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 Wednesday 03 October 2007
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South Africa - The world’s biggest ARV Programme?

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  • Operational Plan for Comprehensive HIV and AIDS Care, Management and Treatment for South Africa
  • Overview of HIV/AIDS in South Africa
  • Joint Civil Society Monitoring Forum
  • The Treatment Monitor
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SOUTH AFRICA: Gaps remain in government's PMTCT programme

Photo: Mujahid Safodien/PlusNews
Despite the government's PMTCT programme, it is estimated that 65,000 infants were infected with HIV in 2005
Almost one in three pregnant women who tested for HIV in South Africa last year were positive, but how many of them received the essential drugs and counselling to reduce their chances of passing the virus to their baby is not clear.

In a report to the United Nations ahead of the General Assembly's Special Session on HIV/AIDS (UNGASS) in June 2005, the South African government estimated that in 2004, 79 percent of HIV-positive pregnant women received nevirapine, an antiretroviral (ARV) drug that reduces mother-to-child transmission (PMTCT) by about 40 percent; UNAIDS put the figure at 57 percent in its 2005 AIDS Epidemic Update.

In 2002, the Treatment Action Campaign (TAC), an AIDS lobby group, won a legal battle that compelled the government to provide nevirapine to HIV-positive pregnant women but, according to national treasurer Mark Heywood, compliance with the Constitutional Court order has been "nominal".

"The [PMTCT] programme is without any type of management or monitoring and, therefore, whether it's properly implemented depends entirely on whether a provincial health department takes the programme seriously," he said.

No HIV test means no Nevirapine

Discrepancies between provinces in terms of PMTCT access and management tend to mirror those surrounding antiretroviral (ARV) treatment. The southern coastal Western Cape Province is strides ahead of the rest of the country in reducing mother-to-child transmissions, while Mpumalanga in the northwest is among the provinces lagging behind.

Mapulaneng Hospital, the regional facility for the Bushbuckridge area in Mpumalanga, has no antenatal clinic - pregnant women are supposed to access antenatal care, including voluntary counselling and testing (VCT) services, at their local primary healthcare clinics. They come to the hospital only to deliver, said Nancy Monareng, who manages the maternity ward.

The hospital does not have a record of whether the women were tested at their local clinic, so there is often no way of knowing who requires PMTCT services. In January the HIV status of just nine of the 320 women who delivered at Mapulaneng was known. After they gave birth, the majority of the women agreed to test and 47 were found to be positive - only three had received nevirapine during delivery.

Monareng does not understand the wisdom of such a system. "It's not enough, but what can we do on the ground?" she said. "Counselling needs time and we're always in a hurry."


30.2% of pregnant women in South Africa tested positive for HIV in 2005

23% of babies born to HIV-positive women in South Africa are infected (DoH)

79% government estimate of HIV positive pregnant women receiving nevirapine in 2004

57% UNAIDS estimate of HIV-positive pregnant women receiving nevirapine in 2004

Public facilities providing PMTCT: 2,500

25-35% probability of HIV-positive mother infecting her baby without preventative interventions (Unicef)
According to Glenda Gray, of the Perinatal HIV Research Unit at Chris Hani Baragwanath Hospital in Soweto, a huge township on the outskirts of Johannesburg in Gauteng Province, erratic access to VCT services at antenatal clinics is a major shortfall in the government's PMTCT programme. Testing uptake is particularly low in rural areas, where clinics often run out of test kits or lack staff trained to do pre-test counselling.

The Health Department is considering running a pilot study to determine whether "opt-out" testing for pregnant women, in which they would routinely be offered an HIV test, could help increase uptake, said Dr Nomonde Xundu, head of the government's HIV/AIDS Unit. She believes stigma is the biggest barrier to pregnant women testing, but admits that the quality of counselling is also a factor.

A PMTCT programme started in the Cape Town township of Khayelitsha in 1999 by medical humanitarian agency, Medecins Sans Frontieres (MSF), has achieved a 95 percent test rate for pregnant women. Good quality counselling partly explains the high uptake, said MSF's Katherine Hilderbrand, but women were also motivated because they wanted to prevent infecting their babies.

Nevirapine: Not the best option

Western Cape health authorities have abandoned the use of single-dose nevirapine for PMTCT in favour of a combination of two or more anti-AIDS drugs, which has seen transmission rates drop from about 13 percent with nevirapine to 5 percent with combination therapy. "PMTCT here in Khayelitsha is a good example of what could have been done, and should have been done, nationally," said Hilderbrand.

Some studies suggest that using nevirapine can create drug resistance, which later complicates ARV treatment for mothers. But despite World Health Organisation guidelines for PMTCT that advise using combination therapy where possible, South Africa's national guidelines still recommend nevirapine.

Mark Heywood argues that with the necessary ARV drugs already in hospital pharmacies, the switch to combination therapy should be straightforward. Dr Xundu maintains that it would require considerable additional resources to train healthcare workers, educate mothers and create formulas, and says the current PMTCT programme is being assessed, but a switch to combination therapy is not officially being considered.

Gray is perplexed by the delay in switching to the more effective combination therapy: "We're one of the richest nations in Africa and we have a very good health budget," she said. "Nevirapine was a very good option when there was no other option, but with drug prices falling we should be committed to driving the transmission rate down and saving children's lives."

The breast or the bottle?

However, a study conducted by Health Systems Trust found that at least half the HIV transmissions from mother to child occurred after birth because of poor feeding practices. Formula feeding carries the lowest risk of transmission, but only if mothers have access to clean water, electricity and an uninterrupted supply of formula milk; without these, breast-feeding is usually the safer option.

The study found that women were not receiving enough information to make the best feeding choice, and clinics were regularly running out of formula milk. As a result, many were mixed feeding, the most dangerous option in terms of HIV transmission.

According to Dr Xundu, clinic staff receive training in counselling women about safe infant feeding, and how to manage their stocks of formula milk, but points out that stigma also poses a significant barrier to formula feeding, which is associated with an HIV-positive status in many communities.

Dr Vivienne Black of the Reproductive Health and HIV Research Unit (RHRU) at the University of the Witwatersrand, who works with the PMTCT programme at Johannesburg General Hospital, believes PMTCT programmes are missing opportunities to get HIV-positive women, their partners and children into the health system.

Post-natal follow-up is often also poor: "At a lot of clinics, women are diagnosed, given a single dose of nevirapine and then that's it for her," she said. "And yet studies show that when mums die, babies are more likely to die, regardless of their HIV status."

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