In theory, protecting babies from HIV infection has become relatively simple: a process involving drugs for the woman before she gives birth and then for the baby after birth. But not in Lesotho, where poor health and transport infrastructure have meant that HIV-positive people living in remote mountain regions are often the last to receive care and treatment; doctors and nurses are in short supply; and almost a quarter of the population lives with HIV.
While Botswana has managed to lower HIV transmission rates from mother to child to as low as 3 percent, Lesotho's rate remains at an unacceptable 23 percent.
Keeping mothers alive is also a challenge in the mountain kingdom, which has one of the highest maternal mortality rates in the world. When Dr Appollinaire Tiam, country director of the Elizabeth Glaser Paediatric AIDS Foundation (EGPAF), first arrived in Lesotho eight years ago, he found the staggering number of maternal deaths "just unbearable". More than half of the 620 deaths per 100,000 live births, about twice the global average, are attributed to HIV-related complications.
The government is working on an accelerated plan to reduce maternal deaths and expand the reach of HIV services. But its most important game-changer could be the recent introduction of Option B+ - giving pregnant women antiretroviral (ARV) treatment for life, regardless of the CD4 count. Malawi adopted this approach in 2010 and within the first year of implementation, the number of HIV-positive pregnant women starting ARV treatment increased six-fold, from 1,200 per quarter, to 7,200 in the quarter ending in June 2012.
Treatment options recommended by the World Health Organization (WHO) to prevent mother-to-child transmission of HIV (PMTCT) have depended on CD4 count tests, which are frequently inaccessible to people living in isolated mountain communities, especially during the cold, harsh winters.
Option A involves single-dose antiretroviral (ARV) drugs for the woman - if her CD4 count is over 350 - from the 14th week of pregnancy, as well as ARVs during labour and delivery, and for one week post-partum. Pregnant women with CD4 counts below 350 are advised to start taking ARVs for their own health. Option B - which WHO introduced alongside Option A in 2010 - involves triple therapy ARVs from the 14th week of pregnancy until one week after breastfeeding has ended, which can be up to one year.
WHO updated its guidelines in July 2012, and added Option B+ to its recommendations. Since then, Uganda and Ethiopia have also started providing life-long treatment to pregnant women, and international organizations such as the US Presidents Emergency Plan for AIDS Relief (PEPFAR) and UN agencies have endorsed it.
The guidelines may have changed in Lesotho, but the number of staff that will have to help patients deal with issues around stigma, serodiscordancy [when one partner in a relationship is positive] and disclosure, have remained the same. In addition, with the large numbers of people to be initiated on treatment, the country will also need to scale up its monitoring capacity by bringing in more viral load testing machines.
"Changing guidelines is never as easy as just switching the pills used - it involves the whole health system. People tend to forget this when we move from one guideline to another," said EGPAF's Tiam. EGPAF assisted the health ministry with training healthcare workers as well as revising Lesotho's guidelines on prevention of mother-to-child transmission.
More healthcare workers, more equipment, and more ARVs – will the government be able to cope? Lesotho finances about 70 percent of its national HIV treatment programme, and Tiam noted that the political will to respond to the epidemic has been "impressive". The roll-out of Option B+ has been "so far so good”, and has not experienced any challenges around drug supply," he added.
"The availability of rapid test kits and dried blood spot test kits, however, is a major problem. In 2010, 40 percent of the country's facilities experienced a stock-out of at least one type of test kit during the previous three months.
When you're pregnant, and have just received an HIV-positive diagnosis, the thought of starting something for life when your CD4 count is high can be overwhelming. Makelebone Motseki, 21, was five months pregnant when she was tested for HIV and says she felt like committing suicide when she found out. Now that her baby is a few months old, and she has had time to adjust to her status, she is quite happy to walk down the hill to her local clinic in Mohale's Hoek to pick up her medication. A community health worker visits her regularly to check that she is taking her ARVs and to monitor the baby's progress. With her husband working in South Africa, these visits are a lifeline.
Blandinah Motaung, the UN Children’s Fund (UNICEF) PMTCT officer in Lesotho, admitted that many women were initially sceptical about Option B+. "In the first month, women didn't understand the change, and didn't see why they should take treatment when they were healthy - especially those who read a lot. They didn't accept it at once... but this is no longer an issue because they have received counselling and they know the benefits."
Nevertheless, activists have raised fears that the name, Option B+ , is misleading. In Malawi, for instance, Option B+ is the only available method to prevent mother-to-child transmission, and women could feel coerced into treatment for life. According to UNICEF senior HIV/AIDS specialist Dorothy Mbori-Ngacha, this is an important concern, as many women will be diagnosed for the first time during pregnancy and will not have had the time to process what being HIV-positive really means.
“It is therefore critically important that women are allowed to make an informed choice on whether they want to start Option B+ or Option B,” she told IRIN.
Option B+ may be simpler, and could lower mother-to-child HIV transmission rates, but what about the health of the mothers? A group of researchers have warned that "the strong push for countries to switch to Option B+ is premature", and too many questions remain unanswered.
In an article in the British medical journal, The Lancet, PMTCT experts in South Africa wonder whether it is ethical to give women with high CD4 cell counts treatment for life without fully understanding the long-term benefits and risks. "For example, increased exposure to ART [antiretroviral treatment], as will be experienced with Options B or B+, may increase adverse pregnancy outcomes such as pre-term delivery and low birth weight... Increased exposure to tenofovir [an ARV] may also increase potential for renal toxicity in mothers, and poor growth outcomes in infants."
Giving life-long treatment to pregnant women could increase tensions between people receiving treatment and those who are not – particularly couples. But Mbori-Ngacha points out that “ideally, pregnant women should test with their partners, and the male partners of positive women should be treated if they also test positive” or when only the man is positive. “Our couple testing rates are too low and this is something that we should be pushing,” she added.
Will women stick to treatment for life after giving birth? National support services will have to be strengthened when countries adopt this new strategy to ensure that women stay in care and lost mothers are tracked down. “So far, we are seeing that about 20 percent of the mothers are getting lost to follow-up. This is a cause for concern,” noted Mbori-Ngacha.In Malawi, Option B+ patients who started ARVs during pregnancy were five times more likely not to return to clinics after their initial visit than patients who started with a low CD4 cell count.
"This goes beyond dishing out medicines... we need to make sure that the mother is being taken into consideration at all times,” Tiam told IRIN. “That is why we have group education, peer support, adherence counselling, family support groups and even mother-in-law support groups."