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PMTCT gains reversed by unsupportive environment
Anso Thom and Kerry Cullinan
2005-06-17
Many of the babies saved by nevirapine from getting HIV from their mothers at birth are being infected with the virus later in communities where health systems are weak and there is little support for their mothers.
This is according to a series of papers presented at the SA National AIDS conference yesterday (wed) from research commissioned by the health department.
Research at three very different sites providing the prevention of mother to child HIV transmission (PMTCT) programme showed that the site in the poorest area had almost double the transmission rate of the best resourced site after nine months.
The PMTCT programme is working in the hospitals, where the transmission rates are as low as those in the clinical trials [of nevirapine]. But the big challenge comes afterwards, once the mothers and babies leave the hospital, says researcher Mickey Chopra of the Medical Research Council.
Research on 665 mother-baby pairs in the PMTCT programme found that, three weeks after birth, only 8.6% of babies born in Paarl in the Western Cape, 11.9% in Umlazi in KwaZulu-Natal and 14.2% in Rietvlei in the Eastern Cape were HIV positive.
But between three and 36 weeks of age, there was a jump in HIV transmission by almost 20% in Rietvlei, the site in the poorest area with the weakest health service.
This meant that almost 30% of babies born to HIV positive mothers in Rietvlei were HIV positive by nine months. This is almost the same proportion that would be infected without any drug treatment, meaning that at Rietvlei the benefits of the drug intervention were effectively cancelled out by the later HIV infections.
In comparison, the HIV transmission rate between three weeks and nine months in the relatively well-resourced Paarl was only 7.8%, while12.3% of babies in Umlazi had became HIV positive in this time.
Most children infected after birth would have got HIV when their mothers mixed breastfeeding and formula feeding.
Exclusive breastfeeding for six months or formula feeding are much safer options.
In Paarl, the health care system was able to offer a reliable supply of formula milk to those mothers who wanted it and more women chose this option than at the other sites.
It was also relatively easy for HIV positive mothers to get child support grants and the environment seemed more accepting of HIV as 72% of the women had been able to disclose to family members that they had HIV.
In all three sites, there were stock-outs of formula milk, said researcher Tanya Doherty of the Health Systems Trust. In addition, far fewer mothers in either Rietvlei (39%) and Umlazi (53%) felt comfortable to disclose their HIV status.
In all three sites, more mothers who opted for exclusively formula feeding were able to maintain this choice than mothers who opted for exclusively breastfeeding.
Babies most at risk of HIV infection were those born to mothers with high viral loads (measure of the virus in their blood), who had low birth weight and lived in poor socio-economic areas.
To reduce the later HIV infection, the researchers proposed more effective counseling of mothers on safer feeding options for their babies, a consistent supply of formula milk and antiretroviral therapy for mothers with high viral loads.
An environment in which mothers felt able to disclose their HIV status is also very important. Women who had disclosed to their families would be less likely to be pressurised by their families to mix breast and formula feeding.
This is the first large scale operational study of the effectiveness of the PMTCT programme in Africa, said researcher Mark Colvin of Cadre.
He stressed that more attention must be paid to the postnatal component of the programme, particularly infant feeding counselling and support, and that health workers and counselors need to be trained to provide this.
The Good Start research was produced by HST in collaboration with the University of the Western Cape, MRC, Cadre and the University of
KwaZulu-Natal.
(Source: Health-e News, June 09, 2005)
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