On Tuesday, exactly 20 years after the discovery of the human immunodeficiency virus (HIV), South Africa’s minister of health announced the government has no plans to make anti-retroviral drugs available in public hospitals. The country’s share of HIV/Aids cases is now approximately 11,5% of the world total Belinda Beresford The government’s persistent reluctance to provide anti-retroviral drugs in state hospitals and clinics seems unaffected by its victory two months ago against the Pharmaceutical Manufacturers’ Association (PMA). The prices of anti-retrovirals had started to drop even before the PMA pulled out of the case, potentially making the drugs accessible to people in developing countries who comprise the vast majority of people living with HIV/Aids worldwide. This week Minister of Health Manto Tshabalala-Msimang told Parliament the government has “no plans to introduce the wholesale administration of [anti-retrovirals] in the public sector … I would, however, like to assure this house that this position is not ideological.” There are huge practical difficulties in introducing anti-retroviral therapy in a country with a health infrastructure as bad as that of South Africa. Although many argue such problems can be overcome and a programme could be rolled out slowly, there are two kinds of cases where intervention is much easier and potentially highly effective. These are the prevention of mother-to-child transmission of the virus and the prevention of transmission after exposure in cases of rape or occupational injury. The government has still not announced when it will fully implement a pilot programme to give Nevirapine to HIV-positive pregnant women that had been due to start in March and that, according to a Department of Health official, would reach about 90 000 women a year. In the case of rape, the government has seemed similarly reluctant to move although health care workers at some state facilities do receive anti-retroviral drugs if they suffer occupational exposure to HIV, for example through a needlestick injury. Two months ago the minister defended the decision of the Mpumalanga government to evict from government hospitals the Greater Nelspruit Rape Intervention Project, which advises rape survivors and raises funding to buy anti-retroviral medication for them. At the time Tshabalala-Msimang said there was no absolute proof that administering toxic anti-retroviral drugs to the survivors of sexual assault reduced their risk of catching HIV from their attackers. She is correct. There is no conclusive scientific backing for the use of anti-retroviral drugs to reduce chances of catching HIV after sexual assault. This is largely because there would be serious ethical and practical problems in designing such a conclusive clinical trial. It would require that the HIV status of the attackers were known, which would be difficult in a country where victims have no right to compel their attackers to take an HIV test. Such a trial would also require that some women be given placebos fake, inactive drugs. Some researchers would have a moral problem with this, given their belief that ARVs do work. There are other factors making it difficult to prove whether such drug therapy prevents infection by HIV. Risk of infection depends on many factors such as how badly traumatised the victim was: how badly torn her vagina, anus or mouth was. Other factors to consider are how many assailants there were and whether they ejaculated or whether either party had ulcerous sores or sexually transmitted diseases. Risk of infection is also greater if the assailant(s) have a high viral load the amount of the virus in the bloodstream.
The lack of conclusive proof of the benefits is one problem in making a policy decision on whether to provide the drugs. In deciding on any medical intervention, the benefits must outweigh the risks and while dangers of taking anti-retroviral drugs are documented, the benefits have not yet been conclusively proven. Although there is not yet full proof, a number of studies have indicated the post-exposure prophylaxis does work. For example, a San Francisco study this year looked at 375 people who had sexual exposure to HIV; 43% knew their sexual partner had the virus and the remainder suspected it. All were given anti-retroviral therapy and none seroconverted. Shaun Conway, from the International Association of Physicians in Aids Care, says despite the lack of clinical trial proof, he would prescribe or take anti-retroviral drugs in cases of sexual assault. “On a first principles empirical understanding level it makes scientific sense.” The logic is that the anti-retroviral drugs prevent HIV from replicating in the body; this allows the person’s immune system time to identify and kill the virus, before it is able to become part of the genetic machinery of the putative victim’s cell that will lead to future copies of the virus being produced. In South Africa the recommendation based on international and local experience is to give 3TC and AZT. This is a combination of drugs that reinforce each other’s efficacy and do not usually have excessively toxic side effects, although all anti-retroviral drugs have notoriously unpleasant side effects. Rape victims at some hospitals are given a starter course of a few days as part of a rape kit, which also contains the morning after pill to prevent pregnancy and antibiotics and a fungicide to prevent infection by sexually transmitted diseases. The recommendation is that such post-exposure prophylaxis be started as soon as possible definitely within 72 hours of the assault taking place. This period is based on studies done on post-exposure prophylaxis following occupational exposure, such as needlestick injuries. It continues for a month, although some physicians Conway is one feel that up to three months can be justified in some circumstances. In some countries a third drug is added to the cocktail, often Nevirapine. This is controversial, however, because Nevirapine can have toxic effects on the liver, especially if used for an extended period. There has been one reported case of a woman needing a liver transplant as a result of taking Nevirapine in a post-exposure prophylaxis combination. Francois Venter, a doctor at the Wits HIV Research Unit, has several patients who have contracted the disease after sexual assault. He strongly recommends that “HIV prevention post-rape has not been as well studied as that for prevention of transmission from mother-to-child. “However, the scientific evidence that is available is fairly convincing, especially from local sites like Sunninghill Clinic. The consequences of developing HIV are devastating, especially in a resource-poor country like South Africa. Side effects of the Centers for Disease Control-recommended drug regimens are not insignificant, but generally most patients complete the course of treatment.” Taking anti-retroviral drugs can have other, less scientific benefits by giving the survivor the feeling that they have some power over their own health in a situation where powerlessness can be part of the trauma. “It can give you hope,” said Venter.