Cash crunch delays shift to WHO-recommended PMTCT regimen

A shortage of money means Uganda is unlikely to shift its prevention of mother-to-child transmission (PMTCT) programmes to a more efficient UN World Health Organization (WHO) regimen soon, say government officials.



In 2010, WHO recommended two equally effective options for PMTCT. The first, Option A, is fairly similar to the system Uganda currently uses. It involves single-dose antiretroviral (ARV) drugs for the mother - if her CD4 count is over 350 - from the 14th week, as well as ARVs during labour, delivery and one week post-partum. Pregnant women with CD4 counts below 350 are advised to start taking ARVs for their own health.



Option B involves triple therapy ARVs from the 14th week of pregnancy until one week after breastfeeding has ended, which can be up to one year. The Ugandan government has expressed its intention to shift to Option B, which is simpler for health providers and mothers to implement than Option A. However, an already stressed HIV budget may make this impossible.



"We cannot straight away go for option B, the country has no drugs for it; the only drugs available are for Option A and if not used they will expire in storage," said Godfrey Esiru, national PMTCT coordinator in the Ministry of Health.



Of the two options recommended by the WHO, option B is more expensive but has the potential to reduce vertical HIV transmission to just 2 percent within two years, if implemented completely.



An estimated 1.4 million women get pregnant annually in Uganda; those with a CD4 count greater than 350 account for about 40 percent of all HIV-positive pregnant women and over 75 percent of overall mother-to-child transmission. Moving to Option B, according to the government, would instantly put an additional 80,000 women on treatment.



The AIDS Support Organisation (TASO), the biggest provider of ARVs in Uganda, with 32,990 clients countrywide, says it would have to add an additional 20,000 clients if it made the move to Option B.



"We would have so many clients who qualify; it is not feasible unless the donors are ready to help us," said Dr Isaiah Kalanzi, TASO medical programme officer for central and south-western regions.



Ensuring tens of thousands more women have access to PMTCT services would also mean all county and sub-county level public health centres - more than 1,100 across the country - would need to be equipped to handle PMTCT, while health workers would need additional training.



"Our challenge is to ensure that the medicines are available," said Esiru. "We also need to train all health workers who handle pregnant women."









''We would have so many clients who qualify [for Option B]; it is not feasible unless the donors are willing to help us''

What is more, fewer than half of all Ugandan women deliver their babies in health centres, so the government would need to step up public information and community mechanisms to reach more women with PMTCT. According to government data, fewer than half of HIV-positive pregnant women access the full range of PMTCT services, while just 27 percent of HIV-exposed babies have access to ARVs.



Despite serious financial and logistical constraints, the government is determined to go ahead with the plan to eventually adopt Option B. "It is a tough decision [but] we shall start rolling it out this year in two pilots," said Zainabu Akol, HIV programme manager at the Ministry of Health.



She said Médecins Sans Frontières and Catholic Relief services would pilot the programme because so far, they were the only organizations that had funds to do so.



According to Esiru, Uganda will first transition all treatment sites to Option A until the end of 2011 and move to Option B by 2012 should resources become available.



"It is the right move; in the context of resources it may not be perfect but we shall go a long way in eliminating mother-to-child HIV transmission," said Addy Kekitiinwa, a paediatrician and executive director of Baylor-Uganda, which cares for more than 4,000 HIV-positive children.



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