Five-year-old Anastasia Enongo lies curled like a fetus in a hospital bunk here, coughing weakly, intravenous medicine dripping into her arm. Born to a mother who died of AIDS, the girl has always been sick, her relatives said, her life a parade of doctors' visits for fevers, coughs and diarrhea.
It was not until February that Anastasia was tested for AIDS. The result explained her maladies, but even then she was not treated, and when she arrived at the Chantal Biya Foundation Hospital here last month, she was nearly unconscious. Often, the children of Africa are still not getting AIDS prevention or treatment drugs, experts say, even though the drugs have become affordable and available.
In Cameroon, the government started providing drugs to prevent the transmission of AIDS from mothers to newborns in 2000, before Anastasia was born. It now offers the full spectrum of AIDS medicine free to children.
But Africa's systems to treat children and pregnant women are weak and overwhelmed by other diseases, and diagnosing HIV in young children can be difficult. So children like Anastasia may go without lifesaving drugs, even as the number of adults in treatment has significantly increased in the past two years.
Of the 15,000 to 40,000 children estimated to have HIV in Cameroon as of last year, only about 400 got the drugs they needed, according to government reports. Only a fraction of pregnant women are getting the two medicines to prevent the transmission of the virus to their babies -- although these are very inexpensive drugs that have eliminated pediatric HIV in Europe and North America.
"The delays in getting this to children are disheartening -- a huge failure," said Tido von Schoen-Angerer, director of the campaign for essential medicines run by Doctors Without Borders.
Although the high cost of AIDS medicines was once regarded as the insurmountable barrier to treatment in Africa, the advent of cheap generics and huge investments by international organizations have brought lifesaving medicines to the continent in the past five years. Beyond that, some new pediatric AIDS clinics have opened, and the treatment of children has begun to improve in parts of the continent.
Even so, UNAIDS, the UN AIDS program, estimates that 24 percent of adults in Africa with AIDS, or about 800,000 people, are getting therapy, a number that doubled last year alone. But experts agree that only a small percentage of HIV-infected children in Africa receive treatment; in some countries, the percentage of pediatric patients getting drugs is only 2 percent or 3 percent of those treated.
"The cost of drugs is an issue, but not the only or even the most important issue for children," said Kevin De Cock, the WHO's chief official on HIV/AIDS, who said at an international conference in Toronto this summer that treatment had "so far left children behind."
"You need to put the medicines into a system that functions," he said. "The fact that children aren't getting treated is a sign of the frailty of health systems."
Chantal Biya, the wife of Cameroon's president, has recently started African Synergy, a foundation of African first ladies whose aim is to address the issue of HIV in women and children, but the demand is overwhelming.
Preventive treatment gives mothers two drugs in the weeks before birth and at the time of delivery. The baby also receives a short course of treatment. Mothers are then advised to use formula instead of breast feeding, because up to 40 percent of mother-to-child transmission occurs during nursing.
But in Mbalmayo, about an hour from this capital, many women arrive at the hospital for the first time already in labor, so there is no time to test for the virus. Others deliver at home, so the treatments cannot be administered.
Even if the medicine is given properly, Saint Luc Hospital in Mbalmayo has not yet been authorized by the government to use the second drug, AZT. A government goal is to expand the number of clinics with such capacity, said Urban Olanguena Awono, Cameroon's health minister, acknowledging that the ability to diagnose and treat HIV is now concentrated in a handful of places.
Of 368 women in Saint Luc's prenatal clinic so far this year, 22 were HIV-positive and 16 others with HIV arrived in labor. Of those who carried the virus, 15 got a dose of one drug, nevirapine, at the time of birth. None got full preventive treatment.
More than half decided to breast-feed despite advice against doing so, in large part because formula is expensive. And in a society where 90 percent of HIV-positive women are rejected by their husbands, holding a bottle is as much a marker of AIDS as a blood test.
Moreover, while the government estimates that 11 percent of pregnant women in Cameroon have HIV, a vast majority of them are unaware of it. Last year, only 10 percent of women at prenatal clinics were tested.
"Prevention is done only in a few places, which is really unbelievable; it's so cheap and easy," said Vittorio Colizzi, an HIV expert from the University of Tor Vergata in Rome who is working with the government.
Catherine Embolo, 26, discovered she had AIDS at the hospital in Mbalmayo, when she went to give birth to her daughter, Orlane Martine Mayi, now 14 months old. Embolo is now doing well on antiretroviral medicines, the sophisticated drugs used to treat AIDS.
Last month, her little girl was hospitalized with pneumonia, a red flag that the child might be infected as well. The baby needed testing and possibly immediate treatment; in Africa half of all children with HIV die by age of 2.
But the standard test for HIV works only on children above the age of 18 months. Before that age, more complicated tests are necessary and they are not performed in Mbalmayo.
"There are so many bottlenecks like this," said Estelle Fouda, a social worker at Saint Luc.
In Batie, 298km from the country's capital, Yves Moumbe has a much more basic problem.
"I need only one thing, that is medicines; I don't have anything at all for children," he said.
He estimated that about half of his pediatric patients were HIV carriers. All he can do is watch children with HIV falter until they become desperately ill, generally by age four or five. At that point, he sends them to a distant hospital.
What happens then?
"I don't know," he said. "They almost never come back," he said.
De Cock said one of the problems in Africa was that "kids don't come to the clinic with a sign that says, `I have HIV.'"
"There's a mass of sick kids," he added. "And how many have HIV, maybe 10, 30, 40 percent? You need a health system that can test them and identify them."
The Chantal Biya Foundation Hospital looks after 200 children on antiretroviral AIDS medicines, by far the biggest group of treated children in the country, said Felix Tietche, the director. But as a sign of how far there is to go, he estimated that there might be 15,000 in need of treatment nationwide.
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