Measles, whooping cough, AIDS...

Children abandoned by HIV-infected mothers are immediately “registered” as sick - there is no special diagnostic equipment. (Photo: Alexander Sorin )

It's quiet time in the department, but the kids don't sleep. The nurse has put two one-and-a-half-year-old boys in the same bed and is playing a simple game with them: she holds out her index finger to each, and they grab it and jump. The nurse is a fit woman of about 45, one of those who doesn’t babysit with children, but talks. “We would like a teacher,” she says, “but teachers are afraid of the very word “AIDS”. Why be afraid of us, eh, Vov? We don’t bite!” Vova smiles knowingly, showing two teeth, and drools.

The Republican Infectious Diseases Hospital in the village of Ust-Izhora near St. Petersburg treats HIV-infected children from all over Russia, including those who were infected in hospitals in Elista, Volgograd and Rostov 11 years ago. In the only one of the three departments where no one objects to the presence of journalists, there lie, or rather live, children from one month to three and a half years old, who were abandoned by their mothers in the maternity hospital. There is no one to object to here. Not all patients are infected: on average, among children born to HIV-infected women, only 25% themselves become infected. But it is impossible to determine whether a child is infected or not using publicly available equipment: the mother’s antibodies remain in the body until the age of two. Equipment that determines the level of virus in the blood is available only in St. Petersburg, Moscow and Nizhny Novgorod. And since in the late 80s the Russian AIDS center was organized in St. Petersburg, children from all over the country are sent to Ust-Izhora “for testing.” “They send us the sick, we return them the healthy,” chief physician Evgeniy Voronin proudly declares. They keep the infected for themselves. In a department of 30 “abandoned” children, there are 13 of them.

There are actually teachers in the department (they just hired a second one), but they only work with children over two years old, and then only in the first half of the day. After a quiet hour, the children are allowed into the playrooms, where nurses drop in from time to time. A speech therapist worked here for several months, but left because she could not overcome her fear of HIV. The children here, oddly enough, do not make such a depressing impression as the children in orphanages: there is no such transparent pallor and terrifying diminutiveness - the food here is good. But three-year-old children speak almost exclusively in primitive sentences - “This is Vova”, “This is pussy”, “These are teeth”, “This is a nose” - and pronounce words in such a way that if it were not for the index finger poking, for example, into my teeth, I would understand it would be impossible. If practically no one talks to a child under two years of age, he is hopelessly behind in development.

It’s good, however, that they can say at least something at all. Kirill is about two years old (no one knows his exact age), but he doesn’t say a word. About a year ago he was found at the entrance to some hospital near Moscow. They checked for everything, discovered HIV and immediately sent me to Ust-Izhora. He clings to the nurses and is calm only in their arms. If a sister does not enter the room for a long time, she gets out of the crib, no matter how high the side is, and tries to climb out of the window. The nurses call him a steeplejack and tie him to his crib. True, neither he nor they make it to the end of the quiet hour, and by the time the rest of the children wake up, Kirill is already sitting in the nurse’s arms, burying his sobbing face in her shoulder.

What to do with the children
The oldest in the department is Anya, a smart and talkative girl with curly hair of three and a half years old. Until recently, there were several of her peers in the department, but all of them were adopted by foreigners through a charitable organization that has long been helping the hospital. “She says: “I’ll leave soon too,” says the nurse. “But who will take her?” The adopted children were healthy, but Anya was infected, and this means that foreigners would not adopt her, much less Russians, and any orphanage would refuse her, even though the law obliges them to accept HIV-infected children on a general basis (after all, the human immunodeficiency virus - unlike, for example, hepatitis viruses or tubercle bacilli - they are not transmitted through household contact).

Until 1998, only 20 children were born to HIV-infected women in Russia. In 1999 - already 300. Considering that approximately a quarter of all HIV-infected people are women aged 18 to 22 years, over the next five years, according to Evgeniy Voronin, about 50 thousand children will be born from HIV-infected people. If the situation does not change, about 25% of them will be abandoned by their mothers in the maternity hospital and about 25% of these children will be infected. As a result, there are more than three thousand HIV-infected children living in infectious diseases hospitals.

HIV-infected children, explains Evgeniy Voronin, are divided into two groups. In 30 - 40% of children, symptoms of HIV infection appear almost immediately; For the rest, the disease makes itself felt only at the age of five or six years. The latter, according to Voronin, should be raised in ordinary children's homes, the former - “in this not entirely clear institution that we are trying to create,” where children are raised under constant medical supervision. In the same institution, most likely, children with a slow course of infection will also be kept: children's homes do not take them, although they should, and no one is going to force them to comply with the law either (this despite the fact that children's homes, unlike orphanages and boarding schools are subordinate to the Ministry of Health, so an order at the federal level could be issued without any complex interdepartmental coordination).

While Evgeniy Voronin has not built the “incomprehensible institution” of his dreams, he warns: “We take care of the body. We can treat these children, but they will be morons.” From a medical point of view, the fate of children with a slow course of infection may turn out quite well: if today’s children, at least in a few years, begin to receive the medications that HIV-infected people in the West are already receiving today, then, according to quite conservative estimates, they will live up to 10 years. when, according to Evgeniy Voronin, it will be possible to count on the appearance of more effective drugs. "The prognosis is very good," he says. It’s wonderful - we will have thousands of mentally retarded young people raised in infectious diseases hospitals by kind nurses who are the only ones who are not afraid of the word “AIDS”.


Evgeny Voronin, the head physician of the republican hospital, where children are sent “for check-ups” from almost all over the country, is proud that they “return many healthy.” (Photo: Alexander Sorin )

There is another way
The amazing thing about this situation, with all its hopelessness, is that it could have been prevented. More than 10 years ago, American researchers came up with a simple idea about how to avoid transmission of infection from mother to child during childbirth. The fact is that the embryo is almost never infected (for this to happen, the “virus carrier” must be the only sperm from which conception occurred, and the probability of this is negligible), and the virus cannot overcome the placenta. So the main risk of infection is posed by childbirth - simply because it is accompanied by physical trauma. Ten years ago, only one drug was used against HIV - azidothymidine (AZT), a drug with long-term use not only ineffective, but also harmful due to its high toxicity. But in the first weeks or months of use, it significantly reduces the amount of virus in the blood. Based on the simple idea that the less virus there is, the less chance of infection, doctors tried giving women AZT in the last weeks of pregnancy and during childbirth. The results of the study - that such treatment reduces the likelihood of having an infected child to about 5% - became known already in the early 90s. It was later discovered that a caesarean section at 38 weeks' gestation - before any damage to the placenta or birth canal is likely - reduces the chance of infection in the newborn to 1%. Many doctors in America, where AZT and cesarean sections have been used for HIV-infected women in labor since the mid-90s, are of the opinion that this one percent is the result of pregnant women not following the pill-taking schedule and that when used correctly, the method provides almost a 100 percent guarantee .

The usual domestic excuse - “in America, where are we before them” - does not work in this case. AZT has been produced in Russia since the late 80s; it is the only drug available to Russian hospitals, AIDS centers and maternity hospitals. Nevertheless, almost nowhere except St. Petersburg is AZT prophylaxis carried out. Here, under the leadership of Voronin, 50 women in labor were given prophylaxis along with cesarean over three years, and all of them gave birth to healthy children.

At the International AIDS Conference, held in South Africa in July, antenatal prevention - or rather, its implementation in poor countries - was one of the main topics (it was understood that in countries where the necessary drugs are available, it has long been introduced). At the end of the conference, I got into a conversation with a former compatriot, a scientist, now working in America. When I indignantly told that most of our doctors are indifferent to the fate of the children of HIV-infected women, my interlocutor politely refused to believe it. I had to explain.

“They believe that HIV-infected women should not give birth at all,” I began. She told me about a young woman whom she met in Novorossiysk. She found out about her infection a year ago, when she came to register at the antenatal clinic (in Russia, pregnant women are required to be tested for HIV, so a significant proportion of infected people find out about infection in this way). “They told me that I should have an abortion, and I did,” the girl told me, during this time she had never recovered from the loss of her desired child. This girl’s gynecologist, foaming at the mouth, proved to me that all infected people give birth to sick children.

- So they simply have no information? - my interlocutor guessed.
- Not certainly in that way. AIDS centers have the Internet, and in Moscow there has long been an organization that distributes translations of medical texts into Russian, so that any doctor who wants information can get it.

“Excuse me,” said the scientist, “but journalists like to generalize.” They can go ahead and blame all doctors, for example. But you wouldn’t argue that all doctors wish their patients harm?
- I won’t, of course. - I admitted. - Apparently, they simply lack orders from above.

Then my interlocutor remembered our homeland and believed. Having returned to Moscow, I submitted a request to the Ministry of Health and received the following written response from the head of the HIV/AIDS prevention department, Alexander Goliusov (I convey it in clumsy letter language, since Goliusov refused to meet with me): “The main problem of preventing vertical transmission of HIV -infection currently lies in the fact that more than 90% of pregnant women infected with HIV are drug users, whose behavior and interests are aimed primarily at obtaining and using narcotic drugs, and not at caring for the unborn child and carrying out preventive treatment, which should begin and be continuously carried out from the early stages of pregnancy under the supervision of medical workers.Even knowing that they have HIV infection and the possibility of free preventive treatment for the birth of a healthy child, they either do not come to AIDS prevention centers to receive medications at all, or do not come regularly , which negates the results of therapy. Thus, given the availability of drugs and technical capabilities, the prevention of vertical transmission of HIV infection depends only on the desire of HIV-infected pregnant women themselves."

Goliusov is either ignorant or pretending to be. Firstly, prevention is carried out not “from the early stages of pregnancy”, but from the 36th week. Secondly, even an IV placed during childbirth in combination with a cesarean section reduces the risk of giving birth to an infected child by almost an order of magnitude. Thirdly, since doctors began to fear HIV, almost everywhere they refuse to deliver births to women who are not registered with the antenatal clinic. And the fact that almost all “abandoned” children are abandoned by HIV-infected women in maternity hospitals or hospitals indicates that we are not talking about asocial women who have completely dropped out of the health care system. And finally, as long as no one informs pregnant women about the possibility of prevention, nothing depends on their desire.

Evgeniy Voronin and his subordinates have just prepared methodological recommendations for the introduction of prenatal prevention. At the same time, they calculated that prevention for 2,500 pregnant women would cost approximately $760,000, while treatment for the first three years of life of infected children (assuming that 25% of them could be born) would cost $11.5 million. Now the methodological recommendations must be approved by the Ministry of Health, then, as Voronin believes, “we’ll figure it out in three years.” True, he adds: “The most difficult thing will be with obstetricians and gynecologists. After all, a caesarean section is recommended at the 38th week, but many resist: there is a lot of blood. Although in the West no one got infected from a caesarean section.”

“Resist” is a very mild word. Often HIV-infected women are simply refused to give birth. In Novosibirsk, a doctor at the AIDS center told me how he had to travel half the night from maternity hospital to maternity hospital with a patient, until finally the infectious diseases hospital agreed to deliver the baby - and only because he accompanied the woman in labor. Recently, Voronin sent two doctors to deliver babies in the Far East: not a single doctor there agreed to deal with an HIV-infected woman.

Evgeny Voronin, however, is quite optimistic. His people travel around Russian cities and conduct seminars for doctors. Recently we were in Irkutsk, which officially ranks first in Russia in terms of the number of HIV-infected people per capita. 61 infected women have already given birth there; no prophylaxis has been carried out until recently, and the proportion of infected newborns is unusually high: 30%. Voronin puzzled over these statistics for a long time and finally realized that the fact is that the epidemic there had just begun: “They become infected during pregnancy, which means they give birth when they are loaded with the virus. The highest concentration of the virus in the blood occurs immediately after infection and in the late stage of the disease. In general, go, it’s very interesting there.”

I went. It's really very interesting there. There they showed me a reminder that HIV-infected people receive when they are informed of positive test results. HIV, the memo says, is transmitted during “pregnancy and childbirth, breastfeeding (therefore, HIV-infected women should take all measures to prevent pregnancy or terminate it).” But the AIDS center proudly informed me that perinatal prevention has been introduced this year. “We check all women at the 14th week, that is, when registering at the antenatal clinic,” Stanislav Zarubin, head of educational work, told me. “Previously, we checked at the 14th and 36th weeks, but Moscow criticized us that We examine too much." Those who test positive, unless forced to have an abortion, receive prophylaxis. But the fact is that from the moment of HIV infection to the appearance of antibodies, the presence of which is determined by the analysis, an average of three to six months passes. That is, when checking at the 14th week, Irkutsk doctors “miss” those women who become infected during pregnancy, that is, precisely those who are most at risk of giving birth to an infected child. No, it’s still impossible to explain this.


More than half of HIV-infected children could live well under normal conditions. But they are kept in infectious diseases hospitals, where full development is impossible in principle. This could have been avoided. (Photo: Alexander Sorin )