ANC national health committee urges further expansion of MTCT sites
A clear statement ‘ demonstrating the intent to steam ahead on the MTCT matter – has now come from the ANC’s health committee. ANC national health secretary, Dr Saadiq Kariem told Health-e that the committee was convinced, following political discussions and directives, that those provinces where the PMTCT programmes could be rolled out, those who have the capacity and resources, should go ahead.
For those who are still confused, in the dark or frustrated because there appears to be a great deal of stalling – nevirapine will be administered to HIV-positive pregnant mothers in South Africa in an effort to prevent the transmission of the infection from mother to child during birth ‘ or that is what one can deduce from several statements over the past few days.
Recent statements from Government and more specifically President Thabo Mbeki and Health minister Dr Manto Tshabalala-Msimang seem to indicate that those provinces who have the capacity and resources to expand the programme ‘ Gauteng, KwaZulu-Natal, Western Cape and to a lesser degree NorthWest ‘ should do so.
But perhaps the clearest statement ‘ demonstrating the intent to steam ahead – has now come from the ANC’s health committee: “We are convinced, following political discussions and directives, that those provinces where the PMTCT programmes can be rolled out, those who have the capacity and resources, should go ahead,” says Dr Saadiq Kariem, the ANC’s national health secretary.
But he adds that there is an urgent need to build up the resources and capacity of those provinces not ready to roll out so they are in a position to expand.
“The basic infrastructure should be in place and this is true of any programme we want to roll out such as TB or Malaria,” he says.
But what are the hurdles on the ground, hampering the complete rollout of the PMTCT programme? Why should those who seem only interested in hearing a yes or no from the health minister, hold their horses and try to see see the bigger picture?
Primary health care system
Many agree that it is not possible to run any programme without a primary health care or basic health system in place. This is lacking in many parts of the country, especially the rural, poor areas.
In some centres they are forced to treat TB patients, for example, without x-rays while in other areas staff are unable to treat an endemic condition such as malnutrition.
Formula feed v breastfeeding
Formula feed is one of the most expensive aspects of the programme. In some provinces this makes the programme unaffordable.
It is also one of the trickiest aspects. There are many cultural issues around formula feed with this practice a foreign concept in many African cultures. Health workers need to be trained around these sensitivities as they are currently communicating conflicting messages.
In some households the formula milk is used to feed the older children while the babies are breastfed while other households do not have access to safe, clean water.
Doctors and nurses need to be trained on how to administer the drug regimens and monitor the patients. Kariem says that many of the doctors have not been trained around the transmission of HIV during birth with some under the false impression that the rate of transmission is 100%.
There are still many reports of unsafe obstetrics procedures where doctors artificially rupture the membrane, dramatically increasing the risk of transmission from mother to child and increasing the risk of exposure for health workers.
Kariem says that Caesarean section does bring down the rate of transmission, but points out that most provinces have not even developed their primary health care structure. “A Caesarean is a first world therapy with no place in a third world setting.”
He does, however, agree that this could be a realistic option for Gauteng and the Western Cape.
Counseling and testing
There is consensus that for the programme to be a success and sustainable staff need to be trained. Lay people need to be trained to counsel mothers while health workers need to be trained on rapid testing and how to interpret it.
It is clear that there needs to be a referral system in place whereby health workers can speak to someone more knowledgeable via the telephone.
Kariem points out that confidentiality is completely lacking in some sites with some women being counseled under trees in an effort to create some confidentiality.
According to research done, personnel at all the sites in Gauteng do not have time to counsel patients which would explain the low rate of uptake.
This is also the case at all the sites in the Northern Province, Mpumalanga, Free State and some in the Eastern Cape.
The research also indicates that most of the sites, except for those in the Northern Cape, NorthWest, Gauteng, KwaZulu-Natal and the Western Cape do not have the space to counsel patients.
“Information and pamphlets don’t work as many people are uneducated or illiterate,” he says.
Some academics and researchers have suggested that this hurdle could be overcome by offering blanket nevirapine, whereby every woman is given the drug without being tested or counseled (despite her HIV status).
But Kariem is adamant that the resources need to be found to counsel patients.
Counseling needs to result in behaviour change otherwise the programme is doomed to failure, he says.
Most parts of the country do not have the luxury of a Groote Schuur, Tygerberg or Johannesburg hospital that offer technical support.
Health workers are extremely frustrated and isolated as they work in places that have not seen doctors or professional nurses for ages.
A telephone system that puts health workers in contacts with professionals at a district level hospital could go a long way towards solving the problem.
Monitoring and evaluation
This could happen with academic support. A system needs to be put in place to monitor the whole system. There needs to be a tracking system (computer or paper based) whereby a woman is followed as she enters the clinic door until the baby is 12 months old. There needs to be an evaluation of uptake, counseling and testing.
“The success of the programme should not be measure according to the number of women reached, but by the number of babies who are not infected,” says Kariem.
This is no longer an issue as the nevirapine regimen is simple and affordable.
Kariem confirms that it has been shown that in single dose nevirapine the side effects can be monitored. “It again comes down to having a monitoring system,” Kariem adds.
He points out that side effects could be monitored using a basic haemoglobin check, which is extremely sensitive, as well as a weight check.
Women who present while in labour, without being tested, are given the drug.
Taking the above factors into consideration it is clear that administering the drug to the mother is the simplest part of the programme.
Kariem admits that the Treatment Action Campaign (TAC) has managed to raise the level of debate, placing issues on the national agenda and accelerating the national priority.
“But their approach is not a comprehensive approach to HIV,” he says.
“It’s about more than the drugs. While their activism is obviously lauded, I still think it is shortsighted.”
But TAC chairperson Zackie Achmat begs to differ.
“TAC’s work encompasses far more than antiretrovirals. We are immersed in a range of treatment and prevention issues, including treatment literacy, legal rights of people with HIV, the improvement of clinics and hospitals, advocacy on the Basic Income Grant, nutritional advice and safe sex education.
“What’s really the problem is that whenever some government officials experience our advocacy on medicines, which are an essential part of dealing with the epidemic, they react irrationally and accuse us of being fixated on drugs. I would encourage Dr Kariem to find out more about TAC before making unsubstantiated comments.”
Government figures reveal that a total of 70 000 mothers attended ante-natal clinics at the research sites since the launch of the programme. Of these, 55% (38 168) opted to test their HIV status and 24,9% of those tested HIV positive. (This figure accords with the prevalence rate recorded in the 2000 national HIV ante-natal survey).
Of the 9 490 pregnant women who tested positive, 3 734 had received nevirapine at the time the figures were compiled and 2 604 babies had received the drug.
The fact that the figures do not “line up” is largely due to the fact that mothers may test their HIV status early in pregnancy, but would only receive nevirapine when they go into labour or a few weeks before there is a chance of an unplanned home delivery.