Garrett: Experts Face Tricky Task in Preventing HIV/AIDS in Africa

A Washington Post article suggests that hundreds of deaths in Botswana may be linked with the promotion of infant formula for mothers with HIV/AIDS. Laurie Garrett, CFR senior fellow for global health, says Botswana’s experience typifies the “lose-lose” scenario for health experts seeking to prevent the spread of AIDS in sub-Saharan Africa. The region’s lack of access to clean water means infant formula, successfully used in the West to avoid the transmission of AIDS through breast feeding, is not an option. But mothers continue to have inadequate access to medications to block the virus from spreading through breast milk. There is also a great deal of suspicion, Garrett says, about distributing new vaccines in poor countries. To make progress, she says, will require “an enormous amount of political education” as well as “some serious diplomatic tact on the part of U.S. foreign aid experts.”

Hear the podcast of the interview here.

The Center for Disease Control’s investigators concluded that the decade-long global push to provide an infant formula to mothers with AIDS backfired. What went wrong?

It started in the United States in the early 1980s when it was recognized that mothers could transmit the virus HIV in their breast milk to their babies and that not all the babies that were “born HIV positive” were actually born infected, but rather acquired the infection during the nursing months in their early life. In the early days, since we didn’t have effective drugs, there was really nothing we could do in the United States except tell those mothers to use formula. That was indeed the norm, but it’s quite different to tell mothers in the United States of America to use formula where the water that comes from the tap is safe to drink compared to the situation in poor countries, particularly in sub-Saharan Africa.

Starting in the late 1990s, we started introducing a drug called nevirapine as a blocker of HIV given to the women during pregnancy who were known to be HIV positive and then in their immediate post-labor delivery time. It has effectively reduced the numbers of babies born HIV positive, but if the mother does not remain fully medicated with a truly effective range of anti-HIV drugs and continues to nurse, it’s virtually a certainty that over time she will pass the virus to her child.  You kind of defeat the whole purpose by giving the drug to block the transmission during birth [because] you virtually eliminate the positive impact with nursing, so there have been a lot of programs initiated over the last ten years aimed at increasing formula feeding among HIV-positive mothers.

But if you don’t have cooking fuel in order to sterilize your bottles and your liquid that you’re mixing the powdered formula with and you don’t either have access to safe water or safe milk or some safe liquid to mix it with, you’re going to end up giving your child shigella, cholera, any of a number of diarrhea-producing viruses and bacterial infections, and then your child is going to be one of those horrible statistics where the number two cause of death for children under five today is diarrhea-related diseases.

The Post article says Botswana’s health minister “angrily recalled” that during the breast-milk-formula debate, some people suggested a two-tiered approach; one to promote breast feeding in poor nations and one to promote infant formula in wealthy nations. Was that the right approach in hindsight? 

Well, we’re kind of over a barrel on this, and I’m not sure anything is served by getting angry at any particular policymakers. Let’s just say you’re a physician and a woman has come into your office. You know she’s HIV-positive, she’s in her eighth month of pregnancy, you’ve got her on drugs to block her transmission of HIV to her baby. If you’re in Botswana, you don’t even have enough money to keep her on drugs after pregnancy, so she’s going to have a lowered level of HIV in her body, but you know that she’s poor, she comes from one of Botswana’s ghetto communities, she doesn’t have access to safe drinking water, she doesn’t have enough water to wash herself well, so her hands are likely to be handling foods and preparing foods with potential contaminants on them, so you have to make a choice. What do you tell that woman to do? If you give her formula, will she have access to any of the necessary equipment to do it properly and safely for her child? On the other hand, if you tell her to nurse while she’s on her antiretroviral drugs, she still has a statistical probability of passing the virus to her child.

In a way, you’ve got this sort of lose-lose scenario. Now, there are countries where bolder solutions have been arrived at through extraordinary levels of external funding from donors, particularly from the United States and the UK, which includes things like buying a stove for that woman, providing her with a weekly ration of propane for her stove, and buying her cooking equipment so that she could safely make formula. That is an extraordinarily expensive thing to do and we’re already getting reports of jealous women who are HIV-negative wishing to fake that they have HIV just so they can get a stove.

An AIDS vaccine is on the horizon and already a similar debate is ensuing over a differing role the vaccine would play in developing nations compared to developed ones, especially in Africa. Could you talk about what’s going on in that debate?

We have the potential that some time at the end of next year or early the following year, Merck Pharmaceuticals is going to unseal the blinded data on a study in which they’ve been comparing various groups receiving various doses of the Merck HIV vaccine to placebo recipients. We hope that vaccine is going to turn out to be effective at some level, though absolutely nobody thinks it will be effective at the level we traditionally expect of a vaccine, meaning near 100 percent ability to block the entry of the virus into your body. The company is really out on a limb on this one. If their vaccine is essentially blocked from use because it’s not 100 percent effective, it will send a message to the entire vaccine industry to stay away from HIV/AIDS. On the other hand, it’s going to be very difficult to figure out politically and socially how to use a partially effective vaccine. 

Let’s just say hypothetically that the Merck vaccine turns out to be 50 percent effective. That would mean that on a statistical basis if two people got vaccinated, one of them would be protected and one wouldn’t, or it might mean on an individual basis that at any given time that you’re exposed to HIV sexually or by other means, the odds are 50/50 you’ll get infected with the virus. We’re not sure which way it would be, but the point is, if you’re in a situation where about a third of the population around you is already infected, every margin of protection is a help, is a good, is something you want, whether it’s a condom, whether its using any of a variety of different approaches to trying to protect yourself sexually, or whether it’s a partially effective vaccine. But it doesn’t make sense particularly to use a vaccine with that low of an efficacy for the general population in a country like the United States where well below 1 percent of the population is infected. 

Instead of thinking of it in the context of how it would play out in Africa politically, ask yourself how it would play inside the United States if the Department of Health and Human Services announces that they’re going to do targeted HIV vaccinations of only black-skinned people living in particular neighborhoods of the United States and homosexual men living in big, urban homosexual communities. You could see there would be a lot of tension around this because there would be a feeling that a given community is being targeted with a product that is less than perfect and that maybe they’re being targeted with that product because they’re considered less than perfect as well. If you take the same sort of tension that you could logically see arising and extrapolate it on an international basis, you can understand why some African countries in particular would look at this and say “Well, why is a product that you don’t think is good enough to use on the general population in America good enough to use on the general population of, let’s say, Botswana?” Something that’s only a partially effective product would not be of utility to save a society if very, very few people in the society have that disease, but in a society or a community where the infection rate is extremely high, even a dismal product can have a benefit. It’s going to be very, very tricky. It’s going to require an enormous amount of political education and conversation, and it’s going to require some serious diplomatic tact on the part of U.S. foreign aid experts.

Overall, what lessons do you think global health experts and policymakers will take away from this infant formula policy?

We’re getting a number of sorry lessons piling on top of each other in the HIV-prevention arena all at once. The first one came related to a microbicide trial. A microbicide is a product that a woman could use in the form of a foam or a cream that she would insert in her vagina to protect her from HIV from her male sexual partner. There has been a whole lot of hope that an effective microbicide could basically accomplish the same deed as a vaccine, but we don’t have a home run product, we have some sort of good products and we need to try them and see if they work. A clinical trial in South Africa of a particular microbicide product that some advocates were enthusiastic about backfired; it turned out that the group of women that received the microbicide had a higher HIV rate than those who received a harmless, useless placebo. This of course sparked huge outcry in South Africa, with many South Africans charging that it was a racist trial, that the United States and the Gates Foundation, which sponsored it, were using Africans as guinea pigs to test out crummy products. 

So, we’re now looking at one thing after another where [there’s] this sensitivity in Africa about how these products are being tried out, who they’re being tried on, and what the outcomes are of those trials.  There’s a tremendous amount of conversation going on about this right now among all the HIV/AIDS community; it’s not as if anybody’s taking this lightly. Everybody’s trying to figure out how to proceed. 

But you can’t get quick results on any product related to HIV unless you test it in a place where the AIDS rate is very high so that the likelihood of an individual being exposed is high. If we did all our trials on HIV products in, let’s say, Des Moines, Iowa, it might take two or three decades to be able to tell a difference between something that looked to prevent HIV and something that looked like it wouldn’t, just because the statistical odds of any given individual in Des Moines, Iowa, being exposed to HIV are tremendously low. If in contrast we do a trial like that in Gaborone, Botswana, where more than 35 percent of the population is infected in the adult sexually-active population, then we could get a result that tells us whether or not there’s a prevention benefit in a matter of months. We have a difficult situation here trying to understand how to walk the walk and talk the talk in terms of getting the kind of scientific answers we need to save millions of people from getting HIV, and at the same time showing the appropriate sensitivity and concern for the needs of people in poor countries, particularly when there is a racial component to this, and those poor people are dark-skinned people and the researchers are light-skinned people.