Correspondence

AIDS Orphans

N Engl J Med 2002; 347:1455-1456October 31, 2002

Article

To the Editor:

Dr. Foster (June 13 issue)1 highlights the epic tragedy of AIDS orphans in Africa and the absolute necessity of providing highly active antiretroviral therapy to adults in Africa. Current initiatives of the United Nations Program on HIV/AIDS that focus on preventing mother-to-child transmission of the human immunodeficiency virus (HIV)2 serve only to exacerbate the orphan crisis. In Africa, where a major determinant of childhood survival is the presence of a healthy mother,3 it seems illogical to allow 28 million adults to die of HIV and then focus on “salvaging” the orphans.

Highly active antiretroviral therapy is the most effective strategy of chemoprophylaxis against mother-to-child transmission.4 It has been argued that Africa lacks the infrastructure and personnel required to provide highly active antiretroviral therapy safely. But many African countries have experience in treating tuberculosis, which involves multidrug therapy and surveillance for resistance. This experience could be built on and rapidly adapted for the provision and management of highly active antiretroviral therapy. The most rational first step would be to treat HIV-infected pregnant women with long-term highly active antiretroviral therapy, thereby ensuring that most mothers survive to look after their own children. Many African countries have vibrant medical schools with the necessary expertise on which to build partnerships with experienced institutions in the United States and other countries in order to make this goal attainable.

Victor M. Moyo, M.B., Ch.B.
University of Connecticut Health Center, Farmington, CT 06030-1315
moyo@uchc.edu

Tawanda Gumbo, M.B., Ch.B.
Ordway Research Institute and Albany Medical College, Albany, NY 12208

4 References

1. 1

   Foster G. Supporting community efforts to assist orphans in Africa. N Engl J Med 2002;346:1907-1910
   Full Text | Web of Science | Medline

2. 2

   UNAIDS statement on United States government initiative to prevent mother-to-child HIV transmission. Geneva: UNAIDS, June 2002. (Accessed October 10, 2002, at http://www.unaids.org/whatsnew/press/eng/pressarc02/USgovMCTC_190602.html.)
   

3. 3

   Boerma JT, Nunn AJ, Whitworth JA. Mortality impact of the AIDS epidemic: evidence from community studies in less developed countries. AIDS 1998;12:Suppl 1:S3-S14
   Web of Science | Medline

4. 4

   Cooper ER, Charurat M, Burns DN, Blattner W, Hoff R. Trends in antiretroviral therapy and mother-infant transmission of HIV. J Acquir Immune Defic Syndr 2000;24:45-47
   CrossRef | Web of Science | Medline

To the Editor:

My organization, the Society for Hospital and Resources Exchange, is a nongovernmental organization that has been working in a rural district in western Kenya for more than 12 years. We have been concentrating our efforts on the orphan problem for the past five years and now support 250 orphans directly and many more indirectly through our work with women's groups and other community groups.

I concur with Foster's statement that it is only through local groups with a long-term commitment who know and work with their communities that community groups will be organized effectively. We have had a difficult time trying to expand our efforts, because external aid is almost always given to large international organizations; we have been told more than once that even though the communities want to work with us, we are too small for these large organizations to fund. The track record of such organizations in our area is very poor; they come for a year or two and then disappear, having spent a great deal of money on administration but having accomplished little. Our communities are aware of these problems and have become very knowing and cynical about such large organizations.

It will be difficult to get the large donors to change their ways. Administering a large number of small projects is much more complicated than administering a small number of large projects. But it would be a great thing if publicity and pressure could be brought to bear to effect such a change.

Renée M. Brilliant, M.D.
Society for Hospital and Resources Exchange, New City, NY 10956
rmbd300@earthlink.net

To the Editor:

In response to Dr. Foster's article regarding the orphan problem in Africa, we would like to describe our experience in caring for orphans with HIV or AIDS in Thailand. Our organization, the Children's Rights Foundation, is a nongovernmental organization for children funded principally from Germany. One of the foundation's projects, Baan Gerda, provides family-style living arrangements and antiretroviral treatment to orphans with HIV infection. Baan Gerda is situated 200 km outside Bangkok on 5 acres of land donated to the foundation by the Prabatnampu temple, a well-known hospice for HIV-infected persons in Thailand. The complex contains five clean and well-ventilated homes, a central kitchen, a playground, and a health center. In each home, there are nine children and two HIV-infected caretakers. The caretakers function as parents to provide love and care to the children in their home. The homes are run independently of one another. There are four staff members on site; all are trained in pediatric nutrition and HIV-related issues. The children generally come to us in bad health, malnourished, and with skin infections. Children undergo thorough medical examinations by a local physician and have their CD4 counts checked. A pediatric HIV specialist handles antiretroviral treatment using (for the most part) generic stavudine, lamivudine, and nevirapine. All children except one have had excellent clinical and immunologic outcomes. The cost of medical care for one child is $100 per month.

Our long-term goal is to prepare our children for adulthood. Our highest priority is to provide them with love and care.

Jintanat Ananworanich, M.D.
Thai Red Cross AIDS Research Center, Bangkok 10400, Thailand
jintanat.a@chula.ac.th

Olivia Tulloch, M.A.
Karl Morsbach
Children's Rights Foundation, Bangkok 10210, Thailand