`A Scandal’ – Children Issues Not On Agenda
Peter McDermott is the Managing Director of the Children’s Investment Fund Foundation (CIFF), one of the largest charities in the United Kingdom. He previously had worked at UNICEF for 21 years, serving as Chief of the HIV/AIDS section in the program division at UNICEF headquarters in New York, as well as holding positions in Africa and Europe. After the Pacific Health Summit in London last week, where he laid out an ambitious agenda for advancing efforts to prevent the transmission of HIV from mother to child and to treat HIV-positive children, John Donnelly interviewed McDermott about his expectations for the International AIDS Conference in Vienna, starting July 18.
McDermott said he will reply to any questions posed in the Comments section and that he welcomes any suggestions for CIFF’s work in these areas.
Q: What are your goals for the AIDS conference?
A: My mind goes back to the AIDS conference where Stephen Lewis was chairing a session with Bill Clinton and Bill Gates, and one of the themes was we would address and eliminate the transmission of HIV from mother to child. That was four years ago. There’s an element of, `We’ve been here before.’ But there’s never progress in the interim. We need to be very sober about what we are trying to do, a little less self-congratulatory, and a little more self-critical.
Q: So what’s realistic?
A: Going in to Vienna, CIFF is very pleased we have made progress globally on PMTCT (prevention of mother to child transmission of HIV) but we haven’t done enough with the resources spent to date. It’s not just about harnessing more resources but using them more effectively.
I see three challenges – a conceptual challenge, a challenge of delivery, and a challenge of measurement and impact.
Within the conceptual challenge, the vocabulary we have used – prevention of mother to child transmission — has been useful shorthand, but now it’s a burden. We medicalized the problem and made it a drug issue about single-dose nevirapine. There’s really been an underinvestment in other interventions, such as preventing infections and preventing unwanted pregnancies and also care and support and treatment of mothers and children. We need to get back to a more comprehensive agenda. We need to get into a more family-based care system.
There have been a significant number of delivery challenges for far too long. Even the distribution of single-dose nevirapine — in and of itself a sub-optimal regimen – we’ve found that mothers have not always taken what they are given. Unless we get more pregnant mothers into the entry of the PMTCT cascade, it doesn’t matter what regimen we make available because you need large numbers of women to be an effective delivery strategy. Then you need to follow up on them.
And the third point, we are measuring the wrong things. We shouldn’t be looking just at how many women are getting new drug regimens, but also have many are using them. We need to make sure people are surviving. One of biggest challenges is that we now have more than 250,000 children on ARVs, but in some countries we have no idea of how many are alive and well. There’s no point doing this unless we know there is long-term survival.
Q: So will there be a shift toward addressing these challenges in Vienna?
A: As in the previous AIDS conference, the absence of children on the main agenda is a scandal. There are no other words for it. Elaine Abrams from Columbia is on one plenary session on mother-to-child-transmission, and that is welcome, but the issue will not see much air time in Vienna. Pediatric AIDS agenda also is conspicuous by its absence. There’s a two-day pre-conference symposium on children, but not much else.
What we should be doing is put PMTCT and pediatric AIDS both under the pediatrics agenda and make the programs more closely aligned. So in a hospital, there should be one clinic for mothers and children, a one-stop shop. We need to look at this issue as family care rather than disease specific care.
Q: What’s important to your foundation at this conference?
A: We have four areas we’re looking at. The first is we still haven’t managed to get significant, sustained uptake of cotrimoxizole for children – it’s a very cheap antibiotic and the impact on mortality will be very dramatic. Two, the Clinton Foundation and UNITAD and others have done a lot in bringing down the cost of pediatric drugs, but the fixed-dose combination drugs to market really haven’t been brought to scale — we need to push it.
Third, the loss to follow-up issue – the issue of initiating a lot of children on treatment, but we don’t know what is happening to them. And four, we come up against a brick wall identifying exposed children; we don’t have a good point-of-care diagnostics tool to identified whether the children are infected – that is the unfinished agenda.