Patrice, Cohen, and Suniti Solomon. AIDS and Maternity in India: From Public Health to Social Sciences Perspectives, Emerging Themes and Debates. Pondicherry (India): French Institute of Pondicherry. 2004. 275 pages, Rs. 350.
This book is a collection of papers from Indian and French specialists that seeks to explore the role of the social sciences in studying HIV transmission from mother to child in India. The prevention of this transmission is a priority of the Indian public health policy and of international organisations. This issue is explored through the understanding of medical, public health and social sciences perspectives. Pregnancy, delivery and breast-feeding are routes of transmission – the understanding of this transmission and its prevention are the subject of this volume.
Reviewing at the end of 2007 a book on HIV published in 2004, however, requires careful judgement, as well as a certain retrospective analysis. Many an acronym has changed, the most recent being the use of ‘HIV’ instead of the old form of ‘HIV/AIDS’. The authors appear unaware of this. Future reprints of this book if any, must consider the necessary terminological modifications.
Considering that the book is on HIV and Maternity in India, the introductory passage on maternity could have come well before its first hundred pages. The first few chapters dealing with the various facets of the HIV epidemic, without a mention of maternity’s effect on HIV or vice-versa, is much like pages written for any other book on HIV. One has to wait till page 106, where at last one comes across a paragraph heading entitled, ‘Pregnancy and HIV’.
It was one of the editors, Dr Suniti Solomon, whose team ‘discovered the first evidence of the HIV infection in India’. This was at the Institute of Venereology, Madras Medical College in 1886 – where the reviewer was then a student. The sample was sent for ‘HTLV testing’, as it used to be called then, to Dr. Jacob John from Christian Medical College, Vellore. Recounting an experience ten years later, Suniti Solomon does well to bring out the difficulties faced in admitting a positive mother for safe delivery in a nursing home. That this had to be done without revealing her HIV-positive status, so that she could be safe to deliver her baby into the world, shows that we are still behind the times. Of more value is Dr. Suniti Solomon’s disclosure that if a woman develops opportunistic infections characteristic of HIV during her pregnancy, treatment should be determined on a case-by-case basis as some medications may be harmful to the foetus. For example, modified are the recommendations for treating tuberculosis in pregnant women, due to the potential teratogenic effects of streptomycin and pyrazinamide. Similarly, a new set of studies show that cleaning the birth canal with chlorhexidine at delivery results in favourable birth outcomes for women, whether they are infected with HIV or not.
In the paper, ‘An Overview of HIV/AIDS Epidemic and Prevention’, R. N. Gupta makes the significant point that studies in India could not demonstrate the efficacy of the risk reduction strategy or show sustained change in the people exhibiting risk behaviour. However, his statement on page 41 that, ’There were 3.86 million people with HIV in India at the end of the year 2000’, could only have been an estimate: Having worked as a medical scientist and Chief of the Social and Behavioural Research Unit at the Indian Council of Medical Research in New Delhi, he could have underscored the point that this number was only an estimate; at best, a good guess estimate! For today, we have a better methodology to make better guesses: The statistics is closer to 2.5 million people with HIV in India, though HIV incidence has not decreased.
P. Kuganantham of UNICEF, Chennai, detailing his agency’s preventing parent to child transmission (PPTCT) programme for Tamil Nadu, reveals that the use of condoms during the antenatal period and breast-feeding are emphasized for HIV positive mothers. Similarly, it is now known that the reason for lower recruitment for treatment with azidothymidine (AZT) for pregnant women is that women return to their parents’ town during the third trimester disrupting the drug schedule regime. However, the author’s conclusion that this strategy will in the long run bring down the HIV prevalence rate in the general population, is questionable.
Shyamala Natrajan, who founded the South Indian AIDS Action Programme, in her piece entitled, ‘Bridging counselling and Care in the HIV Epidemic: General Perspectives and the Case of Women’, exposes the usual practices of healthcare workers. Instead of helping clients explore issues and arrive at decisions largely by themselves, the health workers end up imposing the common hospital practice of forcing testing upon the client under one guise or other. By detailing a few problem cases, Natrajan brings out the lack of a nuanced understanding the of HIV prevention strategy among healthcare workers, which not only adversely affects the outcomes of the PPTCT programme, but also leads to serious problems for the patient due to loss of confidentiality. She suggests making couple counselling and testing the rule in PPTCT interventions.
A number of papers directly address the gender dimension. In her paper, ‘Gender and Health in India’, K. Shanthi highlights the vulnerability of married women, as most of new infections are monogamous women infected by their husbands Marital status however does not diminish the stigma that they have to bear.
K. Geetha discusses ‘HIV/AIDS Infection: Perceptional Studies on Urban Women Commuters’ exploring the vulnerability of mobile working HIV-positive women in Chennai, and the stigma they face.. Only preliminary findings are provided. While the author states that women are taken as the sample group because they are prone to be perceived as the responsible vectors, rather than as the victims, no effort is taken to clear women of this unjust blame.
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The paper,‘Breast Feeding and Infant Feeding Practices Research: A Critical Review’ by Lakshmi Lingam and Siddhi Mankad synthesizes an analysis from a hundred research papers. The authors point to the absence of knowledge on gender perspectives in breast feeding practices. In the process, they demolish an important myth about working women not breast feeing their children. Using National Family Health Survey (NFHS I and 2), survey data shows that working women breastfeed for a longer median duration of 36 months for self employed women, as against 24.7 months median duration for non-working women. The working women come disproportionately from rural areas where breastfeeding duration is relatively longer. The reports also show that that the median duration of breastfeeding is two months shorter for girls than for boys. Most significant is their finding that there is no Indian study on breastfeeding and HIV. Typically, studies that examine the cessation of breastfeeding often find lactation failure as a problem, but do not go the one-step further to examine whether the lactation failure is because of physical or psychological problems.
Taken together, the authors raise a number of issues that hamper prevention of mother to child transmission, such as taboos around sexuality, absence of culturally appropriate HIV based IEC (Information Education Communication) material, changing agendas of funding agencies, trade-related intellectual property rights (TRIPS) regulations that impede attempts at universal access to antiretroviral drugs, limited sexually transmitted infection (STI) services, and almost complete absence of community counselling, short stay homes and other rehabilitation services.
In conclusion, Natrajan brings home the dilemma between individual well-being and public health. In the PPTCT programme, we are testing women and giving them Nevarapine, the drug that prevents mother-to-child transmission of the HIV in pregnant women. However, she asks, whether we are safeguarding their lives or are they just instruments, used as always to improve some other life, that is, the unborn child?. What can we do that does not deny the woman her right to health and well-being?
Although highly readable, the book clearly needs some editorial work– whether to check grammatical and typographical errors or to organise it better. For example, on page 22 of the Introductory Chapter by Patrice Cohen, there is a paragraph on the Medical, Biological and Epidemiological Issues, where one comes across, ’…the contamination episode of the mother – bound to other possible over-contamination episodes – still plays a role in scientific explanation.’ An explanation of the terms ‘contamination’ and ‘over-contamination episode of the mother’ would have certainly helped the reader.
Dr. E. M. Rafique
Resource Person & Moderator
emrafi@gmail.com
UNAIDS India Office,
New Delhi
