Belinda Beresford
In an acrobatic and aerial manoeuvre, the KwaZulu-Natal government has deserted the Department of Health in its fight against the Treatment Action Campaign (TAC)over curbing mother-to-child transmission of HIV.
Instead Premier Lionel Mtshali says KwaZulu-Natal will obey the “moral imperative” and supply nevirapine to all pregnant women who wish to take it. The move nimbly lifts the province from the murky controversy surrounding the national government’s apparent reluctance to extend a programme to reduce the number of babies getting HIV from their mothers.
Meanwhile, it has emerged that the government has for a month had access to a state-ordered report that says there is no reason to delay extending the nevirapine programme where adequate facilities exist. Although this report was presented to a health ministers’ meeting several weeks ago, Minister of Health Manto Tshabalala-Msimang last week publicly attacked Gauteng Premier Mbhazima Shilowa for announcing further roll-outs of the provincial programme in compliance with the recommendations of the report.
Produced by the Health Systems Trust (HST), the study looks at the pilot sites providing nevirapine as part of the government’s national Aids plan.
It highlights the massive problems inherent in the health service, including the lack of infrastructure, staff training and management, and the stigma surrounding HIV/Aids. It also details uncertainties on how best to reduce transmission of HIV through breast milk, including the arguments for and against formula feeding.
“The systemic weaknesses and infrastructural constraints identified by this evaluation are not reasons for delaying action, but are important for informing the planning and expansion of [mother-to-child transmission] services,” says the report.
The recommendations are likely to weaken further the government’s defence in its legal fight with the TAC. In December the TAC won a court battle to force the government to produce firm timelines for the implementation of a nationwide mother-to-child nevirapine programme. Today sees the national and provincial departments of health in the Pretoria High Court seeking leave to appeal.
Although KwaZulu-Natal’s MEC will be listed among the defendants, it is effectively in name only. Mtshali has submitted an affidavit to the court saying that his province does not support the application for leave to appeal, although it will abide by the decision of the court.
The provincial premier also backs a request by the TAC that the Departments of Health be forced to obey the court judgement, even if an appeal is pending. The KwaZulu-Natal premier is therefore supporting a legal action against his own MEC.
Mtshali’s hard-hitting affidavit says it will supply nevirapine to all pregnant women who wish to take it, even if they have not been tested for HIV. Such universal use of nevirapine breaches national government protocols. These say the drug should only be provided as part of a complete package of care for mother and child, including counselling, testing, and formula feeding, if necessary.
The HST study emphasises the importance of a comprehensive service, but says that while this is being developed “nevirapine can and should be provided immediately to all pregnant women who are already known to be HIV-positive, with appropriate counselling and information”.
Mtshali also acknowledges that such a holistic programme is the desirable goal. But he says: “Where there is inadequate capacity for the purposes of testing and counselling then I propose immediately to administer nevirapine to all [pregnant] mothers as a prophylactic measure, subject to these mothers agreeing to the administration of nevirapine. It should be noted that it is in the poorest areas of the province where the infrastructure does not exist for comprehensive counselling and testing. It is in these areas that the greatest urgency and emergency exist, and hence there must be an intervention without further delay.”
Such prophylactic use of nevirapine has echoes in other universal precautionary treatments that can cause adverse health consequences, such as anti-tetanus injections and polio vaccines, says the affidavit.
In his statement Mtshali says that 35% of KwaZulu-Natal’s population is HIV-positive and last year about 40000 children caught the virus from their mothers. To cut HIV infection by up to 50%, pregnant women are given one pill of nevirapine during labour and the baby is given a dose within three days of birth. This easy treatment regime “is well with-in the capabilities of all the public health facilities of KwaZulu-Natal”.
“The programme of administering nevirapine would be warranted even if there were a small number of innocent lives to be saved, such is the elementary moral fact that the sovereign value of life is a fundamental right under the Constitution and therefore imposes the principle obligation to act upon any responsible government.”