KHOPOTSO: The Department of Health promised to release the new guidelines a week after it announced that the new protocol for the prevention of mother-to-child HIV transmission had been approved. This makes provision for dual therapy, where pregnant HIV-positive women and their newborns are given both Nevirapine and AZT to prevent infection in babies. Health care professionals in the public sector are frustrated by the delay. Dr Ashraf Coovadia is a paediatrician based at Johannesburg’€™s Coronation Hospital’€™s Children and Women’€™s unit and advised the Health Department in the development of the new protocol.

Dr ASHRAF COOVADIA: The frustration the provinces are finding ‘€“ certainly, we are finding in Gauteng ‘€“ is not actually having the protocol. While the announcement is there of a dual-therapy, we don’€™t physically have the protocol which we can start using now to really plan and prepare our sites’€¦ so that we can start ordering the stocks, start training our staff, putting in place the systems. So, that’€™s part of the frustrations in terms of planning.

KHOPOTSO: The Department was initially due to release the guidelines late last year. At a meeting of the South African National AIDS Council (SANAC) in November last year, the country’€™s Deputy President and chair of the council Phumzile Mlambo-Ngcuka, said there would be guidelines before the year was out. Fatima Hassan is an attorney with the AIDS Law Project, and a SANAC member representing civil society.

FATIMA HASSAN: The Deputy President said at SANAC that there would be no legal barriers to any of the provinces or doctors working in MTCT sites from implementing dual-therapy, that the guidelines would be finalised within two weeks of that November meeting and then they would be released. And obviously, that has not happened.

KHOPOTSO: But even though the Deputy President gave an assurance that there would be no legal restrictions on anyone who implemented the new protocol, provinces and doctors don’€™t dare take her word before the Health Department formally publishes the guidelines.

Dr ASHRAF COOVADIA: The current protocol that we are adopting’€¦ the science and the rationale for using this approach, we knew about in 2004 through research that had come out at that time. Even at my own institution we would have liked to have implemented this, at least, one-and-a-half to two years ago.                              

KHOPOTSO: Coovadia says facilities will remain paralysed unless the national and provincial departments of Health sign off on the protocol.        

Dr ASHRAF COOVADIA: Even today as we sit here waiting for the new protocol to be formally announced we have the drugs in our pharmacy, we have patients in front of us, and we are bound by this red tape. I think there comes a point when you need to start thinking: ‘€˜How long can I wait and compromise ethical, moral, medical principles versus what you need to do to try and keep up with national policy because national policy is dragging behind?’€™      

KHOPOTSO: Dr Colin Pfaff of Manguzi Hospital, in KwaZulu-Natal decided to go ahead with dual therapy. He is currently facing disciplinary action for rolling out the protocol without permission from the provincial Department of Health.

Dr ASHRAF COOVADIA: Many, many sites are fearful of starting before they get given the green-light. So very few sites, if any, will go against either the provincial or the national Department of Health, even if they have the drugs available’€¦ I can turn your attention to a case that’€™s occurring now in KwaZulu-Natal, in Manguzi ‘€“ A Dr Colin Pfaff who has been reprimanded for having started the new protocol, albeit with NGO funding and he’€™s been implementing it very well and is now at the receiving end of disciplinary action. And this is not an unfamiliar scenario where health care providers working within the public setting actually feel that they are at risk – that they would be providing this at risk of losing their own jobs and of being reprimanded for such action’€¦ not toeing the line.                

KHOPOTSO: The AIDS Law Project has taken up Dr Colin Pfaff’€™s case and is collecting evidence on working conditions of health professionals.

FATIMA HASSAN: There’€™s absolutely a sense of fear and there’€™s definitely a sense of persecution’€¦ And they are reporting to us that they believe they have an ethical duty to provide the best treatment to pregnant women who are attending their clinics’€¦ The WHO revised its MTCT guidelines in August of 2006. At the Toronto International Conference, they were released. Since August 2006, we have been asking the national Department of Health to revise its MTCT guidelines’€¦ So, we haven’€™t just been waiting for months. We’€™ve been waiting since August 2006 and any further delay on the part of the Department of Health is really putting our MTCT programme in further jeopardy and it’€™s putting the lives of pregnant women in further jeopardy.

KHOPOTSO: The Department of Health was given a chance to respond to claims made against it, but it just wouldn’€™t make anyone available to comment.