A winning recipe for PMTCT but few follow it

A success story, at last: Botswana has lowered the rate of mother-to-child transmission of HIV to less than four percent, coming close to developed countries that have almost eliminated paediatric AIDS.

In Europe and the USA, fewer than two percent of babies with HIV-positive mothers are born with the virus; without intervention, the risk of an HIV-positive pregnant woman passing on the virus to her baby is between 30 percent and 35 percent, according to health specialists.

In Lesotho, transmission rates from mother to child are still as high as 37 percent; in Zimbabwe, 100 babies become HIV infected every day.

So how did Botswana do it? It was one of the first countries in Africa to establish a national antiretroviral therapy programme in 2002, and with a population of over 1.7 million people, optimal use of existing resources and a relatively sound health infrastructure, it was always going to be easier to get results.

Dr William Jimbo, chief advisor on prevention of mother-to-child transmission (PMTCT) of HIV at the Botswana/USA health partnership (BOTUSA), also attributed the low rate of transmission to an effective cocktail of political commitment and bold policy decisions.

More than three years ago, the government introduced a policy of routine testing for HIV as part of its strategy for encouraging more people to be tested and access treatment.

All pregnant women attending a health facility are now routinely offered an HIV test unless they decline; those found to be HIV-positive receive immediate counselling and are put on a long course of zidovudine, also known as AZT, at 28 weeks, and given a single dose of nevirapine during labour. The infant is given four weeks of AZT and a single dose of nevirapine.

"Most other countries in the region are still piloting the programmes," Jimbo told IRIN/PlusNews. The World Health Organisation guidelines for PMTCT advise using combination therapy where possible, but the rest of southern Africa has been slow to move away from using mono-therapy, in which mother and child are each given a single dose of nevirapine.

Governments have only recently begun to introduce the newer and more effective combination medication, which can reduce the risk of transmission to as little as five percent.

In Zambia, for example, combination therapy for PMTCT is only available in urban areas, while rural areas continue using mono-therapy. Dr Max Bweupe, national coordinator for the government's PMTCT programme, told IRIN/PlusNews that the new drug regimen was being rolled out in phases, as healthcare workers require training on the new dosages.

Malawi will be switching to a triple combination drug regimen in October 2007, while South Africa has yet to indicate when it will make the change.

Photo: Tiggy Ridley/IRIN
In Malawi UNICEF estimates that around 30 percent of HIV-positive pregnant women pass the virus to their infants.

According to Jimbo, implementing a new method of collecting and testing blood samples from infants as early as six weeks of age, has also helped. The most commonly used HIV-antibody test - the rapid test - cannot distinguish between maternal and child antibodies in infants, because HIV antibodies can cross the placenta and stay in the child's bloodstream for 18 months.

Babies need a Polymerase Chain Reaction (PCR) test, which can detect small quantities of viral protein in the blood, to establish their status. Although the PCR technology has been available in Botswana since 2002, it could only be performed at the two referral hospitals where specially trained doctors are available to perform phlebotomy (draw whole blood from veins) on infants.

However, the introduction of the dried blood spot test has made it possible to train health workers at all clinics to obtain blood from infants, using a simple method of pricking the heel, toe or finger. The dried blood spot is cheaper and faster, and requires less skill than the liquid blood PCR tests. One a child is identified as HIV-positive, it's health can be better managed.

"There is no refrigeration required and there are no blood samples to carry in vials over long distances, and samples can be collected from a clinic anywhere in the country and transported immediately to remote laboratories," said Jimbo.

"During the past two years, we have been working on early infant diagnosis, taking it out to all rural districts in the country, so that even the most distant health post can effectively collect a sample for testing and send it through to a central laboratory for testing," said Dr Molly Smit, a BOTUSA PMTCT advisor in the northern town of Francistown.

Last week, health minister Sheila Tlou said that if the country kept at the same pace, their PMTCT programme could eventually reach levels of HIV transmission of below one percent.

"For the rest of Africa - they are still struggling. In some African countries the uptake is only 30 percent, and they often wonder how we managed to do it."

What about the rest of the region?

Across the border in South Africa there is little to celebrate. In KwaZulu-Natal province up to 30,000 infants are being infected with the virus by their mothers each year, while the rate of HIV transmission remains unacceptably high in other parts of the country.

According to UNICEF, of about 1.2 million women who visited antenatal facilities in 2006, 708,000 were tested for HIV and 27 percent of those were positive, but only 59 percent received treatment to prevent passing on the virus to their infants.

Nathan Geffen, spokesman for the AIDS lobby group, Treatment Action Campaign, described these figures as "absolutely pathetic". "The MTCT programme is being implemented poorly in many parts of the country, the government is still using the sub-optimal single-dose regimen and far too few people are taking up the programme. The opportunity to treat women who present with AIDS is not being sufficiently used."

More on PMTCT in Southern Africa
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 Positive mothers, children need more to reach MDGs
 Gaps remain in government's PMTCT programme

Frustration has been mounting in South Africa over the government's delay in rolling out combination therapy. Apart from the Western Cape Province, where a combination of drugs for PMTCT has been used for several years, the country is still using single-dose nevirapine.

"On the positive side, there are new draft guidelines and, if these are adopted, the policy will be in place and will go a long way to improving things," Geffen added.

Nevertheless, political commitment was still a major obstacle. "The continuous delays in making simple policy changes are a consequence of the minister of health's incompetence," he said.

Malawi is also struggling: only 28 percent of the 544 clinics that provide maternal services offer PMTCT services. Miriam Chipimo, Reproductive Health and HIV/AIDS manager for UNICEF, told IRIN/PlusNews that the government was hoping to roll out the programme at all clinics by the end of 2008.

The rollout has also been constrained by budget shortfalls related to bottlenecks in donor fund flows, and severe staff shortages that have crippled the health sector.

But Chipimo is optimistic about the potential for reducing mother-to-child transmission: "The political will in Malawi is tremendous ... and there's a lot of momentum to scale up. They're getting a lot of support from partners and donors."