Mother-to-child HIV sets back Uganda

Uganda’s success in fighting Aids has been justly celebrated. In 1993, the country had an HIV prevalence rate of 30%—this according to the Uganda Aids Commission, which was set up by the government to coordinate the fight against HIV. The rate now stands at 6%.

Health workers continue to face challenges in a crucially important area, however: the prevention of mother-to-child transmission of HIV.

Ida Ssekasi’s* story provides some indication of why this is.

After falling pregnant, Ssekasi took an Aids test at an antenatal clinic and discovered she was HIV-positive.
A counsellor advised Ssekasi to bring her husband along during the next check-up—something she never got the chance to do, as he threw her out of the house when he discovered her status.

“When I told him I was positive and that the counsellor wanted to see him, he asked me why I took the test, beat me up and chased me away,” she says.

Says Aids counsellor Cissy Kinaawe: “We get many cases of women who are thrown out of their homes by their husbands because they told them that they were positive. There are also many incidences of divorce.”

In 1999, researchers reported that a single dose of nevirapine to HIV-positive mothers and their new-born children reduces the risk of HIV transmission by 50% or more. In the absence of intervention, transmission occurs in the womb, during labour or as a result of breast-feeding.

But, four years after the government introduced a programme to prevent mother-to-child transmission through the use of HIV testing, medication with nevirapine and other measures, ignorance and stigmatisation of Aids continue to stand in the way of the programme’s complete success. (In certain hospitals, HIV testing for expectant mothers has become mandatory—but it remains optional in others.)

Health workers say many pregnant women are reluctant to enrol in the programme because they fear negative reactions from their spouses. Some are simply not aware of the programme, while others are too poor to travel to the health centres that offer nevirapine.

Certain mothers-to-be turn to women who have traditionally served as community midwives, rather than go to health centres where anti-retrovirals (ARVs) can be administered.

Poverty has also stood in the way of preventing women from passing HIV on to their babies through breast-feeding. With about 44% of Ugandans living below the poverty line of $1 a day, many mothers find they simply cannot afford to buy infant formulas to feed their children.

In other instances, the stigma surrounding Aids encourages women to persist with breast-feeding. Those who don’t breast-feed fear their failure to do so will alert others in the community about their HIV status.

Health statistics tell the dismal tale of what this accumulation of fear, poverty and ignorance has led to. HIV/Aids is currently the fourth-most-important cause of death among children under the age of five, according to Uganda’s Ministry of Health.

When one considers that about 24,4% of all babies born in Uganda are delivered to HIV-infected mothers—this according to the United Nations Joint Programme on HIV/Aids—the necessity of tackling the problem of mother-to-child transmission becomes even more evident.

Aids activists say it’s essential that the government ensure ARVs are available everywhere, even in remote corners of the country.

“The PMTCT [prevention of mother-to-child transmission] programme people will tell you that nevirapine is everywhere,” says an Aids counselor in the capital, Kampala.

“But the truth is that women in the rural areas do not have access to the drug. It’s only found at the referral hospitals,” she said, adding: “Even if it’s free, there is still uneven distribution.”

PMTCT coordinator Saul Onyango admits that there was a countrywide shortage of nevirapine in Uganda last year. The programme is backed by a five-year donation of free nevirapine from German manufacturer Boehringer-Ingelheim, while the United States-based Gates Foundation and the US Agency for International Development also provide support.

However, authorities hope that by the end of 2004, clinics in all 56 districts of the country will be supplied with ARVs. A concerted effort will then have to be made to ensure pregnant women and their partners are aware of the benefits of HIV testing, ante- and post-natal care.

“If you ask around, you realise that many still do not know about the PMTCT programme. You cannot take services that people are not aware of,” says Onyango.

“If we want them to take up the services, we need to improve the communication component. Get them to be aware before they go to the clinic, so that by the time they get there, they know what is there.”

Chris Baryomunsi, HIV/Aids adviser at the UN Population Fund office in Kampala, agrees with Onyango’s views.

“The biggest challenge ... is that the programme is still not reaching the majority of the people who are living in the rural areas,” he says, adding: “The further away you go from Kampala, the more difficult it becomes.”

Even condom access in rural areas remains a problem.

Baryomunsi says there is also a need for greater cultural sensitivity when formulating HIV prevention campaigns for pregnant women: “For instance, what are some of the factors that cause expectant mothers not to visit the health facilities?”

In the initial stages of their pregnancies, mothers-to-be do tend to visit antenatal clinics, where they are given the necessary information on HIV testing and encouraged to deliver their babies in the health facility. However, many ultimately give birth at home or with traditional birth attendants (TBAs).

According to statistics from the Ministry of Health, up to 94% of expectant mothers visit antenatal clinics at least once during their pregnancy, but only 40% are estimated to deliver their infants in hospitals.

“That means for the PMTCT programme to be effective, it must also address the issue of mobilising communities, the women and TBAs to be able to appreciate that they must deliver at the antenatal,” Baryomunsi says.

Studies done in western Uganda have further shown that cultural norms require women to give birth in a squatting position. In clinics, women are placed on a delivery bed and give birth from a prone position.

In addition, the placenta is disposed of in clinics, while tradition in Uganda dictates that it should be saved.

“Those are some of the cultural setbacks that deny women access to the drugs. These are vital issues that we must look at and integrate in our national programme because they affect some of the outcomes,” Baryomunsi says.

Health workers also agree that more needs to be done to ensure new mothers return to clinics after they have given birth, so that their own health and that of their children can be monitored.

“We have been encouraging the mothers to come back to the health facilities, but in reality, few are coming back. And we are recognising that unless we strengthen that component, we are likely to be missing out,” Onyango says.

He says the programme is now looking at policies to ensure new fathers play a role in post-natal care.

“One of the objectives of this programme is to bring men on board. But it’s not as easy. Even in the rural areas when they escort their women to the maternal clinics, they just remain seated under a tree,” Onyango notes.

Cissy Kinaawe says her efforts to council the men have also run up against difficulties.

“In most cases these women come from polygamous marriages,” she says. This complicates efforts to include men in counselling sessions.

For any significantly extended counselling effort to go ahead, more health workers will be needed. Those involved at present are already over-worked.

But, Baryomunsi emphasises that adequate counselling is central to the success of efforts to prevent mother-to-child transmission of HIV.

“At times when people talk about PMTCT, they only talk about the drug. But it involves a whole package, including information and services, which reduce the risk of MTCT,” he says.—IPS

* Certain names have been changed to protect the identities of those concerned.

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