AIDS deaths as antiretroviral programs for pregnant women.

But top officials with the Bush initiative refused to allow the AIDS money to be used to buy birth control, said Daniel Halperin, one of the study's authors and now a researcher at the Harvard School of Public Health.

"The first few years were a nightmare. You couldn't even say the words 'family planning,' " he said. "This is probably the clearest example of when PEPFAR politics trumped evidence."

Program officials say they do not object to family planning but chose to focus funding on initiatives they regarded as more directly related to AIDS. The program does pay for the purchase of condoms because of their ability to block HIV transmission during sexual intercourse, but surveys show that Africans rarely use them to prevent pregnancies.

"There are many, many issues out there, so the best that PEPFAR can say is we are focused on HIV," said Michele Moloney-Kitts, a top official with the program.

Providing antiretroviral drugs to pregnant women and newborn babies has been among PEPFAR's signature initiatives. But the effort has been hindered by Africa's weak public health systems and the tradition of women here giving birth mainly at home.

Juma gave birth in her dirt-floored hut because she did not have money to go to the hospital in a nearby city, she said. There was no antiretroviral pill for her, no syrup for her two newborns.

One of the babies, Handison, seemed strong from the beginning. But Javan developed a strange rash on his back -- a possible sign of HIV infection -- three days after his birth. Over the next few weeks, the rash climbed over his shoulder and onto his left hand before gradually retreating.

But it did not disappear, causing Juma intense worry about whether Javan, who also appears less vigorous and fusses more than his twin brother, has HIV. It will be several months before he can be reliably tested.

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