While the government holds up its mother-to-child HIV-transmission programme as the continent’s largest, it is turning into a shambles in many provinces.
Investigation has revealed that mismanagement within the HIV/Aids sections of the national and provincial health departments could result in the dismal failure of the programme.
It appears as if the government’s interest in the programme is waning rapidly. National staff have failed, repeatedly, to attend crucial meetings. Key provincial posts have been vacant for more than a year and there is a chaotic approach to crucial issues such as infant feeding, HIV testing, drug dosages and the following-up of babies and mothers.
This does not bode well for an effective national treatment programme, which is in the offing.
Recorded minutes from the quarterly prevention of mother-to-child transmission (PMTCT) national steering committee meetings paint a picture of chaos, confusion, empty promises and a programme reaching a very small percentage of the women and babies who need the anti-HIV drug nevirapine. The drug reduces by up to half the chances of an HIV-positive woman transmitting the virus to her baby during birth.
Often touted in government PR as the largest on the continent, the PMTCT programme, in at least five provinces, has not expanded much beyond the pilot sites. The Western Cape, KwaZulu-Natal and Gauteng, to a lesser extent, are the exceptions: all show wide expansion. The political will displayed by the premiers and ministers of these provinces has been central to the success of this life-saving programme. Without this degree of commitment, a national treatment programme will be as patchy as the mother-to-child prevention experience.
The minutes also reveal that four provinces failed to attend the meeting held in Pretoria last month, with some sending junior staff who were unable to give thorough report backs or answer crucial questions.
From a painful and troubled birth, the infant programme has not matured.
It is worthwhile to look at its track record. Launched by the government in June 2001, the PMTCT programme was shrouded in controversy even before it got off the ground.
Six months after the government gave the go-ahead for the provinces to implement two pilot sites each in June two years ago, the Treatment Action Campaign used the high court to force the government to expand the programme even further.
The government appealed the decision, but the Constitutional Court upheld the ruling in July last year. Several issues are central to the confusion that has filtered from the national department down the provinces. Firstly, there is no protocol for the non-pilot sites one year after the Constitutional Court ruling.
Sources confirmed that the United States Centre for Disease Control in Pretoria is in the process of assisting the department to formulate new guidelines.
‘Provinces received virtually no direction, so they have just started doing their own thing,’ said a researcher. This has led to positive and negative consequences. For example, the successes in KwaZulu-Natal, Gauteng and the Western Cape are the result of political commitment, resource allocation and planning.
In stark contrast, Mpumalanga has had no HIV director since March and no PMTCT coordinator since July last year. An administrative clerk manages the programme.
Voluntary counselling and testing also seem to be in a shambles in most provinces. In the Free State and Mpumalanga there are no counsellors at non-pilot sites. Pregnant women receive no counselling, a crucial part of any effective drugs programme.
In the North West the uptake rate of HIV testing among antenatal clients is only 14% at two pilot sites. This means that 86% of pregnant women at these sites do not have the opportunity to enter the programme, which defeats the purpose of PMTCT. Those on the ground feel the main problem is that there is no system to adequately monitor effective implementation.
‘The drugs may be in the cupboard, but is the service actually being delivered? I think one can more or less assume it is not taking place,’ aid a health worker. There is also no national infant feeding policy for non-pilot sites, causing provinces to develop their own guidelines according to resource constraints and local policy. For example, the Free
State and the Eastern Cape have opted not to supply formula feed outside the two pilot sites, while Mpumalanga has decided to supply formula to infants up to three months old.
Although exclusive formula feeding carries no risk of HIV transmission, it is important that the mother is counselled about risks of diarrhoea and respiratory infection that can occur if the feeds are not prepared under safe conditions. Clean water, reliable sources of fuel and a constant supply of formula are necessary. Research has shown that HIV can be
transmitted via breast milk although the risk is reduced significantly if the baby is breastfed exclusively (no other fluids or foods).
Without training, mothers will not know the procedures and safeguards that are essential to make the anti-transmission programme work. A further constraint facing the programme is the poor follow-up of the progress of infants across all provinces, which makes it impossible to determine the efficacy of the programme in terms of HIV-free infants.
Early indications are that in most provinces a significant number of babies who received nevirapine at the pilot sites were not returned for an HIV test when they turned one. Scientists at an HIV summit recommended that babies be tested for HIV at six weeks, as this would improve the follow-up and would have implications for infant feeding counselling.
In addition, women and babies on the programme are not being given crucial complementary antibiotics and multivitamins. The picture could get worse. In
June and July this year, government-funded PMTCT co-coordinators’ contracts will end. These positions are meant to be absorbed by provinces, but few have budgeted for this.
‘A balls-up,’ is how a doctor, working in one of the poorer provinces, described the programme. One of the most consistent and serious complaints is that, in some provinces, professionals have been sidelined by political appointees who have taken over the programmes.
‘It is very centralised, very secretive and no research is being shared outside of the project,’ said a doctor. In such an atmosphere, knowledge is not being shared so laggard provinces are not benefiting from the experience of the three front-runners.
Professor Hoosen Coovadia, a leading HIV/Aids researcher at the University of Natal, believes there is some cause for optimism and that huge advances have been made in the past year. He added that the delays could mainly be attributed to a lack of infrastructure and personnel as well as ‘disquiet’ on the side of the government.
‘I can’t imagine a simpler regimen [than nevirapine] and look how long it has taken to implement. This is partly because of politics and some red herrings, but in the rest of Africa where they do not have these hurdles it is taking just as long. Clearly it is going to take us many years to provide anti-retrovirals,’ he said.
Coovadia said that the PMTCT programme had shattered suspicions about treating HIV, proving there were ways and means to manage the disease. Clearly the situation does not bode well in the light of the increased pressure on the government to roll-out a national anti-retroviral treatment programme for the more than 4-million South Africans living with HIV.
There are charges that it is not in the interests of some denialist politicians for the PMTCT programme to succeed, as this is the first step towards a state-sponsored anti-retroviral treatment plan. Getting the drugs to the hospitals and clinics is the easy part, ensuring that there is the political will for effective implementation on the part of the premiers and their provincial ministers, is an entirely different matter.