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New Therapy May Cut AIDS in Newborns

TIMES MEDICAL WRITER

World health authorities are poised to embark on a treatment program that they say could reduce the number of children with AIDS in developing countries and save as many as 5,000 children’s lives in the first year alone, researchers said Monday at the 12th World AIDS Congress.

Of the 16,000 people who contract AIDS every day, 1 in 10 are infants who are infected during childbirth.

Reports presented here indicate that a relatively inexpensive treatment, a short course of the anti-AIDS drug AZT, can dramatically reduce transmission of the virus from mother to child.

Other findings indicate that giving pregnant women multiple vitamins and using more effective antibacterial agents during labor can improve the health of the mother and child and may also reduce viral transmission.

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Buoyed by these new findings, the Joint United Nations Programme on HIV/AIDS (UNAIDS) announced that it would begin a dramatic new program--the first of its kind--to bolster the health care of at least 30,000 women in the next year and provide them with AZT treatments.

Now, many pregnant, HIV-infected women in the United States undergo a three-month course of treatment costing more than $800. The feasibility of short-term therapy, starting as late as the 36th week of pregnancy, lowers the cost to about $50--enough for UNAIDS to undertake such a program in developing countries.

The $3-million-plus program will begin almost immediately.

“We’ve made dramatic advances in the last four years in reducing mother-to-child transmission of HIV in developed countries,” said Dr. Lynne M. Mofenson of the National Institute of Child Health and Human Development in Rockville, Md. “With the now-proven efficacy of the short course of AZT . . . I hope we may see a similar impact in the developing world in the next four years.”

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An untreated HIV-positive woman who is pregnant has about a 1 in 3 chance of delivering an infant who is also infected, according to UNAIDS. The greatest risk of transmission occurs during delivery, when the infant may swallow some of its mother’s blood. Breast-feeding leads to about one-third of the cases.

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Studies completed in 1994 showed that a combination of three months of treatment with AZT before delivery, intravenous infusions of the drug during labor and delivery, and treatment of the child reduce the risk of transmission by two-thirds. Results reported here Saturday--as well as a much larger study to be reported today--show that combining the AZT regimen with caesarean sections reduces the risk below 1%.

In the United States, the average rate of transmission is 2% to 3%.

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But the cost of such programs, even without caesarean surgery, ranges from $600 to $800, far too expensive for developing countries. Researchers have hoped that a shorter--and less costly--course of therapy might be just as useful.

A recently completed study of such a short-term therapy conducted in Thailand, Uganda, Tanzania and the Ivory Coast examined the use of twice-daily doses of AZT beginning very late in pregnancy, about the 36th week, and continuing through delivery. Final results of the study, presented Monday, showed that the regimen reduced transmission from 18.9% in the group not receiving drugs to 9.4% in the AZT group, said Dr. Nathan Shaffer of the U.S. Centers for Disease Control.

That treatment costs about $50.

Based on these results, UNAIDS and UNICEF announced a pilot program that will treat 30,000 women at 30 sites in 11 countries--the four where the technique was tested, plus Botswana, Burkina Faso, Cambodia, Honduras, Rwanda, Zambia and Zimbabwe.

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“We’ve always had programs to reduce child mortality, but we became disturbed that they could soon be undermined by the HIV pandemic,” said David Alnwick of UNICEF. “We’re now committed to practical action.”

But the task will not be easy. According to Thierry Mertens of the World Health Organization, 30% of women in developing countries receive no prenatal care and 43% do not have medical personnel present during labor. The AZT regimen will be of little use if prenatal care is not increased, and UNAIDS estimates that will cost another $50 per mother.

Furthermore, 90% of HIV-positive people in the developing countries do not know that they have contracted the virus, so testing also will have to be expanded, at the cost of another $20 per person. The cost for 30,000 women will be more than $3 million.

“We have the resources to get started,” Alnwick said, but not the resources to expand it to all pregnant women.

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Some other potentially useful interventions also could be inexpensive. Dr. Wafaie Fawzie of Harvard University reported on a study of 1,085 pregnant, HIV-positive women in Tanzania. Half received daily doses of Vitamin A (because 30% of the group were deficient), while the other half received daily multivitamin supplements that did not contain Vitamin A.

Fawzie found only 30 maternal deaths among the women taking multivitamins, compared with 49 among those taking only Vitamin A. Furthermore, the multivitamins reduced the number of infants with low birth weight by 44%, the number of pre-term births by 39% and the number of infants who were small for gestational age by 43%.

The researchers have not yet analyzed the data to determine if the multivitamins reduced the transmission of AIDS, however.

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Fawzie said the vitamins cost about 5 cents per day, and could be even cheaper if purchased in large quantities.

Another intriguing possibility is the application of the inexpensive disinfectant chlorhexidine to the vagina during conventional labor. A recent study in Malawi found that the treatment did not reduce HIV transmission in most women, Mofenson said, but the transmission among those whose membranes ruptured more than five hours before birth--a high-risk group--was reduced.

Moreover, the treatment had many benefits for the mother. The number of postpartum hospital admissions dropped from 40 per 1,000 in the untreated group to 29 per thousand in the treated group. Admissions due to sepsis from potent bacterial infections dropped from five to two per 1,000.

“In the best of all worlds, every mother would receive the best treatment available,” said Rebecca Denison, an HIV-positive mother of uninfected 2-year-old twins. “But most people don’t live in the best of all possible worlds, and we simply have to do what we can.”

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