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A pregnant woman with HIV, and the cost of U.S. foreign aid cuts

When I met a woman I'll call "Mary" in Luwingu, a remote district in northern Zambia, she had already seen three of her children die. She did not know that she had contracted HIV until she arrived at the clinic where for the past few months I had been supervising care for pregnant women living with HIV.

Like many women, when she learned that she was HIV-positive, she required counseling to be able to grasp her situation — that she would need to be on medication for the rest of her life and that there was a strong possibility that her baby could be born with HIV unless she adhered to antiretroviral treatment and followed the prevention of mother-to-child transmission (PMTCT) program. Women in the program must come to the Doctors Without Borders/Medecins Sans Frontieres (MSF)-supported clinic monthly for check-ups and refills.

Mary's child is part of the "AIDS-free generation" that Secretary of State Hillary Clinton called for this month at the National Institutes for Health. But this vision is under threat in Congress.

The House and the Senate are discussing significant cuts to the 2012 Obama administration request for global health funding. The House is proposing cuts of around 18 percent, while the Senate is proposing 9 percent cuts. In many respects, they will be deciding the fate of women like Mary.

Maryland's congressional representatives will play a critical role in the future of funding for programs like the one that helps Mary. As a member of the Senate Appropriations Committee, Maryland's Sen. Barbara Mikulski will be asked to vote on a fiscal year 2012 bill that calls for a $640 million reduction in President Barack Obama's request for the President's Emergency Plan for AIDS Relief (PEPFAR) and the Global Fund to Fight AIDS, TB, and Malaria (GFATM). This would diminish PMTCT and HIV programs in some of the countries hardest hit by the HIV epidemic.

Meanwhile, Rep. Chris Van Hollen Jr. of Maryland is a member of the Joint Select Committee on Deficit Reduction (the "supercommittee") that has been tasked with issuing recommendations on how to reduce the deficit by at least $1.5 trillion over the next 10 years, which will potentially affect the U.S. government's broader support for global health programs over the next decade.

Like much of sub-Saharan Africa, Zambia has been devastated by the HIV epidemic, with an estimated 14 percent prevalence in 2009, according to UNICEF. An estimated 80,000 infants are born at risk of contracting HIV each year. Mother-to-child transmission of HIV drops from 25 percent to 40 percent to less than 2 percent with adherence to PMTCT, according to the World Health Organization. In a setting with poor access to pediatric HIV services, most children born with HIV die by age 5 without treatment.

In the U.S., babies are rarely born with HIV because most HIV-positive pregnant women here have access to HIV treatment and counseling. In developing countries, maternity programs with a PMTCT component like ours in Luwingu provide an opportunity for mothers be tested for HIV (as well as other dangerous conditions for pregnant women) and to take the steps needed for them and their babies to live healthy lives; as well as for communities to gain productive members instead of incurring yet more losses.

According to the American Foundation for AIDS Research, a modest 5 percent cut in the U.S. foreign aid budget would mean 69,000 fewer HIV-positive women will receive PMTCT services worldwide.

Once Mary understood her situation, she came twice a month, sometimes more. She worried that she may be doing something wrong and had endless questions for the health staff. Her husband was not supportive of her decision to get treatment; he blamed her and would not get tested himself. When asked why she came to the clinic, she replied, "I don't care what he thinks anymore, I am tired of being sick and am here to take care of my own health and my baby's health."

She was not the only woman who came to the clinics with that kind of determination in spite of the daunting stigma around HIV/AIDS and having little social support. Many women realize how important treatment is for them and their children and have prioritized it in their lives. Mary ended up delivering a healthy baby boy. Children in the program need to be followed and tested several times over 18 months to ensure they have not contracted the virus. When I left, Mary's son was still testing negative at 6 months.

MSF does not accept any U.S. government funding, so our work will not be affected by the massive cuts being recommended. However, Zambia's health authorities and many other nongovernmental organizations working to combat the country's high HIV rate through prevention and treatment programs, such as PMTCT, are likely to be severely affected.

MSF is currently treating 83 women and children in its PMTCT program in Luwingu and aims to treat more than 250 during the existence of the project. The Zambian Ministry of Health, along with other nongovernmental organizations, treats a great deal more, mostly in urban areas. They currently lack the resources to extend effective PMTCT and HIV services into many rural areas. Much of the care they are able to provide comes from U.S. funding through PEPFAR and GFATM. Although the country still has a ways to go to live up to its commitment to make treatment available to everyone, it has made significant strides in the fight against AIDS — in large part because of funds from those two programs.

If Congress votes to sacrifice that progress, Zambia and Africa will lose many women like Mary, who, given the resources, will do everything in their power to give their children healthy lives. Those resources are not the kind you cut — they are the difference between life and death.

Dr. Jeanie Yoon is a physician with Doctors Without Borders/Médecins Sans Frontières (MSF). A longtime resident of Laurel, she recently moved to Seattle. Her email is jeanie.yoon@gmail.com.

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