DURBAN, July 12 (reproduced by persmission of Inter Press Service News Agency) - It is tempting to call it a "no brainer": the idea that attempts to prevent transmission of HIV from mothers to children should be matched by initiatives to keep these mothers alive after they give birth. For all this, efforts in South Africa to prioritise the health of HIV-positive mothers have fallen short over past years, although there are signs that government may be starting to give the matter the attention it deserves.
According to the 'National HIV and Syphilis Sero-prevalence Survey in South Africa 2003' (conducted by the Department of Health, and released in September last year), 27.9 percent of pregnant women in the country were infected with the AIDS virus in 2003.
The fact that almost a third of South African new-borns stand to lose their mothers to AIDS-related diseases is a chastening one - particularly in light of research about the effects that maternal death can have on children.
Infant mortality of HIV-negative children of two years of age whose mothers are chronically ill or have died appears to be as high as mortality amongst HIV-positive children of the same age, says Dr Tshidi Sebitloane of the Department of Obstetrics and Gynaecology at the University of KwaZulu-Natal, located in the south-eastern KwaZulu-Natal province.
However, attention has so far focussed on preventing mother-to-child transmission of the HIV-virus, rather than on the future health of HIV-positive mothers.
This may partly be a reflection of the fact that free antiretroviral (ARV) treatment through the public health system has only been available in South Africa for the past 18 months. Before government began supplying the drugs, medical practitioners were obliged to use privately-funded ARV programmes when seeking help for HIV-positive mothers - an option too costly for many.
But even after the advent of free ARVs, regulations to improve these mothers’ access to the drugs have yet to be put in place. Such guidelines are "still being finalised", hopefully within the next couple of months, says Nomonde Xundu, chief director of HIV/AIDS, tuberculosis and sexually transmitted infections at Department of Health.
At the moment, HIV-positive mothers need to be referred to a government ARV site to receive treatment, she added.
One of the main obstacles to giving new mothers quick access to drugs relates to the fact that CD4 cell count tests, which quantify the number of blood cells that ensure immunity, are not generally available at antenatal clinics in South Africa.
As a result, the extent to which AIDS is progressing in a new mother tends to remain unknown until she visits an ARV site -- by which time the woman may be very ill, and unable to give her baby the attention he or she requires.
Sebitloane believes the Department of Health needs to make voluntary counselling and testing for HIV and CD4 cell count tests available at all of the country’s antenatal clinics. This would enable counts to be taken routinely when pregnant women test positive for the virus -- and open the door to instant provision of ARVs where necessary.
According to Hoosen Coovadia, a professor researching HIV/AIDS at the University of KwaZulu-Natal, between 10 and 15 percent of pregnant women who visit antenatal clinics in South Africa have a CD4 cell count below 200 cells/mm3, which qualifies them to receive ARV treatment.
But, at this point in time, few health facilities encourage pregnant women or other patients to register for ARV treatment, says Sebitloane, because "ARVs are not widely available, because of the delay in the (governmental ARV) rollout."
Efforts to provide AIDS drugs to all who need them are hampered by a variety of factors, ranging from shortages of ARVs to insufficient equipment for measuring CD4 cell counts.
One of the earliest programmes to improve care for HIV-positive mothers is the MTCT-Plus initiative (MTCT is the acronym for "mother-to-child transmission" of HIV), launched by the United States-based Columbia University about two years ago. This project, which aims to improve treatment and care in poor communities, offers a number of services to HIV-positive mothers, their partners and children, including nutrition and ARV adherence counselling, as well as actual provision of ARVs. The programme also helps to train health care workers, and monitor and evaluate health services.
MTCT-Plus has been implemented at 13 sites in nine countries in sub-Saharan Africa and Asia, and has given 7,000 individuals access to ARV treatment so far. In South Africa, three sites have been selected for the programme: the Langa Clinic in the Western Province, the medical school at the Durban campus of the University of KwaZulu-Natal, and the University of the Witwatersrand in Johannesburg, South Africa's economic capital.
Anna Coutsoudis, an associate professor in the Department of Paediatrics and Child Health at the University of KwaZulu-Natal, who runs the Durban MTCT-Plus programme, emphasises that well-trained, committed health care staffers are "absolutely vital" to the success of the initiative.
However, a lack of adequately-qualified health workers has undermined the calibre of counselling offered to HIV-positive pregnant women in South Africa, perhaps with fatal consequences.
A recent study by the government-funded South African Medical Research Council, the Health Systems Trust (a non-governmental group) and the University of the Western Cape showed that counsellors were failing to communicate crucial information about how the feeding of babies could lead to them being infected with HIV.
Research has shown that mixing breastfeeding and formula feeding carries a high risk of HIV transmission. This may be because children who are fed with a mixture of breast milk and formula risk developing irritation within their bowels, making them vulnerable to contracting the virus.
Women should be advised to choose either exclusive breastfeeding, with early weaning at three to four months, or formula feeding if they have access to the clean drinking water essential for preparing the mixture safely.
But, only a third of the women surveyed in the study who chose to use formula were provided with instructions to this effect. Once again, it has become apparent that what happens to an HIV-positive mother after she leaves the delivery room is just as important as what goes on before.