American Foundation for AIDS Research, October 2001
Dave Gilden

The latest South African projections on the spread of AIDS are appalling: The country's Medical Research Council (MRC) estimates that AIDS was the cause of a quarter of all South African deaths last year. Without effective treatment or prevention, AIDS will account for more than double the number of deaths due to all other causes by 2010. South Africa, with a current population of 44 million, will lose five to seven million people to AIDS over the next decade if no further action is taken.

The MRC's estimates, released in a mid-October report, faced stiff government criticism even before they became public. The government called for a national HIV survey to gather more exact data. The Council held up publication for several weeks while it responded to the government's critique. South African president Thabo Mbeki has referred the report to the government statistics agency for review. In the meantime, he told parliament that there were no plans to expand anti-AIDS programs.

Medical measures to prevent HIV and AIDS have been minimal in South Africa. The national government has moved very slowly to establish a program to prevent mother-to-child transmission (PMTCT). It currently has in place a pilot project at two sites per province that offers nevirapine to women in labor and to their newborn babies. The small size of this project sparked a lawsuit this summer by the Treatment Action Campaign, a South African activist group.

The national government's plodding has not stopped some local governments from moving ahead with their own plans. Western Cape Province, whose capital is Cape Town, has just embarked on its own large-scale PMTCT program. Western Cape has a maternal HIV prevalence of 8.7%, relatively low compared to a national average of 24.5%. "There is ten times more need in the other provinces," noted Nick Koornhof, the provincial Minister of Health.

Clinics in six towns now offer nevirapine to HIV-positive women in labor and their newborns. These clinics are in the areas of highest HIV prevalence and potentially can reach half of all HIV-positive pregnant women. By 2003, additional clinics will serve the rest of the province.

The Western Cape program is based on a three-year-old demonstration study in Khayelitsha, a 325,000-person all-black township outside of Cape Town. The Khayelitsha clinics administered a short course of AZT (starting at 34 weeks of pregnancy and extending through labor) to mothers testing HIV-positive.

Only about two-thirds of the women agreed to be tested, and of those testing positive, only a little more than half received four or more weeks of AZT. The type of HIV counseling that the women received was important for their future participation in PMTCT efforts. Of the two clinics involved in this study, the one that offered individual as well as group counseling did considerably better in both of testing for HIV and distribution of AZT.

2,700 mothers tested positive at the Khayelitsha clinics. Follow-up has been poor. The HIV status of 791 babies is known at nine months. 11.9% contracted HIV. This percentage could be reduced if more mothers were able to exclusively bottle-feed (see table on PETRA trial results)

As part of the complete program, Western Cape will offer free formula for a baby's first nine months.

Of course, long-term anti-HIV combination therapy would suppress many mothers' viral loads and dramatically reduce transmission through breast- feeding. A type of "PMTCT-plus" program could easily be built on the existing program and the Western Cape's substantial existing network of clinics and doctors. The big hurdle is funding. "South Africa is fairly well off in terms of health infrastructure. We're ready to move forward," remarked Koornhof.

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