The South African Department of Health this week published new guidelines for prevention of mother to child transmission in South Africa. However activists and doctors say they still leave South Africa out of step with poorer and less well resourced nations.
South Africa will not adopt the regimen described as `more efficacious` by World Health Organization guidelines issued in August 2006 - seven days of AZT and 3TC for mothers after single dose nevirapine at the time of delivery – but instead use AZT alone for the infant - but not the mother - in the week after delivery. The guidelines document makes no mention of postpartum AZT treatment for mothers.
WHO made its recommendation in 2006 on the basis that use of the two nucleoside analogues together would provide better protection against the development of maternal nevirapine resistance as levels of the drug declined in the week after delivery. Use of the two drugs by mothers and infants has also been shown to reduce the risk of HIV transmission to a greater extent than AZT alone in a meta-analysis of studies, the WHO guidelines point out.
The failure to recommend the use of AZT/3TC was condemned last month by the South African HIV Clinicians Society, but Health department AIDS chief Dr Nomonde Xundu today told Health-e that South Africa would continue to international guidelines to suit “the national situation”.
Dr Francois Venter, president of the South African HIV Clinicians Society, said: “We are a middle income country behaving like an economic basket case.”
Rwanda, which must finance the majority of its health sector from international donor aid, began to implement the AZT/3TC postpartum regimen for mothers and infants in September 2005.
The new South African guideline also ignore a WHO recommendation that HAART should be considered for all pregnant women in WHO stage 3 with a CD4 count below 350 cells/mm3.
New South African recommendations
Women with CD4 counts below 200 or at WHO stage IV: start three-drug antiretroviral therapy for the mother’s health in line with national guidelines, start cotrimoxazole prophylaxis.
Women already taking antiretrovirals when pregnancy is confirmed: if taking efavirenz, switch to nevirapine in the first trimester. If prgenancy is confirmed after this point, an efevairenz switch is no longer necessary but a foetal anomaly scan is recommended due to the possible adverse effects of efavirenz exposure on the foetus during the first trimester.
Mothers not requiring antiretroviral therapy for their own health: start AZT at week 28 or as soon as possible thereafter unless anaemic and take single dose nevirapine at the onset of labour.
Infants: single dose nevirapine after delivery and AZT for seven days. AZT should be given for 28 days if the mother received less than four weeks of AZT or HAART during pregnancy, or if the mother received only single dose nevirapine.
Infant feeding options should be discussed with mothers, and for each woman the acceptability, feasibility, affordability, sustainability and safety (AFASS) of exclusive formula feeding should be discussed, with a recommendation for exclusive breastfeeding if the AFASS criteria are not met.
The guidelines are available for download from the South African Department of Health website at http://www.doh.gov.za/docs/policy/pmtct-f.html.