SOUTH AFRICA: Focus on nevirapine programme

johannesburg, 21 February 2002 (PlusNews) - All state hospitals in South Africa's Gauteng province will provide the antiretroviral drug nevirapine to HIV-positive pregnant women this year, the provincial government announced this week.

Gauteng, the thriving commercial hub of the country, is now the fourth province to defy government policy by making the drug available. But doctors and staff at some of the existing 18 pilot sites raised concerns that logistical problems could hamper the smooth roll-out of the programme.

Kalafong Hospital - situated on the outskirts of Pretoria, near the township of Atteridgeville - is one of the two pilot sites in the capital. Within the next 100 days, the programme will be launched at a third hospital in the city. The hospital has been providing nevirapine to HIV positive pregnant women since June 2001.

"The whole programme is certainly possible, we've managed to successfully implement it here, despite some problems," Dr Jeffreys, one of the hospital's antenatal clinic doctors told PlusNews.

One of the problems has been the low numbers of women choosing to undergo HIV testing. Only 45 percent of women attending the antenatal clinic were tested, while other pilot sites tested up to 80 percent of their patients, said Jeffreys. This was "completely realistic" and reasonable as many women feared knowing their status because of the stigma that still surrounded the pandemic, she said.

As a referral hospital, many of the women who came to the hospital were already high-risk patients and had not received adequate care at local primary health centres. "When the roll-out goes ahead, nevirapine must be taken to where the people are," said Jeffreys.

According to Sabina, one of the two lay counsellors at the site, more voluntary testing and counselling (VCT) services should be provided at local clinics to encourage more women to be tested.

Educating women about nevirapine is critical, as many patients incorrectly assume that the drug will cure them as well as their babies. When they found out that the drug was not an AIDS cure, many lost the will to live and take care of their babies, said Sabina.

Counsellors at the Chris Hani Baragwanath hospital's Perinatal HIV research unit in Soweto have also dealt with this misconception. "They (the provincial government) are going to find themselves in deep water soon as they will have to start thinking about HAART (highly active antiretroviral therapy) for the mothers," according to Agnes Fiamma, project manager for the nevirapine programme at the unit.

The issue of feeding options for infants was a "potential problem", according to Jeffreys. Infant formula was provided for six months at Kalafong hospital and 80 percent of the women chose this option. "We're fortunate to have a dietitian on site and women are advised about their options," she said. Some women however feared disapproval from their spouses and families and chose to breastfeed, despite the risks. "There's no easy answer to this, because breastfeeding does have its advantages," she added.

The heavy workload of the programme was a major problem for some pilot sites. HIV testing took a long time and could not be assigned to junior staff, noted Jeffreys. Integrating the nevirapine roll-out in existing antenatal clinics could prove to be a challenge for the provincial government, as the staff would be overworked, possibly becoming hostile towards the service.

"It all depends on the motivation of the staff and one way to make it more attractive to midwives is by employing extra staff, because they are overworked as it is," said Jeffreys.

The Western Cape government solved the problem by contracting NGOs to employ counsellors and by employing extra nurses at clinics. "Gauteng must be prepared to spend money on basic things like counsellors, rapid tests and extra staff," Dr Fareed Abdullah, deputy-director general of the provincial health department, told PlusNews.

The donor-funded Perinatal HIV research pilot site at Chris Hani Baragwanath has trained dedicated staff, which concentrates solely on MTCT. This relieved the burden of antenatal clinic staff that could be "extremely difficult and uncooperative" said Fiamma. A high percentage of women had been tested at the unit, as there was enough staff to cope with testing and counselling, she added.

A source of "great frustration" for doctors and midwives was knowing a pregnant woman was HIV positive, but not being allowed to prescribe nevirapine, said Abdullah. "It would be easier to allow doctors to prescribe nevirapine and cut out the unnecessary steps," he added.

The national government has indicated that it will not make the drug available at state hospitals until the research from the 18 government pilot sites has been completed. They have cited the "toxicity" of the drug and inadequate medical infrastructure as reasons for refusing to distribute the drug. In a statement issued on Tuesday, Health Minister Manto Tshabalala-Msimang said her ministry "disassociates itself from Gauteng's nevirapine roll-out programme".

"Morally, I would like to see this roll-out done as fast as they possibly can, but we shouldn't lose focus and forget about other things such as syphilis testing," said Jeffreys.

Despite all the problems encountered, staff remain positive that the rollout to all public hospitals and clinics is possible. "We are very excited that this has happened, this is a milestone," said Fiamma.

"Gauteng has the capacity, what they shouldn't do is stall and wait for everything to work, they should go ahead and fix the problem as they go along," said Abdullah. There was a lot of expertise at the local level and the province had to be generous and give them resources and facilities to make the roll-out successful, he added.

Theme (s): Care/Treatment - PlusNews, Children,

[This report does not necessarily reflect the views of the United Nations]