The HIV/AIDS epidemic in Sub-Saharan Africa is decimating populations, depressing economies, deepening poverty and destabilizing traditional social orders. Various programs to prevent and treat HIV/AIDS have been developed, but few have demonstrated the capacity to make an on-going difference to a large number of affected individuals, their families and their communities.

A study published in the December issue of the Journal of General Internal Medicine reports on why AMPATH, a program which broadly defines health care, is successful in fighting AIDS and improving lives.

AMPATH, which stands for the Academic Model for the Prevention and Treatment of HIV/AIDS, was initiated in 2001 and grew out of a long-standing partnership between the Indiana University School of Medicine, Moi University and Moi Teaching and Referral Hospital, both in Eldoret, Kenya.

The first AMPATH patient was enrolled 6 years ago; today AMPATH serves an estimated 52,000 HIV-positive people in western Kenya.

"If we think that we can succeed in treating people with HIV/AIDS without attending to all their needs, we are mistaken," said Thomas Inui, M.D., M.S., principal investigator of the JGIM study. "The story of AMPATH is the story of attention to health and to restoring lives, not just immune systems." Dr. Inui is president and CEO of the Regenstrief Institute, Inc., Sam Regenstrief Professor of Health Services Research and associate dean for health care research at the Indiana University School of Medicine.

AMPATH takes a comprehensive approach to HIV/AIDS, attending to medical care, nutritional sufficiency and economic security. It assisting patients and their families by providing education, preventive services, treatment, dietary assistance, and by helping them grow food and hold jobs. Once individuals with HIV/AIDS are able to again earn a living and become vital members of their community once again, even the stigma associated with HIV/AIDS disappears.

Today AMPATH has expanded to include a consortium of U.S. medical schools led by the IU School of Medicine. Patient enrollment is rising by 2000 per month. AMPATH's high-production farms and demonstration farms provide food assistance to up to 30,000 people every month.

For theJGIM study, Dr. Inui and colleagues conducted oral interviews with individuals involved in AMPATH -- Kenyan physicians, clinical officers (similar to physicians' assistants in the U.S.), nurses, nutritionists, pharmacists and others working within facilities operated by the Kenya Ministry of Health. The interviews demonstrate how these individuals go beyond humane and compassion treatment.

Initially, health personnel were aware that families frequently walked for hours or even days, sometimes pushing a wheelbarrow as a means to transport a loved one, to a clinic. It was apparent that unless the doctors and healthcare workers could ensure continued nourishment to the patients and means for the families to survive economically, there would be no return to health. >From this need grew educational and vocational programs for patients and their families and the farms to provide both crops and training and ultimately health (half the patients are on anti-retroviral drugs) and income security.
In the UK HIV testing has been recommended to all women attending for antenatal care since 2000, and high test uptake and appropriate management for diagnosed women has reduced the mother-to-child transmission rate from 25%1 or higher to about 1%. However, there is still room for improvement, according to a joint report published today by the Audit, Information and Analysis Unit, the National Study of HIV in Pregnancy and Childhood, the Children's HIV Association and the London HIV Consortium.

Across the UK more than 30 infants are still infected annually with HIV, and each carries a substantial human and economic cost. Despite the decline in the proportion of children being infected, the actual numbers each year have not changed significantly because of the overall increase in the number of HIV infected women giving birth.

This audit examined the circumstances surrounding 87 recent cases of mother-to-child transmission (among infants born in England between 2002 and 2005). Nearly two-thirds of these infants were born to women whose HIV infection remained undiagnosed during pregnancy, highlighting the importance of ensuring that all pregnant women are offered every opportunity to be tested antenatally.

Reassuringly, the audit found no cases in which transmission occurred following optimal care and good maternal health. However, despite the generally positive picture, a number of areas were identified where changes in policy and practice, and closer adherence to national guidelines, could make a difference in individual cases and further reduce the overall transmission rate.

Hermione Lyall, Chair of CHIVA said:

'As a paediatrician looking after HIV infected children, I know how hard it is for families living with this chronic disease. Even though HIV is now treatable it cannot yet be cured and an infant infected with the virus will need to be treated life long. With the interventions currently available to interrupt transmission of the virus from mother to child, very few infants should now be infected. Indeed if any infant is found to be HIV positive in the UK today, the details of the case should be examined to try to understand why.

This audit has demonstrated some of the areas where we can improve our management for the benefit of mothers and their babies. We need to ensure that:

- Antenatal HIV testing is offered and recommended to all women, even those who present late or in labour.
- Positive HIV test results are rapidly reported to clinicians.
- Teams looking after women with HIV have failsafe lines of communication so that pregnancy treatment plans can be devised and implemented in a timely fashion.
- Units follow the BHIVA guidelines for the management of HIV in pregnancy.
- Newly diagnosed women are holistically supported throughout the pregnancy.

HIV care for the pregnant mother is classified as emergency care and is free to all women, regardless of immigration, asylum or residence status.

Over the years one of the great parts of my job has been the opportunity to inform a mother that her baby's tests are negative and her baby does not have HIV. We hope that units will take the recommendations of the audit onboard, review their practice and all of us will work together to optimise the care of pregnant women with HIV.'
In addition to Dr. Inui, co-authors of theJGIM study, which was funded by the Purpleville Foundation of Ontario, Canada, are Winston M. Nyandiko, M.D., and Sylvester N. Kimaiyo, M.D., of Moi University School of Medicine, Tadeo Muriuki, B.S., of AMPATH, Richard M. Frankel, Ph.D., Joseph J. Mamlin, M.D., Robert M. Einterz, M.D., and John E. Sidle, M.D., of the Indiana University School of Medicine. Dr. Frankel is also affiliated with the Richard Roudebush VA Medical Center in Indianapolis.