KHOPOTSO: At a recent presentation, Dr Vivian Black, of Wits University’s Perinatal HIV Research Unit set out ‘ in numerical terms – why government should revise its protocol for the prevention of mother-to-child HIV transmission from mono-therapy to, at least, dual therapy.
Dr VIVIAN BLACK: In 2006 there were just over a million births. And with a background ante-natal prevalence of 29.1%, we assume that there were over 300 000 HIV-exposed infants being born in the year 2006. With a country transmission rate averaging probably about 20%, this results in just over 60 000 infants being HIV-infected annually’¦ For those who actually reach the PMTCT programme ‘ with our current single-dose Nevirapine strategy, we manage to reduce transmission to somewhere between 8% – 12%. If we improve the current PMTCT regimen to reduce this transmission to 2% – 5%, we will certainly reduce overall transmission rates.
KHOPOTSO: The government’s new five-year plan on HIV/AIDS aims to reduce the rate of mother-to-child HIV transmission to less than 5%. Changing the protocol to include AZT will assist in realising that goal. A fortnight ago, the national Health Department finally published the new guidelines after more than a year of lobbying by activists and clinicians.
Dr NOMONDE XUNDU: There is no question that there is established evidence on the use of AZT and single dose Nevirapine for the indication of prevention of mother-to-child transmission.
KHOPOTSO: Dr Nomonde Xundu, the Chief Director of the national Department of Health’s TB, STIs and HIV/AIDS Directorate. Previously in 2002, the Department had instituted its PMTCT programme using mono-therapy after the TAC had taken it to court. Until now, only the Western Cape had used dual-therapy. Dr Ashraf Coovadia is a paediatrician based in Johannesburg.
Dr ASHRAF COOVADIA: With mono-therapy or the single dose Nevirapine to mother and to child, we were looking at a reduction in transmission down to, at best, 10% from transmission rates of in the mid-20s if you did nothing at all. So, it was about a 50% efficacy. Now, with the addition of AZT to the protocol’¦ we’re looking at getting the transmission rates to below 5%.
KHOPOTSO: The new protocol works like this: If at an antenatal care facility a woman is found to be HIV-positive and further tests show her CD 4 count to be below 200, she will immediately be put on AIDS treatment. All pregnant HIV-positive women will receive AZT from 28 weeks of pregnancy and during delivery they will be given a single dose of Nevirapine. Mothers will continue taking AZT for seven days after birth. Their newborns will receive a single dose of Nevirapine soon after birth, accompanied by a week-long course of AZT. If the mother took AZT for less than four weeks of pregnancy, the baby will then take AZT for 28 days.
According to Dr Coovadia, a PMTCT programme should aim to achieve three goals.
Dr ASHRAF COOVADIA: One is to drive down HIV transmission from mother to child, decrease infant mortality and morbidity and also, importantly, address maternal morbidity and mortality.
KHOPOTSO: However, the issue of infant feeding options to reduce the risk of HIV transmission from mother to child following birth, still remains unresolved. The new protocol encourages mothers to make a choice between six months of exclusive breast-feeding and six months of infant formula feeding. After this, babies should get food. It is also recommended that they be tested for HIV at six weeks and at 18 months.
But experts have denounced the lack of a ‘tail’ segment to the new protocol. The ‘tail’ is an addition of a third drug, 3TC, to be given to women together with AZT for seven days after giving birth. This is a standard recommendation by the World Health Organisation to reduce the risk of the women developing resistance to Nevirapine when they need to take ARVs for themselves. The Department of Health says it didn’t include this recommendation due to insufficient scientific evidence about its effectiveness.
Dr NOMONDE XUNDU: All we need is supportive evidence, adequate evidence to inform a large-scale programme’¦ If there is corroborative evidence to support what is being recommended we will consider that. There is no question about that.
KHOPOTSO: Half the women who receive a single dose of Nevirapine develop resistance to the drug for the first six months after taking it. Without the addition of 3TC to the ‘tail’ regimen, many women who will need ARV therapy themselves in that period will probably be let down by the treatment. But Coovadia says the lack of the ‘tail’ should not be allowed to stall the implementation of the programme any further.
Dr ASHRAF COOVADIA: I think that (with) any PMTCT programme the first priority, really, is to reduce transmission (of HIV)’¦ Reduction of side-effects; reduction of resistance are all secondary. The first priority is to reduce transmission in the most effective way and proven ways. So, the addition of dual-therapy is most welcome. The absence of the tail is regrettable, but I don’t think we should not implement the new programme as soon as possible. Certainly, the issue around the ‘tail’’¦ we can review as our PMTCT protocol must be reviewed now more vigorously and more regularly’¦ Perhaps more research and more evidence will come to light that will enable us to argue the case for the ‘tail’.
KHOPOTSO: As provinces are scrambling to train health professionals to implement dual-therapy, the challenge remains of ensuring that all pregnant women with HIV get into the PMTCT programme.