Reducing mother-to-child transmission of H-I-V/AIDS has become one of the main health priorities in Ivory Coast. The country has the highest prevalence of H-I-V-positive pregnant women in west Africa -- more than 10 percent. Every year, about 20-thousand Ivorian babies contract the virus that causes AIDS through their mothers. With help from the U-S Centers for Disease Control and millions of dollars in U-S aid, the government is working to reverse that trend. But poverty, a run-down public health system and social stigmas pose enormous challenges.
At the Koumassi health center in Abidjan, nurses take care of babies -- both H-I-V-positive and healthy. A team of health workers is trying to reduce the number of babies born H-I-V positive. Studies indicate that, without assistance, up to 40 percent of mothers with the virus will transmit it during pregnancy, delivery or breast-feeding.
When pregnant women arrive at the clinic for their first consultation, they are brought together in an AIDS education class. The women are encouraged to return to take an AIDS test. More than 70 percent agree.
After being tested, women wait several hours for the results, squeezed together on uncomfortable benches. For some, it will be their last visit to the clinic, regardless of the test results, because some will be pressured by relatives to give birth at home.
Viviane Bahie, who is expecting her second child, is nervous, even though every one in her family seems healthy.
She says, "These tests are important, because they allow us to be sure and to have confidence in our husbands. But it makes you nervous. It might be positive, who knows, So, it's difficult. Everyone here is very courageous. In a way, it allows us to liberate ourselves. It's also a question of life, so we need to do it."
If a woman is H-I-V-positive and she returns to the clinic for delivery, she will be given one dose of the drug Nevirapine during labor. Her baby will be given a dose of the same infection-blocking drug within three days of birth. Studies suggest this simple treatment effectively cuts mother-to-child transmission of H-I-V by 50 percent.
Some women are also given formula to feed their babies instead of their own milk. That can cut the 15-percent risk that breast-feeding will lead to transmission of the virus. At the Koumassi clinic and dozens like it in Ivory Coast, also supported by the U-S Centers for Disease Control, the drugs and formula are given to mothers for free.
The Ivorian coordinator of this program is Edith Boni-Ouattara. She says H-I-V-positive pregnant women want to participate, but that most are afraid to tell others about their condition because of the social stigma surrounding the disease and the strong traditions governing the care and feeding of newborns. This, she says, makes it more difficult for them to take the necessary measure to prevent mother-to-child transmission, including avoiding breast-feeding.
She says, "When they are H-I-V-positive, there is no real resistance. They come, and they want the best for their children. The problem is the environment, the family, because notification -- the disclosure is low, the rate is less than 10 percent. After, when they choose the artificial milk, there are problems. The biggest challenge is social, so we (also) need important community mobilization around these women."
Some women who refuse to disclose their H-I-V status, but still want to avoid breast-feeding make up stories, saying their doctor told them their milk was bad. Family members are often suspicious of the artificial milk, especially if they are poor. Also, sanitation can be a problem, and if the formula is mixed with dirty water, it can make the baby sick."
Exclusive breast-feeding for a limited period of just six months is often recommended as an adequate, if not perfect, alternative. Recent studies show that exclusive breast-feeding has a lower likelihood of transmission than what is called mixed feeding, which is mixing breastfeeding with other food and liquids.
After six months, mothers are instructed to stop breast-feeding completely. Scientists say this method seems to lessen the risk of transmission substantially.
In more developed countries, the use of extended drug treatments, birth by caesarian delivery, which has less exchange of blood than a natural birth and feeding clean artificial milk can completely reduce mother-to-child transmission. But all these options are not possible in Ivory Coast, because it is simply too expensive, the drugs aren't available, there isn't expertise for caesarian deliveries and clean water is sometimes hard to access.
Despite the campaign to end mother-to-child transmission of H-I-V in Ivory Coast, less than two percent of H-I-V-positive mothers have so far been helped, because there is so little public health infrastructure outside of big cities.
Compounding the difficulties, a civil war erupted in Ivory Coast last year, and there are no U-S-funded clinics yet in northern and western rebel-held regions. The project's director, Monica Nolan, says, even in areas where there are clinics, many more babies could be saved, but the extra burdens placed on local staff also interfere.
She says, "To get there, women need to actually be counseled and choose to be tested in an environment where there's still stigma and enormous barriers to that. And to ask health workers to incorporate yet another duty with voluntary counseling and testing, as well as the counseling of Nevirapine and infant-feeding, that's very challenging. The pay, the salary, the staff morale in the public sector in many African countries is really an enormous challenge."
Despite this, Mrs. Nolan says, the program in Ivory Coast is encouraging because it offers what she calls an "entry point" in tackling H-I-V/AIDS. She says the disease used to be a medical death sentence, but now is increasingly an economic and social problem, as treatment and care become more available.
The three-year, 15-billion dollar U-S initiative to fight AIDS also includes programs in seven other sub-Saharan African countries -- Botswana, Ethiopia, Kenya, Mozambique, Rwanda, South Africa and Uganda. Next year, the program will expand to four more --Namibia, Nigeria, Tanzania and Zambia.