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Many challenges for pregnant HIV mothers programme
Kerry Cullinan
2005-08-12
South Africa now has the biggest prevention of mother to child HIV transmission (PMTCT) programme in the world. Health-e speaks to the health departments Dr Nomonde Xundu about its challenges and successes.
Health-e speaks to the health departments Dr Nomonde Xundu about its challenges and successes. Pregnant HIV positive women can now get the drug nevirapine to help stop the transmission of the virus to their babies at every hospital in the country, and at almost all health centres and clinics. This is a far cry from 2001, when the health department had only 18 pilot treatment sites, and was ordered by the Constitutional Court to immediately expand the programme. But Dr Nomonde Xundu, governments Chief Director of HIV/AIDS, says the court order caught government off-balance and it is still facing operational problems.
The rapid expansion of PMTCT was an activity that was not originally planned for, says Xundu, who was at the time overseeing the PMTCT programme in Gauteng. The whole plan with the pilot sites was to give us information as to how best we should operationalise the programme. Ideally, PMTCT should have been integrated with the ante-natal care and child care services as well as other HIV services, but it was not possible at the time, explains Xundu.
Now that PMTCT services are available at 2 525 sites countrywide, Xundus department is considering moving the management of the PMTCT programme to the Maternal and Child Health Directorate.
One of the programmes biggest weaknesses is that it is very difficult to measure the impact of nevirapine on the transmission rate from mothers to babies. This is because so few HIV-exposed babies are brought back for HIV testing at 15 months.
Normal HIV tests only work on babies over 15 months when they no longer have their mothers antibodies in their bloodstream. The more expensive PCR tests can tell if a baby is HIV positive at six weeks, but the National Health Laboratory Service lacks the capacity to test all HIV-exposed babies, says
Xundu. The programme is also hampered by a lack of district management in some areas. As a result, some sites have had to operate without lay counsellors and have run out of supplies of formula milk. Counsellors are essential to explain to pregnant women how the programme works and to advise them on how to feed their babies.
The HI virus can also be also transmitted in breast milk, and research shows that mothers should either only formula feed their babies from birth or, in places where this is not possible, only breast feed for six months. Babies are most likely to get HIV is their mother mixes both breast and formula feeding.
Xundu is deeply concerned about the high incidence of mixed feeding and the role it plays in increasing the transmission of HIV after the baby is born. There is agreement that we encourage exclusive breastfeeding. However, formula feeding is recommended where it is accessible, available, acceptable, feasible, safe and sustainable, she said.We would encourage breastfeeding mainly in rural areas where poor access to clean water and health services is a problem. However, we find that few women are able to exclusively feed either way and are therefore not enjoying the maximum benefits of the programme.
Good Start, a study commissioned by the health department to assess its PMTCT programme, showed that many babies saved by nevirapine from getting HIV at birth are being infected later in communities where health systems are weak and there is little support for their mothers. The study was conducted in three areas rural Rietvlei in the Eastern Cape, urban Umlazi in KwaZulu-Natal and the small town of Paarl in the Western Cape. It followed 665 mother-baby pairs. Three weeks after birth, only 8.6% of Paarl babies, 11.9% of Umlazi babies and 14.2% of Rietvlei babies were HIV positive.
But by the time the babies were nine months old, almost 20% more Rietvlei babies were HIV positive. This meant that over 30% of babies born to HIV positive mothers in Rietvlei were HIV positive by nine months around the same proportion that would be infected without any drug intervention. Thus, at Rietvlei the benefits of the drug intervention were effectively cancelled out by the later HIV infections.
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. Xundu said she had been hoping for the study to show how effective the overall PMTCT programme had been, but that the sample had been too small. But the lesson from the study, added Xundu, was that poor women were not benefiting properly from the programme. The study size is not adequate for us to generalize, but it is clear that these women did not have equal access to services and that this impacted on the transmission rate. But we do welcome the study as it guides us as to what some of the issues are that we need to address, said Xundu. Xundu is also concerned about evidence that the current single dose of nevirapine, even though proven to effective in preventing HIV transmission, may mean that mothers may develop resistance to this drug.
This may mean that those mothers who need antiretroviral treatment themselves wont be able to take nevirapine. As soon as we are better appraised of these findings, we will explore available options, said
Xundu. Over a year ago, the Medicines Control Council advised government to use more than one drug in its PMTCT programme to prevent drug resistance, which could undermine the national ARV programme. Xundu is also ensuring that doctors who deal with pregnant women in antenatal clinics have training in antiretroviral treatment. This would then ensure that the women is not referred to other service points. We believe such a step would also go a long way in reducing both the risk of transmission and resistance. The drugs and the protocols are there, we just need to get the training done, she said.
The following are challenges that need to be addressed to improve the PMTCT programme:
1 Integrate the PMTCT programme into other mother and child programmes.
2 Stem the high turnover among lay counsellors by ensuring that they are appropriately paid, trained, supported and mentored.
3 Introduce an opt-out system for testing where instead of first offering a whole range of counselling services, the woman is routinely offered anHIV test with the choice to opt out.
4 Improve the continuous counselling around baby feeding options to stop mixed feeding in the first six months.
5 Expand the drug regimen to include dual therapy for all HIV infected mothers who book at antenatal care. Also, make ARV therapy available toall HIV infected women who qualify for this treatment.
6 Implement PCR testing for infants within the first two months of life.
7 Encourage partner participation in an effort to improve follow-up, reduce transmission and support exclusive feeding options.
8 Improve middle-management in those provinces not performing optimally.
9 Continuous education of those women opting for formula feed to decrease the incidence of diarrhoea among the babies.
10 Train obstetricians and midwives to administer anti-retroviral therapy.
(Source: Health-e, 10 August 2005)
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