Mail & Guardian Online - August 2, 2009
Mara Kardas-Nelson

This is despite a report released by the Health Systems Trust, which states that access to prevention of mother-to-child-transmission services is declining throughout the country.

The report shows that rates of access to Nevirapine -- a single-dose drug given to mothers before delivery and to the newborn baby -- have dropped in several provinces in the past few years.

The Free State has fared worst: all the province's districts have prevention-treatment coverage rates below 40%. According to Tanya Doherty, a researcher at the trust, poor data collection and limited analysis have resulted in "coverage rates being hugely overestimated in most years". She said the national coverage rate was less than 60%.

Dr Glenda Gray, of the Perinatal HIV Research Unit at the University of the Witwatersrand, said: "There is no reason why [increased prevention treatment] shouldn't have happened."

Gray said Motsoaledi's proposed plan was unnecessary, as universal prevention treatment "can be done with existing human resources. I don't understand why this isn't possible."

But new evidence suggests South Africa's programme may not be adequate to reduce mother-to-child transmission. Scientists at last week's fifth International Aids Conference on HIV Pathogenesis, Treatment and Prevention claimed that placing women on antiretrovirals early in their pregnancy, rather than just before and after delivery, as is the case at present, can significantly diminish mother-to-child transmission rates.

Several studies suggest that HIV-positive women with higher CD4 counts -- a measure of immune response -- are less likely to transmit the virus to their child through birth and breastfeeding.

Dr Christian Pitter of the Elizabeth Glaser Pediatric Aids Foundation presented evidence that the transmission rate was above 30% if a woman's CD4 count was below 200, but dropped to less than 10% if the CD4 count was above 350. Since antiretrovirals increase CD4 counts, placing women on treatment earlier could decrease transmission rates.

In South Africa, public-sector patients are given anti-retrovirals only when their CD4 count drops below 200, despite World Health Organisation (WHO) guidelines that recommend beginning treatment when the CD4 count dips below 350. South Africa's policy has been hotly criticised by the WHO, activists and scientists within the country.

Although Gray agreed that placing women on treatment early in pregnancy is ideal, she said such a programme cannot be implemented with current low rates of antenatal testing.

A study done by the Reproductive Health and HIV Research Unit at the University of the Witwatersrand found that 50% of HIV-infected mothers in Gauteng had not had an HIV test before delivering the child and therefore had not had access to preventative treatment.

"We've got to get first things first, and we've got to get better coverage," said Gray. "To throw [increased antiretroviral coverage] into a system where there isn't enough testing and treatment ... will just make things more difficult."

Gray said that under the current system pregnant women who test positive with CD4 counts of below 200, who are in need of immediate treatment, "get lost in the system".

"They're tested and then told to go to another clinic to get [antiretrovirals] and put on a [waiting] list there and by the time they're in labour they don't even get [prevention treatment]. They're not prioritised and they wait for weeks. No one sees a woman with a pregnant belly and HIV and says 'emergency'."

But Ashraf Grimwood, of Absolute Return for Kids, and a prominent South African HIV clinician, said Motsoaledi would provide essential leadership for improvement of the system. Speaking at last week's conference, he said: "With the [new] president, deputy president and minister, I think the environment is ripe for rapid growth."

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