Calls are mounting for an end to the nevirapine programme for HIV-infected pregnant women, on the grounds that it is not working and should be integrated into wider healthcare measures.
Four years after the nevirapine-based prevention of mother-to-child transmission (PMTCT) programme was introduced, following the Treatment Action Campaign’s watershed court victory over the government, one in 13 children in highly HIV-affected KwaZulu-Natal communities is still thought to be dying of Aids before turning five.
South Africa is one of only seven countries where the child mortality rate is rising. About 90 000 children a year are infected with HIV during pregnancy, birth or breastfeeding.
Experts say the programme is failing because many women are not using it, or do not complete the treatment. Some doctors and activists are calling for it to be ditched; others want the nevirapine regime modified and simplified. And the health department is criticised for failing to provide adequate leadership and resources.
The percentage of eligible women receiving nevirapine varies geographically from 30% to 70%. Of the women and babies enrolled in the PMTCT programme, fewer than 10% attend the six-week post-natal follow-up — when the baby should be rechecked for HIV and given prophylactic treatment against opportunistic infections.
Some doctors argued this week that the six-week follow-up is scheduled too late, as mothers are likely to have returned to work or to distant homes by that time. The child may also be in the care of a relative who may not know its status, or that of the mother.
Nigel Rollins, of the University of KwaZulu-Natal, called for a change in focus, from stopping HIV transmission at birth to ensuring that the child is alive and healthy at five years of age. Rollins argued in favour of universal screening of children during routine vaccinations.
A further obstacle to the PMTCT programme — women’s reluctance to reveal their HIV status — could be partly cleared by routine voluntary testing.
Rollins applauded KwaZulu-Natal’s move to integrate the PMTCT programme into general maternal and child healthcare.
Studies in Uganda and South Africa have found that mother-to-child infection can be reduced to about 11% in resource-poor settings, down from more than a third without interventions.
Yet Rollins’s research has found that one in five infants born to HIV-infected mothers monitored at primary healthcare clinics in Durban and elsewhere in KwaZulu-Natal is HIV-positive — twice what he regards as the minimum target. Up to 40% of pregnant women are thought to have the virus.
Transmission rates among infants born to HIV-infected mothers at seven research sites who admitted they were HIV-positive were between 14% and 15%. However, among the women who claimed they did not have the virus, 31% of babies were HIV-positive.
This implies either that they were unwilling to disclose their status to the research team or that they simply did not know it.
They may have become infected during pregnancy, when women appear to be more vulnerable to the virus, or they may have tested negative during the ”window period” when newly infected people have not yet produced detectable antibodies.
One of the simplest ways of reducing child infections would be to test HIV-negative women repeatedly during pregnancy.
The PMTCT programme is also failing to identify women with a low CD4 count and to fast-track them on to chronic antiretroviral care.
When the PMTCT programme was designed it depended on a single dose of nevirapine to the mother during labour, then additional doses to the newborn child within the first three days of life.
Doctors are now calling for guidelines to be changed so that women are given a four- to eight-week course of the antiretroviral AZT, plus nevirapine. The longer course of treatment reduces the mother’s viral load, improving her health and reducing the chance of the virus establishing itself in the infant.
Providing AZT over such a period is a more challenging option, but the Western Cape has already moved to this system. Elsewhere in South Africa, doctors and activists say healthcare workers and managers are reluctant to deviate from the nevirapine-only guideline, for fear of angering the health department.
Mark Heywood of the Treatment Action Campaign said the Gauteng department of health had indicated it could start providing the AZT prophylaxis, but no individual had taken this step for fear of department of health sanction. Health Minister Manto Tshabalala-Msimang is deeply suspicious of AZT.
François Venter of the South African Clinicians Society admitted healthcare workers had not realised the complexities of PMTCT. ”It is harder than we anticipated. But this is used by many parties as an excuse to do nothing. Many, many lives have been saved. We need to simplify and expand the programme, and look critically at why it isn’t working in some areas.”
Rollins is more forthright: ”Going down to the wards and seeing those kids is reprehensible. It is too late for them, and they are suffering. We have the means to change that, but there are not enough committed resources, PMTCT coordinators and support staff are being pulled to the ARV roll-out.
”But it is better to prevent than to treat. There has unquestionably been a lack of leadership at the top; the minister’s tendency to redirect discussions has taken away energy.
”South Africa signed the Convention on the Rights of the Child 12 years ago, yet child mortality is on the increase — even though the minister tried to soften it and to obscure that fact.”