South Africa cannot afford not to treat HIV-positive pregnant women with anti- retroviral drugs Howard Barrell The government will save the South African taxpayer more than R800-million a year – and will save more than 8 000 children’s lives each month – if it makes anti- retroviral drugs and milk formula available to all HIV-positive women who are pregnant. Testing all pregnant women for HIV and giving those who test positive these drugs and the milk supplement for their infants will cost far less than the hospital and welfare costs of the children who might otherwise get Aids, says a Cape Town health economist.
Calculations by University of Cape Town postgraduate student Jolene Skordis seriously challenge arguments in some South African government circles that the country cannot afford to offer anti-retroviral drugs to all HIV-pregnant women to prevent mother-to-child transmission of the disease.
“The truth of the matter is that South Africa cannot afford not to offer this treatment,” says Skordis, who is also associated with the healthcare consultancy Pulse Track, in a draft academic paper. Skordis has produced several scenarios and highly detailed tables on a variety of medical, welfare and other costs associated with HIV/Aids to arrive at her conclusions, which she will present to a seminar at the University of Cape Town on July 28. According to Nicoli Nattrass, professor of economics at the university, who supervised the study: “Skordis’s excellent research shows the high costs to the state of doing nothing to prevent mother-to-child transmission of HIV. Her assumptions about costs were deliberately conservative, so the real costs to the state are certainly even higher. “The government should stop its unconvincing mantra that we cannot afford to save the children. It is costing the state more to let them get sick and die,” Nattrass said. At the recent World Aids conference in Durban, Nelson Mandela called for greater access to treatment for those suffering from or vulnerable to HIV/Aids. He also called for an end to the dispute over the causes and best treatments for HIV/Aids – a dispute in which his successor, President Thabo Mbeki, has involved himself. South Africa’s former minister of health, Nkosazana Dlamini-Zuma, ruled out the provision of anti-retrovirals to pregnant HIV-positive women on the grounds of expense. Under her successor, Manto Tshabalala-Msimang, the government has sent out mixed signals on how large a part cost issues still play in its reluctance to make anti-retroviral therapies available on a large scale. The government has seemed recently to prefer to rely on fears about the side effects of anti-retrovirals to justify its hesitancy. South Africa has the fastest-growing HIV/Aids epidemic in the world, with an estimated 5,6-million people in sub-Saharan Africa already infected. Skordis has examined the cost of treating HIV-positive pregnant women with the drugs AZT and Nevirapine, and of providing them with milk formula with which to feed their newly born infants in preference to breastfeeding (which increases the chances of HIV transmission to infants). She has found that the cost of treatment and care for a child once he or she is HIV-positive is between three and seven times higher than the cost of any interventions with anti-retrovirals and/or formula feeding. “At most, the cost of saving a child using no drugs and only encouraging formula feeding instead of breastfeeding would be R5 243,48 per child saved,” says Skordis. “Alternatively, using Nevirapine to reduce mother-to-child transmission would cost a maximum of R489,81 per child saved. AZT alone would cost a maximum of R2 752,59 per child saved. “Each of these costs,” Skordis says, “is significantly less than the R18 966,70 that every HIV-positive child costs the state. And this figure is a gross underestimate. It excludes the cost of medicines for treating opportunistic infections such as, say, pneumonia, the economic costs of a parent or guardian staying home from work to care for a sick child and the transport costs of getting the sick child to medical care.”
The most effective known treatment to prevent mother-to-child transmission is the provision of both anti-retroviral drugs to the pregnant woman and milk formula to her child after birth in order to avoid breastfeeding.
“This combination,” says Skordis, “can save up to 99 275 children a year at a cost per child saved of R2 968.” Skordis produces eight scenarios and probabilities for the incidence of HIV/Aids in South Africa in coming years. Using the most likely of them, Skordis calculates that the total lifetime expected basic hospital costs for all HIV-positive babies born each year, where no intervention to prevent them contracting HIV has been made, is R1,7-billion. By comparison, the total cost a year of all HIV-positive children born in that period, where AZT is provided to all HIV- positive pregnant women and where formula feeding of infants is encouraged, is R901- million. That is a saving of more than R800-million a year. If Nevirapine alone is used as an intervention, the total cost a year is slightly higher at R973-million, producing a slightly lower saving of R728-million a year for the taxpayer. This saving would be likely to rise substantially if Nevirapine were combined with formula feeding, as formula feeding would increase the number of infants not contracting HIV/Aids. South Africa’s total health budget each year is running at about R6,3-billion a year. The slice of it that would be taken up by antiretrovirals and/or milk formula in cases of HIV-positive pregnant women could therefore be somewhere between 14,3% and 15,4% – but would very probably be lower than that. In his budget this year, Minister of Finance Trevor Manuel announced a special additional R75-million would be spent to fight HIV/Aids. This would rise to R125- million next year and R300-million in 2002/2003.
There appears to be a growing awareness within the Department of Health about the scale of the hospitalisation and welfare costs that result from the birth each year of tens of thousands of HIV-positive infants – 131 263 is Skordis’s best estimate.
A reckless recent comment to the American magazine Science by presidential representative Parks Mankahlana – that the South African government did not want to provide anti-retroviral drugs to HIV- positive pregnant women because this would save the lives of thousands of children who would then become orphans and, so, a financial burden to the state – drew a sharp response from the Department of Health.
Nono Simelane, head of the department’s Aids programme, said Mankahlana’s comment was a gross misrepresentation of policy. She said the government’s view was that it would not be saving costs by refusing treatment to HIV-positive pregnant women as the state would still have to pay for treating and looking after HIV-positive children who survived. “They do live and they are often presented with illnesses for which they need repeated care,” Simelane said. Skordis challenges Mankahlana’s comment on other grounds as well. She argues that children who are saved from contracting HIV/Aids through the provision of anti- retroviral treatment to their HIV-positive mothers should be considered part of the normal population of South Africa and should not be thought to place any unusual strain on state resources. “Although such a child’s mother is more likely to die shortly after its birth than an HIV-negative mother, it is reasonable to assume that, in most cases, an alternative member of the child’s family or community will take responsibility for the child’s upbringing,” Skordis says. “It is also reasonable to assume that, at some point, each HIV-negative child will be able to ‘refund’ the state for any investment in its upbringing. Loosely speaking, these children are as likely as any other South African child to survive to adulthood, find gainful employment, pay taxes and so on. “So, although many HIV-negative children may receive a child support grant for their first six years, this is not regarded as a ‘cost’ in my study because they are likely to more than compensate the state for this expense when they grow up to become productive, tax-paying adults. By contrast, the welfare spending on HIV-positive children is unrecoverable,” Skordis says.
@ state doctors treat infants in defiance of jail threat Peter Dickson Eastern Cape doctors have been threatened with imprisonment if they bring the anti- retroviral drug Nevirapine on to provincial hospital premises. But they are going ahead with plans to supply it at other venues to stop an estimated 80 HIV-infected babies dying every day. One state doctor, outspoken Aids campaigner Dr Costa Gazi, has not only bought a stock of Nevirapine out of his own pocket, but is also carrying out blood testing for pregnant mothers – which is not routine in health clinics. This means thousands of mothers go into labour each year in a province with 500 000 people with Aids.
Although Nevirapine has not yet been licensed for preventive use in (one-off) mother-to-child transmission, it has been withdrawn for the next three years as one- third of an anti-Aids cocktail in dozen of trials across South Africa by European and American drug companies. There is a world of difference between the two uses, Gazi says. Once a drug has been licensed, doctors can use it for any purpose. For example, Myzopterol, invented for treating gastric ulcers, was also found to induce abortion and is widely used by South African gynaecologists. This is not illegal or unethical, Gazi says, and no case can be brought unless in the event of extreme negligence or recklessness. Gazi has submitted a proposal to the Department of Health that he be removed as head of public health at East London’s Cecilia Makiwane Hospital and 20 community clinics to run a full-time HIV-screening service throughout the Eastern Cape. Bolstered by a flood of donations, he has bought a sizeable stock of Nevirapine and distributed it to other doctors. After provincial MEC for Health Dr Baven Goqwana’s jail threat, Gazi, the Pan- Africanist Congress’s national health secretary, approached community organisations to set up counselling for HIV-positive mothers. It takes just three tiny drops of paediatric Nevirapine – costing 18c – administered to a baby seconds after birth to drive the HIV virus out of the infant’s bloodstream. The mother is given a single once-off tablet, costing R25, that wards off infection through breastfeeding. Gazi says post-birth tests on the drug, declared safe at the World Aids conference in Durban last week and submitted to the Medi-cal Control Council’s scientific committee several months ago, showed no side effects after nine months.