New improved PMTCT brings challenges

Prince Mshiyeni Memorial Hospital, just outside the port city of Durban, in KwaZulu-Natal Province, has one of South Africa's busiest maternity wards. About 1,200 women a month give birth here, of which about 40 percent are HIV-positive, according to figures from the antenatal clinic.

For staff working in the hospital's antenatal clinic and maternity ward, implementing the government's new guidelines for the prevention of mother-to-child HIV transmission (PMTCT) has not been easy. "We're still struggling," Thembi Dlamini, the Sister-in-Charge of the hospital's PMTCT programme, told IRIN/PlusNews.

Under mounting pressure from activists, South Africa's health department revised its PMTCT guidelines in January to include the more effective dual antiretroviral (ARV) therapy, rather than the single dose of nevirapine to mother and child previously administered.

HIV-positive mothers with CD4 counts over 200 should now receive zidovudine, also known as AZT, from their 28th week of pregnancy until labour, as well as a single dose of nevirapine during labour. Their infants should get a single dose of nevirapine, and then AZT for seven days (or four weeks if AZT was started late).

Dr Akhtar Hussain, who heads Prince Mshiyeni's HIV/AIDS programme, including its PMTCT services, welcomed the new guidelines which he felt were overdue. The hospital was among the first wave of health facilities in KwaZulu-Natal to begin implementing the revised guidelines in April.

"We want to give everyone maximum prevention therapy," he said. "The results were there; [most other countries] had started dual and triple therapy, but we had to wait, mostly for economic reasons and lack of resources."

Better treatment means more work

The new drug regimen means extra work for the hospital staff, while the number of doctors, nurses and counsellors providing PMTCT services at the hospital has not increased.

There's a lot of motivation, although it's extra work...we have to go the extra mile

Dlamini said the number of pregnant women coming to the hospital for voluntary counselling and HIV testing (VCT) and PMTCT services has also increased since word has spread that more effective treatment is available.

"There's a lot of motivation, although it's extra work," Hussain told IRIN/PlusNews. "We do stress that we have to go the extra mile ... babies are dying, mothers are dying."

The feeling among the nursing staff is less upbeat. "This dual therapy came at the wrong time," said Dlamini, explaining that maternity nurses were already disgruntled about not benefitting from recent salary increases approved by the health department for some categories of nurses. Many of the nurses say more staff are needed, especially to deal with the increased record-keeping burden the new guidelines have created.

Dlamini and some of her colleagues attended a one-day workshop on the new guidelines in March, but "it wasn't enough," she said; for example, they were not shown how to fill out the more complicated patient registers.

Staff who attended the workshop were entrusted with training those who did not, but Dlamani said not everyone has been reached, especially night staff. As a result, there have been missed nevirapine doses and lapses in recording when patients started AZT (which determines how long their infant should receive the drug).

Other frustrations include the length of time it takes to get the results of essential tests such as CD4 counts, which are needed to determine whether a pregnant woman should receive dual therapy to prevent transmission or needs to begin life-long ARV treatment.

Despite having on-site laboratory facilities, a shortage of staff means that it can take two weeks to get the results of a CD4 test.

PCR tests to determine whether babies as young as six weeks have contracted the virus have to be sent to Nkosi Albert Luthuli Hospital in Durban, which has the only laboratory that can process PCR tests in the province hardest hit by the HIV/AIDS epidemic.

The backlog means that it often takes two months for staff at Prince Mshiyeni to find out whether an infant is HIV-positive, negating much of the benefit gained by early testing. Babies infected with the virus often deteriorate rapidly if they are not diagnosed and treated.

Despite such challenges, and even before the introduction of dual therapy, Hussain said because of the combination of nevirapine and counselling mothers to make use of free formula milk, Prince Mshiyeni had succeeded in reducing its mother-to-child HIV infection rate to about six percent, below the provincial average of 15 percent.

Delay allows for preparation

Lenore Spies, manager of KwaZulu-Natal's PMTCT programme, told IRIN/PlusNews that the delay in approving the new guidelines had given the province more time to prepare for the change to dual therapy. "We'd already planned the training and negotiated the drug supply, this is why we were able to so rapidly upscale [implementation]."

By the beginning of June, 64 percent of the 513 clinics providing PMTCT in the province had switched to the new guidelines.

The new PMTCT guidelines have been criticised for not raising the CD4 count at which pregnant HIV-positive women can start ARV treatment from 200 to 350, and for not including a "tail" regimen, in which two ARV drugs are administered for a week after giving birth to reduce the likelihood of future drug resistance.

Spies said her department was happy with the guidelines. "They were based on the latest data. There's nothing definitive on the benefits of the tail regimen, and we want to start with what we know for sure, especially with our numbers."

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