January 30, 2005
U.S. Is Close to Eliminating AIDS in Infants, Officials Say
By MARC SANTORA

IDS among infants, which only a decade ago took the lives of hundreds of
babies a year and left doctors in despair, may be on the verge of being
eliminated in the United States, public health officials say.

In 1990, as many as 2,000 babies were born infected with H.I.V., the virus
that causes AIDS; now, that number has been reduced to a bit more than 200 a
year, according to health officials. In New York City, the center of the
epidemic, there were 321 newborns infected with H.I.V. in 1990, the year the
virus peaked among newborns in the city. In 2003, five babies were born with
the virus.

Across the country, mother-to-child transmission of H.I.V. has dropped so
sharply that public health officials now talk about wiping it out.

"This is a dramatic and wonderful success story," said Dr. Vicki Peters, the
head of pediatric surveillance for the New York City Department of Health
and Mental Hygiene. This winter, Dr. Peters presented a report in Bangkok
for World AIDS Day documenting the improvement in New York.

The success in fighting mother-to-child transmission, a sweeping victory for
public health officials, was made possible largely because of better drugs,
but aggressive public education and testing, as well as cooperation at the
federal and local levels, also played a significant role.

The advent of AZT, a drug used to attack H.I.V. in the blood and central
nervous system, was critical. But equally important was simply getting
mothers to know their H.I.V. status before they gave birth, a problem
complicated by privacy and political and social issues.

Much of the developing world continues to be ravaged by AIDS, however. In
sub-Saharan Africa, more than two million people died of the disease last
year. "We have had incredible progress," said Dr. Lynne Mofenson, the chief
of the Pediatric, Adolescent and Maternal AIDS Branch of the National
Institute of Child Health and Human Development, part of the National
Institutes of Health. "But if you think about the U.S. and New York and then
you think about Africa, it is like a tale of two cities, a tale of two
epidemics."

The advances in this country are considered stunning, given the scope of the
problem two decades ago.

"What we were grappling with was death," said Dr. Stephen Nicholas, a
pediatric AIDS specialist at Harlem Hospital Center, remembering the late
1980's and early 1990's. "We were preoccupied by death."

As AIDS spread from the gay community to drug users, women and finally their
children, Dr. Nicholas recalled, frustration and hopelessness grew. At his
hospital, 30 to 40 babies were dying a year. Mothers were giving birth to
H.I.V.-infected children at an alarming rate across the country, estimated
at 2,000 a year. While health officials did not track infant H.I.V. cases
nationwide, they did count infants with AIDS, a figure that peaked near 900
in 1992. New York City was especially hard hit, accounting for about 22
percent of the infant infections.

Central Harlem and the South Bronx had the highest rates of infection in the
country. Yvonne, a 37-year-old woman from the Bronx, gave birth in 1994 at
Harlem Hospital Center, and learned that both she and the baby had H.I.V.
only after the child, her second, began developing strange rashes and
swollen glands.

"I got hysterical and I went into a rage and I started throwing things,"
said Yvonne, who asked that her last name not be used because her friends do
not know she has H.I.V. "I thought everyone was lying and out to get me. I
got really scared, to where I really didn't want to touch my child.

"I thought I was going to die. I thought me and my children were going to
die. I just assumed we all were doomed."

Just after Yvonne gave birth, the tide began to turn. Several months after
her son was born, a groundbreaking study was completed that changed the way
pregnant women infected with H.I.V. would be treated.

Doctors suspected that AZT could be effective at reducing the presence of
the virus in the bloodstream and significantly decreasing the chances of
transmission, but there was reluctance to give the drug to pregnant women.
Eventually, faced with thousands of sick babies, the National Institutes of
Health allowed a test in which some mothers were given a course of AZT and
others were given a placebo. Public health officials anxiously awaited the
results.

"I remember the day," Dr. Mofenson said, recalling when the results were
released in 1994. "It was absolutely incredible."

The study showed a 67 percent reduction in the risk of transmission.

Moving with unusual speed, the federal government immediately allowed the
women in the study group who had been taking placebos to switch to AZT, Dr.
Mofenson said, and the babies born to those mothers also had a lower H.I.V.
infection rate. Soon, women across the country were being treated.

With no intervention, the likelihood that an infected mother will pass
H.I.V. to her child is 20 to 25 percent, according to the Centers for
Disease Control and Prevention. A year after the introduction of AZT
treatment, the risk had dropped to 8 percent, Dr. Mofenson said.

Since then, a combination of ever better drugs, more rigorous testing and
partner notification, and greater awareness of the necessity of safe sex
practices has contributed to reducing the risk even further.

AZT was most effective if taken during the second trimester and administered
during labor. But many women, like Yvonne, had little if any prenatal care
and did not know whether they had H.I.V. Dr. Lucia Torian, the director of
H.I.V. surveillance for the city's health department, said that in the first
years treatment was available, the city and state were still finding
infected mothers only when they gave birth to infected children.

The stigma of AIDS posed a significant barrier to the flow of vital
information. While the state started an AIDS surveillance program in 1981
and tested all newborns for H.I.V. beginning in 1988, for years the program
was conducted blind, meaning that no names were attached to the data. If a
mother gave birth to a sick child, she would not be told that she or the
child had H.I.V. Often the mother would not learn that both had the
infection until the baby showed serious, usually fatal symptoms. And health
workers did not track down and notify sexual partners of those who had the
disease, a standard practice with other sexually transmitted diseases.

David Rosner, a professor of public health history at the Columbia
University Mailman School of Public Health, said the fear that AIDS patients
would suffer discrimination was not without reason.

"When this disease struck, it was often seen as being brought on by the
individual himself," he said, noting that in other epidemics - from
tuberculosis to cholera - a similar reaction had occurred.

Dr. Guthrie S. Birkhead, director of the AIDS Institute and the Center for
Community Health at the New York State Department of Health, said that in
1997 the state finally began attaching patient information to the newborn
H.I.V. tests it conducted and then passing that information along to a
patient's doctor, so that mothers could get treatment.

In 1998, a state law was passed that required hospitals to conduct immediate
testing of newborns. The results could be learned in 12 hours, and patients
could be treated promptly.

"The newborn testing became a safety net," Dr. Birkhead said.

Although New York was hit harder by AIDS than any other state, New York
lagged when it came to AIDS reporting, said Dr. Torian, of the city's health
department.

"It is very hard for us to understand at this point," Dr. Torian said. "It
felt from the public health point of view, and even from the personal view
of the mother, not to be a rational stance."

In the last four years, only one baby has been born with H.I.V. at Harlem
Hospital Center. Gone are the days when every bed in an orphanage created to
take in children born with H.I.V. was filled as quickly as it became
available.

The city's health commissioner, Dr. Thomas R. Frieden, said the turnaround
in New York was "absolutely a success story." But he cautioned that there
was more to be done. He ticked off all the information he has at his
fingertips when it comes to a disease like tuberculosis - from the type of
drugs patients are taking to key lab tests to whether they are responding
well to treatment - and noted that no similar system existed to closely
monitor H.I.V. and AIDS.

"We're not legally able to collect that information, and even if we were,
New York State law would prevent us from using this data to improve patient
outcomes," he said, referring to state privacy laws.

And success in treating AIDS has raised the concern that the public may be
growing complacent about AIDS prevention. A survey conducted by the city's
health department in 2003 showed that 40 percent of people who had sex with
multiple partners said they did not use condoms.

But as the struggle with pediatric AIDS shows, much can be accomplished when
there are a clear focus and a concerted effort. Not only are children born
with H.I.V. living longer, mothers now can take action to make sure they
never pass on the virus, and there is anecdotal evidence that many now feel
free to have more children.

Yvonne and her H.I.V.-positive son, who just turned 11, are leading full
lives. She had another child 14 months ago, this time getting treatment
during her pregnancy that allowed her to give birth to a healthy baby, free
of the virus.

"We don't need to be bringing sick babies into the world," Yvonne said. "We
need to let everyone know it is still out there, but we can do something
about it."