How a few doctors and some antiviral drugs brought a child with AIDS--and thousands like him--back from the dead.
It's hard to believe that these photos are of the same little boy. When 8-year-old Bokang Rakabaele arrived at the new pediatric-AIDS clinic in Maseru, the capital city of Lesotho, in May, he weighed less than 20 lbs. and was suffering from AIDS, pneumonia and tuberculosis. Today he's 18 lbs. heavier, his shy smile has returned, and he plays once again with other kids in the neighborhood. When I visited the clinic in August, Bokang was already on the mend. He was asked through an interpreter why he thought he was feeling so much better, and replied very simply, "It's the medicine."
Leave it to a child to get to the heart of the matter. For years, giving antiretroviral drugs (ARVs) to children living with AIDS in the poorest parts of the world was perceived as a lost cause. It's hard enough, the experts thought, to get ARVs to pregnant, HIV-positive women to reduce the chances they will infect their babies in utero or at birth. Pediatric versions of the drugs are expensive, and cutting down an adult dose of the medication to give it to a child is tricky. Without treatment, however, nearly a third of HIV-positive infants die by their first birthday, and half die by age 2.
Now Bokang and thousands of African children like him are getting the lifesaving treatment they need. What changed? Researchers showed that children respond faster and better than adults to ARVs, and it no longer seemed fair to ignore poor youngsters with AIDS. Then several groups rose to the challenge. The President's Emergency Plan for AIDS Relief allocated $63 million this year for the treatment of pediatric AIDS. The Clinton Foundation negotiated a 50% reduction in the price of a key medication. And a handful of nonprofit organizations, corporations and faith-based groups began sending more doctors to the developing world to help plug some of the health-care gaps for children.
The need is great. More than 2 million children in Africa under age 15 are living with HIV, according to a study published last week by UNAIDS and the World Health Organization. Of these youngsters, perhaps 660,000 are sick enough to require medical intervention. Yet only 1 in 20 children who need ARVs get them. In addition, fewer than 1 in 10 HIV-positive mothers receive the drugs they need to keep from transmitting the virus to their newborns.
This is usually the point at which most of us in the rich countries of the world throw up our hands in despair. Not so Dr. Mark Kline of the Baylor College of Medicine in Houston. "If you focus on the enormity of the problem, you'll never get started," says Kline, who has cared for hundreds of HIV-positive children over the years in the U.S. and has seen many of them grow old enough to have children of their own (see box). "You have to tackle it piece by piece."
Kline's plan for dealing with the ongoing emergency in Africa was to create several pediatric centers of excellence for AIDS. (Four have opened--in Botswana, Lesotho, Malawi and Swaziland--and four more are in the planning stages.) Then he set about finding the staff and the money to run them. Since there aren't enough doctors and nurses in most African countries, that meant recruiting young physicians from the U.S. to spend a year or two at the clinics. Most of the funding for the first class of 52 doctors in his Pediatric AIDS Corps comes from Bristol-Myers Squibb (BMS) and Baylor. The clinics were built with money from BMS and Abbott. But the day-to-day operating budgets of the centers are the responsibility of local governments.
You can already see the difference in Lesotho, a tiny mountain kingdom of 2 million people surrounded by its much larger and richer neighbor, South Africa. At least 22,000 Basotho children are HIV positive, but as of two years ago, fewer than 20 were on ARVs, and there were only two doctors in the whole country looking after children with AIDS. In the year since the children's clinic opened on the outskirts of Maseru, 700 kids--including Bokang--have received treatment from 10 pediatricians.
Kline expects that the influx of U.S. doctors will be temporary. The plan is to dramatically increase the ability of local health-care staff to treat children with AIDS. To that end, the children's clinics and their doctors, including the Pediatric AIDS Corps, have provided training in the past six months for about 3,600 health-care workers.
The Americans aren't alone in their efforts. Dr. Edith Mohapi was born in Lesotho and left when she was 17 to pursue advanced studies and medical school. She returned last year to run the clinic in Maseru and was joined earlier this summer by her daughter Dr. Lineo Thahane, also a pediatrician and one of the first Pediatric AIDS Corps members. The nurses, social workers and other staff are also from Lesotho.
Their optimism in the midst of extreme difficulty is contagious. "It's hard to see children that sick," Mohapi says. "But children respond so quickly--that's why I went into pediatrics--and after just a few weeks of us treating them, they come back, and they're smiling, they're running, and they're eating better."
Not everything runs quite as it should yet. While the ARVs are free, getting to the clinic is not. A ride in one of the ubiquitous minivans everyone uses for public transportation can cost $1 or more--an exorbitant sum when you're living on $1 or less a day. Because the government's telecommunications agency wants more money than Mohapi's budget allows to set up high-speed Internet access, the clinic still depends on a sluggish dial-up connection. Meanwhile, the center has become a de facto emergency room for the neighborhood--further evidence of the fragile state of basic health care in the region.
What happens next in Lesotho and the rest of sub-Saharan Africa depends a lot on how broadly these first efforts expand. All the ARVs in the world aren't going to help much if children and their families don't have enough food to build up their strength or clean water to keep from picking up infections. Tough as it has been to focus attention on children with AIDS, it has been harder for clinics to get and use a common antibiotic to prevent pneumonia and other ills in HIV-positive children who don't yet need ARVs. "One of the biggest obstacles in treating children has been having a consistent guardian," says Dr. Martha Sommers, head of clinical services at Embangweni Hospital, a church-run facility in rural Malawi. "Often the guardian is sick or dying, or the children are orphans and getting passed from one guardian to the next."
Some of the challenges go even deeper. "I did not realize how much women lack basic rights in this country," Dr. Julia Kim writes from Swaziland, north of Lesotho. Women traditionally turn over all their income to their husbands, she says, and defer to them on matters of treatment--a practice Kim struggled with when trying to convince one father that immediate care was needed for his daughter whose immune system had collapsed.
Nor are all children who come to the clinics infected at birth. In some parts of sub-Saharan Africa, teenage girls are now eight times as likely to be infected with HIV as their male peers. Study after study has shown that the best way to ensure that young girls who are HIV negative remain that way is to keep them in school, delay sexual intercourse and marriage, help them get good jobs and allow them greater control of their income.
Still, there is reason for hope. The mortality rate for children with AIDS at Baylor's pediatric clinic in Botswana has fallen from nearly 5% in 2003 to 0.3% this year. Other groups are scaling up. More than 1,400 children are receiving antiretroviral therapy in Rwanda--up from 354 in 2004--and more than a third of pregnant women are getting treatment to preserve their lives and reduce the risk of delivering an HIV-positive infant, according to UNICEF. There will always be more to do, but at long last the work has begun.
To see video from the Lesotho clinic and read more about U.S. doctors in the Pediatric AIDS Corps, visit time.com/aidskids
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