Sunday Times (Johannesburg) - July 29, 2007
Kerry Cullinan**

The Department of Health is stalling the introduction of treatment that can prevent more than 90% of pregnant HIV-positive women from passing the virus to their babies.

Currently, as many as 30 000 infants in one province alone are being infected with HIV by their mothers each year.

A leading paediatrician has described the treatment delay as "shameful", while the Treatment Action Campaign (TAC) says it is considering taking the government to court to force it to expand its programme.

At present, national treatment for the prevention of mother-to-child transmission consists of administering a dose of Nevirapine to women when they are in labour and a dose to their babies within 72 hours of birth.

However, a year ago the World Health Organisation recommended that pregnant HIV-positive women in developing countries should get "dual therapy", comprising Nevirapine and a short course of AZT to protect their babies from HIV infection.

The Western Cape has been using both Nevirapine and AZT since May 2004 and has managed to reduce its mother-to- child HIV infection rate to around 8%.

By contrast, in KwaZulu-Natal, with its nevirapine-only regimen, 22% of HIV-positive mothers are passing on the virus.

"In KwaZulu-Natal alone, 20 000 to 30 000 children are being infected with HIV each year and half of them will need antiretroviral drugs by the age of 12 months," said Professor Nigel Rollins, head of the Centre for Maternal and Child Health at the University of KwaZulu-Natal.

"The delay in introducing dual therapy is shameful. How can women and babies be denied treatment when people on the ground say it can be implemented?" Rollins said.

South Africa is one of only nine countries in the world where the child mortality rate is increasing- instead of dropping - mainly as a result of children dying of Aids-related illnesses.

The Medical Research Council, the National Essential Drugs Committee and the Medicines Control Council have all recommended to the government that the country adopt dual therapy.

Many doctors working in government hospitals say they were told in December to prepare themselves for the imminent introduction of dual therapy.

But the National Health Council - made up of the health minister, provincial health MECs and heads of department - has consistently failed to make dual therapy national policy or even to set up a task team to investigate its introduction.

Health spokesman Sibani Mngadi confirmed the council had discussed dual therapy, but he refused to be drawn on whether the department intended to change its protocol or when this might happen.

"The National Strategic Plan, adopted by Cabinet, has made room for the introduction of dual therapy," said Mngadi.

But when asked if hospitals that were ready could introduce dual therapy, he said "ideally this should not be the case since overarching policies and guidelines stem from the national Department of Health".

Many hospitals in KwaZulu- Natal and Gauteng are ready to implement dual therapy. The Northern Cape Health Department has already approved dual therapy but is waiting for the national government's go-ahead before implementing it.

KwaZulu-Natal health spokesman Leon Mbangwa said that while his province was preparing to introduce dual therapy, this would not be done "until we have received a national directive to do so" as "it is not yet national policy to use dual therapy in South Africa".

Dr Victor Fredlund confirmed he had "been corresponding with the national and provincial departments for the past eight months about the desire of five hospitals in Umkhanyakude [in the far north of KwaZulu-Natal] to implement dual therapy". Fredlund's Mseleni Hospital is offering the therapy to patients who can afford AZT.

Gauteng health spokesman Zanele Mngadi simply said that dual therapy was "under review" and "it is envisaged that a decision will be made in this regard soon".

A Tshwane doctor who asked not to be named said his hospital had already started dual therapy as "we think it is better to have to say sorry afterwards than to ask permission".

TAC spokesman Nathan Geffen said his organisation could not understand the delay, as "dual therapy will save the lives of babies and reduce the burden on the health system of caring for sick children".

Geffen said although it would prefer not to, the TAC was considering court action to compel the government to introduce dual therapy.

In 2003, the TAC succeeded in getting the courts to compel the government to make Nevirapine available to pregnant HIV-positive women.

This week the Joint Civil Society Monitoring Forum, which represents more than 20 health and civil society organisations, wrote to the Health Department and asked it to immediately allow provinces that were ready to offer dual therapy and to set up a task team to consider how best to implement the WHO recommendations on dual therapy.

Forum spokesman Fatima Hassan said: "There is no good public-health reason to stall the implementation of dual therapy. It is not difficult to implement. If we are serious about preventing HIV, we must start by preventing babies from getting HIV."

In May, Dr Francois Venter, president of the SA HIV Clinicians Society, wrote to the SA National Aids Council asking it to investigate the delay.

"Several doctors and ARV managers in both rural and urban environments have raised the issue that they have been promised updated guidelines repeatedly, but these have not been forthcoming," he wrote.

The new National HIV/Aids Strategic Plan aims to reduce the rate of mother-to-child transmission to 5% by 2011.

Pregnant women with high viral loads and low CD4 counts (the measure of immunity in the blood) are most likely to transmit HIV to their babies, but this risk can be substantially reduced by treating them with at least two antiretroviral drugs to make them less infectious.

"We will never cut the transmission rate to 5% with one dose of Nevirapine. In the US and Europe, mother-to-child transmission has been reduced to around 2% with the use of two to three antiretroviral drugs," said Venter.

"If we fix mother-to-child HIV transmission, we don't have to expand child HIV treatment," Venter said.

** SOURCE: Health-e News Service

Web site: www.health-e.org.za

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