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Agnes Moses: preventing maternal transmission of HIV in Malawi
Perspectives
Profile Agnes Moses: preventing maternal transmission of HIV in Malawi Doctors like Agnes Moses are rare and valuable in Malawi. The country has just one doctor for every 50 000 people; the UK, by contrast, has one for every 250. A senior investigator at the University of North Carolina’s (UNC) HIV Project in Malawi, Moses has pioneered a programme to prevent HIV-positive mothers from infecting their babies. That she has kickstarted such a programme at all is remarkable in a country with a crumbling health-care system. Moses joined the UNC Project-Malawi in 2001 as a programme manager on what would be one of the country’s first local attempts to prevent mother-to-child transmission of HIV. When the initiative began, about 24% of pregnant women in the capital Lilongwe were infected, and by 6 weeks after birth about 27% of their children would catch the virus from them. Initial results suggest that the UNC programme is working—HIV infection rate at 6 weeks is about 11–14%, although Moses cautions “the numbers are small and may not be representative”. It was crucial that the approach the UNC team took was affordable enough to be sustainable in the future by the local health system. In 1999, a key trial called HIVNET012 had shown that giving nevirapine to HIV-infected pregnant women and their babies straight after birth could be effective and inexpensive. One of their first challenges in Malawi was to detect infection in pregnant women. In 2002, only about half the pregnant women in the area were being tested, but after instituting an opt-out system, 99% of women were being tested by 2005. The project received an extra boost last year when Moses was awarded the 2009 International Leadership Award from the Elizabeth Glaser Pediatric AIDS Foundation. The award will mean that Moses receives funding for 3 years to train health-care workers to improve their programme to prevent mother-to-child transmission (PMTCT). Much is riding on the success of the programme— if it is successful, Malawi’s Ministry of Health will incorporate the most effective components into a national scheme to reduce mother-to-child transmission of HIV. As a native Malawian, Moses feels very strongly that any approach to tackling HIV should be culturally sensitive. As part of the groundwork before rolling out the UNC’s programme, Moses and her team assessed the way HIVinfected Malawian mothers felt about their bodies. This piece of social science has clinical relevance, she says. “In Africa, a healthy woman is perceived to be one who looks plump or even obese”. Many of the women with HIV were so concerned about their disease-related weight loss that they felt they shouldn’t breastfeed their babies. For Moses, this emphasises “how strongly linked infant nutrition is to maternal nutrition, and that programmes focused on the one cannot ignore the other”. www.thelancet.com Vol 375 March 6, 2010
The use of traditional birth attendants is also culturally embedded in Malawi, and Moses’ team has relied on their assistance in getting prophylactic treatment to pregnant women. Moses says the government is “reluctant” to use these attendants as caregivers, but since 40% of Malawian women still give birth in this way, the clinic felt it right to enlist these workers. “The role of traditional birth attendants in our programme has been to make sure that mothers have nevirapine and pre-packed nevirapine for the infants and that it is actually administered”, Moses explains. Moses became interested in the maternal aspect of HIV transmission when she worked in a district hospital in Chiradzulu, where HIV prevalence in pregnant women was startlingly high. Of the 91 000 children in Malawi with HIV/AIDS, 90% become infected through mother-to-child transmission. For Moses, the high rate of infant infections had a particular poignancy—once, she herself had been a baby in that same district. As one of eight children brought up by a single mother, she knows well the challenges of raising a family with little access to health care. Moses says she found her calling to medicine early, while at primary school. But before she could become a doctor, she had to leave Malawi to train. After securing a scholarship, the 20-year-old found herself on a plane to Adelaide in Australia. Exchanging an African village for a wealthy developed city was “the biggest shock of my life”, Moses says. “Most people I grew up with had never even been to school.” By her third year, she returned to Malawi to join the country’s first medical school. After joining the UNC Project-Malawi, the organisation financed Moses’ education in internal medicine at the University of the Witwatersrand in Johannesburg. Charles van der Horst, professor of medicine at UNC, recalls that “Agnes was my first hire in Malawi, a quiet, funny, smart recent graduate of the University of Malawi College of Medicine”. What she has achieved is remarkable says van der Horst: “Her task was daunting, start a PMTCT programme in Lilongwe as fast as possible. This small, quiet woman was a whirling dervish, meeting with Ministry of Health personnel to get the requisite approvals, hiring staff, renovating space. Within 18 months we were testing 20 000 pregnant women at four centres. Only Agnes could have accomplished so much in such a short time. Malawi is truly fortunate to have her as a doctor.” Someone with Moses’ talent and determination could probably make a more lucrative living in a richer country, but she can’t yet contemplate leaving Malawi. The need for doctors like her is greater there than almost anywhere in the world.
For more on UNC ProjectMalawi see http://www.med. unc.edu/wrkunits/2depts/ medicine/id/malawi
For more on the International Leadership Award from the Elizabeth Glaser Pediatric AIDS Foundation see http://www. pedaids.org/GrantsandAwards/ Awards/InternationalLeadership-Award.aspx
Priya Shetty [email protected]
797
Profile Agnes Moses: preventing maternal transmission of HIV in Malawi Doctors like Agnes Moses are rare and valuable in Malawi. The country has just one doctor for every 50 000 people; the UK, by contrast, has one for every 250. A senior investigator at the University of North Carolina’s (UNC) HIV Project in Malawi, Moses has pioneered a programme to prevent HIV-positive mothers from infecting their babies. That she has kickstarted such a programme at all is remarkable in a country with a crumbling health-care system. Moses joined the UNC Project-Malawi in 2001 as a programme manager on what would be one of the country’s first local attempts to prevent mother-to-child transmission of HIV. When the initiative began, about 24% of pregnant women in the capital Lilongwe were infected, and by 6 weeks after birth about 27% of their children would catch the virus from them. Initial results suggest that the UNC programme is working—HIV infection rate at 6 weeks is about 11–14%, although Moses cautions “the numbers are small and may not be representative”. It was crucial that the approach the UNC team took was affordable enough to be sustainable in the future by the local health system. In 1999, a key trial called HIVNET012 had shown that giving nevirapine to HIV-infected pregnant women and their babies straight after birth could be effective and inexpensive. One of their first challenges in Malawi was to detect infection in pregnant women. In 2002, only about half the pregnant women in the area were being tested, but after instituting an opt-out system, 99% of women were being tested by 2005. The project received an extra boost last year when Moses was awarded the 2009 International Leadership Award from the Elizabeth Glaser Pediatric AIDS Foundation. The award will mean that Moses receives funding for 3 years to train health-care workers to improve their programme to prevent mother-to-child transmission (PMTCT). Much is riding on the success of the programme— if it is successful, Malawi’s Ministry of Health will incorporate the most effective components into a national scheme to reduce mother-to-child transmission of HIV. As a native Malawian, Moses feels very strongly that any approach to tackling HIV should be culturally sensitive. As part of the groundwork before rolling out the UNC’s programme, Moses and her team assessed the way HIVinfected Malawian mothers felt about their bodies. This piece of social science has clinical relevance, she says. “In Africa, a healthy woman is perceived to be one who looks plump or even obese”. Many of the women with HIV were so concerned about their disease-related weight loss that they felt they shouldn’t breastfeed their babies. For Moses, this emphasises “how strongly linked infant nutrition is to maternal nutrition, and that programmes focused on the one cannot ignore the other”. www.thelancet.com Vol 375 March 6, 2010
The use of traditional birth attendants is also culturally embedded in Malawi, and Moses’ team has relied on their assistance in getting prophylactic treatment to pregnant women. Moses says the government is “reluctant” to use these attendants as caregivers, but since 40% of Malawian women still give birth in this way, the clinic felt it right to enlist these workers. “The role of traditional birth attendants in our programme has been to make sure that mothers have nevirapine and pre-packed nevirapine for the infants and that it is actually administered”, Moses explains. Moses became interested in the maternal aspect of HIV transmission when she worked in a district hospital in Chiradzulu, where HIV prevalence in pregnant women was startlingly high. Of the 91 000 children in Malawi with HIV/AIDS, 90% become infected through mother-to-child transmission. For Moses, the high rate of infant infections had a particular poignancy—once, she herself had been a baby in that same district. As one of eight children brought up by a single mother, she knows well the challenges of raising a family with little access to health care. Moses says she found her calling to medicine early, while at primary school. But before she could become a doctor, she had to leave Malawi to train. After securing a scholarship, the 20-year-old found herself on a plane to Adelaide in Australia. Exchanging an African village for a wealthy developed city was “the biggest shock of my life”, Moses says. “Most people I grew up with had never even been to school.” By her third year, she returned to Malawi to join the country’s first medical school. After joining the UNC Project-Malawi, the organisation financed Moses’ education in internal medicine at the University of the Witwatersrand in Johannesburg. Charles van der Horst, professor of medicine at UNC, recalls that “Agnes was my first hire in Malawi, a quiet, funny, smart recent graduate of the University of Malawi College of Medicine”. What she has achieved is remarkable says van der Horst: “Her task was daunting, start a PMTCT programme in Lilongwe as fast as possible. This small, quiet woman was a whirling dervish, meeting with Ministry of Health personnel to get the requisite approvals, hiring staff, renovating space. Within 18 months we were testing 20 000 pregnant women at four centres. Only Agnes could have accomplished so much in such a short time. Malawi is truly fortunate to have her as a doctor.” Someone with Moses’ talent and determination could probably make a more lucrative living in a richer country, but she can’t yet contemplate leaving Malawi. The need for doctors like her is greater there than almost anywhere in the world.
For more on UNC ProjectMalawi see http://www.med. unc.edu/wrkunits/2depts/ medicine/id/malawi
For more on the International Leadership Award from the Elizabeth Glaser Pediatric AIDS Foundation see http://www. pedaids.org/GrantsandAwards/ Awards/InternationalLeadership-Award.aspx
Priya Shetty [email protected]
797