As the South African Treatment Action Campaign celebrates its recent victory in the High Court, the Western Cape Province of South Africa is already in the forefront of reducing HIV transmission to babies in Africa. Experience from the Western Cape was among the strongest presentations on this subject at the recent 12th ICASA in Ouagadougou, Burkina Faso.
Although most publicity has focussed on the use of antiretrovirals to prevent transmission, the greatest single cost in the Western Cape programme is not nevirapine but providing formula feed to prevent breastmilk transmission. The High Court judgment demanded an action plan by March 2002 on how counselling and testing could be offered nationwide, with formula feed as well as nevirapine provided freely to positive mothers.
One of the greatest challenges in the programme has been the provision of the counselling. Not so much because of staffing issues - since the Western Cape has found that trained lay counsellors can perform this role more than adequately - but because clinics don't have rooms for private consultations. Group counselling has not proven satisfactory; this really does have to be one woman, or ideally a woman and her male partner, at a time.
This report offers a selection of the ideas that are currently being discussed across Africa as communities, health workers, international agencies and governments grapple with the challenge of delivering effective programmes in this area.
Short-course nevirapine – strengths and weaknesses
The finding that galvanised public health officials into action was that just two doses of nevirapine, one to a mother at the time of going into labour and a second to the infant, ideally 72 hours after birth, could greatly reduce the rate of HIV transmission. There is no serious argument against the cost-effectiveness of this intervention in any country, even though the cost of the drugs is only a very small part of the whole cost. It is no surprise, therefore, that the South African High Court has ordered the national and provincial governments to provide this as soon as possible. However, the other programmes which have been ordered – namely the provision of counselling, testing, and safe alternatives to breastfeeding – are equally important in the view of most people in the field.
Some people have considered reducing the cost even further by giving nevirapine to all mothers and babies in high prevalence areas without testing for HIV. While this may be acceptable to mothers it may also amount to substandard medical practice, mainly because it does not address transmission through breastfeeding, but for other reasons too, which emerged in several sessions of the ICASA meeting. After all, a reduction in HIV transmission of 30 to 60 per cent, achievable with nevirapine, is still nowhere near the 95 per cent or greater reduction achieved in western countries, once pregnant women are known to be HIV positive.
The greatest strength of nevirapine remains the fact that it is cheap and, when used together with rapid HIV tests, can be delivered even when women have minimal access to antenatal healthcare. One hidden weakness of this is that the opportunity for education and counselling when contact with healthcare workers is very brief is also limited. This may even be a reason for preferring “short-course” AZT or AZT/3TC programmes, since the extra follow-up gives women more time to ask questions and get more help in coming to terms with their situation.
Breastmilk transmission
Substitute feeding with infant formula is definitely back on a public health agenda as a positive strategy after years in which breastfeeding has successfully been promoted as the single most effective means of improving the health of mothers and babies. The South African High Court has ordered that free infant formula must be offered to women who test positive, and this is in fact the most costly element of the programme that is already being implemented in Western Cape Province.
The finding from the Kenyan randomised controlled trial of breast feeding versus formula feeding in Nairobi that maternal death rates were 10 per cent higher when mothers were allocated to breast feeding, than when they were allocated to formula feeding, has still not been confirmed in any other study – but such studies are so hard to conduct that it may never be directly repeated.
Apart from traditional problems with formula feeding, there is now a definite stigmatisation since people may assume that a formula-fed baby has an HIV positive mother. A community survey found that this is not the only explanation that would come into people’s minds, which might be good news, except that some of those other explanations – e.g. that a baby has been stolen and is being brought up by a woman who is not its mother – are even more stigmatising!
As a serious alternative to breastfeeding, why not put the mother onto HAART and rely on suppression of the viral load in her milk to protect the child throughout the period when it is being breastfed? Pill-taking is easier to keep private than formula feeding a baby, and the benefit to the mother’s health from antiviral treatment is likely to outweigh any extra risk to her from breastfeeding. There is an urgent need for African studies of the effect of different HAART regimes on virus levels in breastmilk. Already there is evidence for a “separate compartment” so that viral load in breast milk doesn’t automatically reflect that in blood. There is still a question about toxicity of the ARVs to mother and child. Also, if the child acquires HIV and is then exposed to minimal levels of the drugs through its mother’s milk, could this promote drug resistance?
An emerging issue is the effect of discontinuing HAART while a mother is breastfeeding. There is now some evidence of a “viral load rebound effect” which is more pronounced for HAART than it is for monotherapy or dual therapy (e.g. short-course AZT, Combivir or Duovir) which is the main alternative to nevirapine that has been evaluated. This may even lead to a child being infected, who would not have been infected if the mother had not been treated. “Do not stop ARVs while breastfeeding” may need to be added to the already long list of complex health messages that pregnant women and breastfeeding mothers are exposed to.
Male involvement
Testing male partners alongside pregnant women can protect HIV negative women and their babies by giving a rationale for an HIV positive man to use condoms. It also counters the stigmatisation of women as the people who "bring AIDS into the family" (a common but often entirely false impression, created when only women are tested) which can lead to violence and other kinds of rejection.
Some programmes go so far as to target public education on mother-to-child transmission to men, asking them to persuade their wives and female partners to be tested. This was the approach taken in the very traditional and still, to some extent, polygamous Tonga society in Zambia, by workers at Keemba and Monza hospitals after careful anthropological analysis of how decisions are taken in that community. By starting "at the top" talking to chiefs, village leaders and church people, it has reported some considerable success.