South Africa has begun implementing a massive programme to provide free anti-retrovirals and milk powder to HIV-positive pregnant women to retard the transmission of the virus to babies.
In a dramatic move, the government, while not officially changing its policy stance on the treatment of HIV/Aids, is swiftly rolling out a comprehensive approach to prevent babies from being infected with HIV. This will save the lives of tens of thousands of babies each year. It follows approval unannounced by the Medicines Control Council of Nevirapine for the prevention of mother-to-child transmission of HIV/Aids.
President Thabo Mbeki has given the Ministry of Health the go-ahead for the programme. This makes South Africa the second Southern African country to implement such a programme after Botswana, which is providing universal access to anti-retrovirals for pregnant HIV-positive women and rape survivors.
The responsibility for funding the programme is shared by the government and nine provinces. The government has identified at least two pilot sites for the programme in each province in addition to existing hospitals and clinics that already have measures in place to prevent mother-to-child transmission. As a consequence, access to free treatment for HIV-positive mothers has been more than trebled.
All pregnant women presenting at public hospitals and clinics covered by the programme will be tested for HIV/Aids. This will greatly improve South African statistics on the prevalence of the virus. Most of the biggest hospitals across the country chosen for their high birth rates will, from the beginning of next month:
- test all pregnant women;
- provide free anti-retroviral medication for HIV-positive pregnant women; and
- provide free milk formula for the first six months of the babies’ lives to ensure they are not at risk of getting HIV from breast milk.
Two provinces already have mother-to-child transmission programmes in place. They are the Western Cape, since late 2000, and the Northern Cape, since October 1999 as well as the South African National Defence Force since 1999. Limited trial programmes elsewhere in the country will continue at Chris Hani Baragwanath hospital, King Edward hospital and Coronation hospital.
The Department of Health has been moving toward this approach for two years. Provinces approached milk formula companies to slash costs in 1999. Since then the companies have bid against each other in tenders and, along with pharmaceutical companies, are likely to come under pressure from international Aids activists this year to slash profits on milk formula.
The benefits of this new approach by the government will not only extend to state hospitals. Latisa Mabe of Hope Worldwide, an NGO in Soweto, said her organisation had been promised milk formula at R10 a can that would be supplied in the near future through hospitals.
Late last year each province had to present data to the government detailing the numbers of babies born each year with HIV; how they could give access to free anti-retrovirals for mothers and babies; how they could provide free milk formula to mothers; and what funding sources were available.
In Gauteng R15-million a year will be required at present infection rates to test mothers, provide anti-retrovirals, and give milk formula for the first six months of the infants’ lives. The rapid HIV test the government plans to use in the programme costs less than R3 a time. The government will, for the present, take up the Boehrringer Ingelheim offer of free Nevirapine delivered to clinics by the drug manufacturer for the next five years.
Marike Bodenstein, a senior official in the Gauteng Department of Health, said that according to the department’s data: “We informed the national Department of Health that 30 000 babies are born HIV-positive in Gauteng each year.” This is significantly higher than estimates from the South African Paediatric Association, which said that nationally 70 000 babies were born each year with HIV.
When asked for national figures for babies born with HIV annually, the health department referred the Mail & Guardian to nine different department heads. Messages were left for the head of the Aids directorate, Nono Simelela, and Dr Eddie Mahlanga, head of the women’s division to no avail.
Aids activists are delighted by the government’s moves. While they are campaigning for generic anti-retrovirals, the government is investigating manufacturing them. This is largely why Mbeki took a huge delegation with him to Brazil last year where generic anti-retrovirals have been successfully manufactured. Aids activists in South Africa have thus far failed to campaign for no- name milk formula, or cheaper formula prices. Trials examining the link between HIV and breastfeeding are under way in KwaZulu-Natal and the Western Cape, and Gauteng will launch a study in February.
The government’s stance comes at a time when conflict has erupted between Unicef, doctors and mothers about HIV-positive mothers breastfeeding. Unicef has been lambasted in some quarters for endangering babies by sticking to what its opponents say is a long-held antipathy to the makers of milk formula and for telling HIV-positive mothers to breastfeed. A third of HIV-positive mothers will pass the virus on to their babies through breastfeeding. But things are not that clear cut. In many areas, a lack of clean water imperils the lives of babies who receive formula milk.
A report last week by the World Health Organisation showed a community of 800 000 in KwaZulu-Natal had no access to clean water. Dr Peter Cooper, head of paediatrics at Johannesburg hospital, points out: “At the moment anti-retrovirals are cheaper than a six-month supply of milk formula [R600] — Nevirapine costs about R30 for a dose to mother and one dose to baby. There has been talk at national health level of providing a no-name brand formula.”
Cooper says about half of mothers do not breastfeed. He says that at Johannesburg hospital about 30% of pregnant mothers tested are HIV- positive. However, admissions to paediatric wards are more telling. Of those children tested, 40% are HIV-positive and 75% of paediatric deaths mostly children under the age of two are Aids related.
Professor Olive Shisana of the Medical University of South Africa and a former director general at the health department, said: “Clean water is a basic constitutional right. There is a need to reprioritise spending so women and children can access clean water, sanitation and breast milk substitutes. “Secondly, there has to be serious discussion about no-name breast milk substitutes. In the United States this has been a standard for many years. We can’t wait for government. NGOs must begin this work. This whole Aids area could create masses of jobs, too.”
Hospitals participating in the programme
Within the next six weeks Nevirapine will be available free of charge to pregnant mothers with HIV in all of South Africa’s provinces. The government project will begin in 18 major hospitals and their feeder clinics and will extend to more hospitals during the year. The Department of Health has told provinces it is “urgent” that they begin soon. Gauteng begins on February 1 and the Eastern Cape soon after. All health departments will meet on Friday to iron out the final details of the project. A senior official at the health department said it was important that there was a “rural, urban balance. However, we also need to extend this project to those hospitals where most births occur to ensure cost effectiveness. There is a national budget with provincial contributions too.”
Hospitals that have long been giving antiretrovirals to prevent mother- to-child transmission King Edward hospital in Durban and Chris Hani Baragwanath hospital in Johannesburg provided their protocols to the health department, and are partnering with other hospitals to help staff implement the programme correctly. Chris Hani Baragwanath will help Gauteng and Northern Cape hospitals. The Western Cape will assist the Free State, Eastern Cape and Northern Province. Hospitals where the project will be implemented include:
- Gauteng: Kalafong hospital, Natalspruit hospital. Later this year Leratong hospital, Krugersdorp hospital and Johannesburg hospital will be added to the project.
- Northern Cape: De Aar hospital, Kimberley hospital.
- Eastern Cape: Cecilia Makiwane hospital, Rietvlei hospital.
- Western Cape: Guguletu day hospital, Vanguard Obstetric Unit, Paarl hospital, Worcester hospital, George hospital, Khayelitsha clinic, Groote Schuur hospital.
Thandi Tshane, head of maternal health in the Gauteng Department of Health, said Kalafong and Natalspruit hospitals had been chosen to kickstart the project because they average 5 000 deliveries a month between them. “Later this year we will phase in Johannesburg and Leratong. How soon depends on how well we progress at the first two.” The Eastern Cape will begin the project “as soon as we receive the drugs, which we hope will be early February. Everything else is ready, the rapid tests, the training, the counselling, the lot,” said Sister Nomvula Silwana-Kwadjo, local programme manager for the project.
The project is already under way at one of the two identified Western Cape pilot sites. At the obstetrics section of the Guguletu day hospital the project began on January 3. Western Cape Aids coordinator, provincial deputy director general Dr Fareed Abdullah, said the second pilot site identified jointly by national and provincial health officials at Paarl hospital would start issuing Nevirapine in April.
The Western Cape started providing AZT to pregnant women at the Khayelitsha day hospital towards the end of 1998. Of the around 14 000 women who have been assessed since then, around 18% have been identified as living with HIV/Aids. Abdullah said the AZT programme would continue as this would help compare the impact of reducing mother-to-child transmission of the two different drugs — Additional reporting by Marianne Merten