E-drug: UN session tackling African pandemic (cont'd)
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Dear E-druggers,
My apologies for returning to an old "string" which seemed to have
been put to rest - Valeria Frighi wrote (in relation to access to
nevirapine-based PMTCT programmes in Africa): "Many thanks to
Elizabeth Gardiner for her clear and detailed reply. Another question,
why is Botswana so special?" One of the points made by Elizabeth
Gardiner was this one: "For instance, South Africa and Zimbabwe
have not distributed nevirapine due to commitment and infrastructure
issues".
While there are elements of truth in that, the situation is fluid - while
the South African national government was initially very slow to roll
out access to PMTCT, that was not true of all provincial governments
(SA has a quasi-federal system). The Western Cape moved far
faster, and now claims universal coverage, and is also considering
moving to more effective regimens and eventually to full HAART for
pregnant women. A Constitutional Court battle resulted in the national
government being forced to roll out access to nevirapine where
infrastructure existed (rather than restrict access to pilot sites only),
but that has been patchily executed. The HEALTH-E story below,
from June this year, is a good summary of the situation - showing
how infrastructure deficits and a lack of political will (or active
resistance) can impact upon access to PMTCT.
For a more technical appraisal of the initial pilot scheme, the Health
Systems Trust report can be accessed at
ftp://ftp.hst.org.za/pubs/pmtct/ - here's a very important quote from
the HST's interim report -"There are no good reasons for delaying a
phased expansion of PMTCT services in all provinces. The pilot sites
have already generated a lot of useful and important lessons that can
now be put to use. The systemic weaknesses and infra-structural
constraints identified by this evaluation are not reasons for delaying
action, but are important for informing the planning and expansion of
PMTCT services" - that's the challenge now facing the treatment plan
roll-out.
Botswana? The confluence of so many factors: a relatively small
population, but the highest prevalence anywhere; relative wealth; the
presence of a large employer which decided to do something; political
will, and the willingness to accept help from outside; availability of
externally funded programmes looking for a suitable operational
research site; but above all, clear political will.
regards
Andy
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http://www.health-e.org.za/view.php3?id=20030618
Mother-to-child HIV transmission programme in trouble
by Anso Thom
27-06-2003
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.
Andy Gray MSc(Pharm) FPS
Senior Lecturer
Dept of Experimental and Clinical Pharmacology
Nelson R Mandela School of Medicine
University of Natal
PBag 7 Congella 4013
South Africa
Tel: +27-31-2604334/4298 Fax: +27-31-2604338
email: graya1@nu.ac.za or andy@gray.za.net
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