PMTCT programme in trouble

Less than four percent of HIV-positive pregnant women in Uganda use Nevirapine to prevent HIV transmission to their babies, despite the drug being free. Nine out 10 pregnant women visit an antenatal clinic where they are offered treatment to prevent mother-to-child transmission (PMTCT), but the low uptake has meant that about 25,000 Ugandan babies are born HIV-positive every year. They account for 15 percent to 25 percent of all new infections, with most infants dying before they reach five years old. But a single dose of Nevirapine, given to mother and baby, halves the chances of infection during labour, the riskiest stage of transmission. PMTCT has been operational in 93 regional and district hospitals since 2000, and the government hopes to expand it to 240 health centres in all 56 districts. In theory this could reduce mother-to-child transmission by 30 percent in 2006. HIV prevalence rates have declined from over 20 percent in the early 1990s to a current 6.4 percent. Among pregnant women, HIV infection dropped from a peak of 30 percent in 1992 to about 6 percent in 2003. But the PMTCT programme is fraught with problems. "HIV-positive mothers have their backs against the wall," said Dorothy Ochola-Odongo, a UN Children's Fund (UNICEF) PMTCT officer. The first hurdle is getting pregnant women to test for the virus. Although Uganda has encouraged testing since 1990, stigma is still a problem, particularly in rural areas. Consequently, many women are afraid of being blamed for bringing HIV into their families. Seventy-four percent of pregnant women who are offered counselling in clinics accept it, and 65 percent get tested; nine out of ten pregnant women visit a clinic just once, and only 15 percent return for a post-natal check-up. To make matters worse, most babies are born at home and just 20 percent of births take place in a health facility, placing Uganda 13th among the countries with the worst maternal mortality. In 2000, for every 100,000 births, 505 mothers died during or shortly after delivery. "The challenge is to reach women just before labour," said Dr Chris Baryomunsi, an HIV/AIDS officer with the United Nations Population Fund (UNFPA). A Nevirapine tablet is taken by the mother during labour, and the baby receives six drops of the syrup within the first 72 hours. Paediatric Nevirapine is available in a 50 ml bottle, enough for 25 babies; it has a three-month shelf life and should not be exposed to heat and sunlight. These conditions make it difficult for mothers to store the syrup. According to UNICEF, a solution would be to train women who have been on PMTCT as helpers. Another solution would be to increase public awareness. A local NGO, Community Action to Protect Children from AIDS, has been training Muslim and Catholic leaders to educate their communities about PMCT for the past three years. In the capital Kampala, 750 trained volunteers reached half a million men and women at church gatherings, group talks and home visits in 10 parishes. The training manual, produced by the Islamic Medical Association, links quotes from the Bible and the Koran to prevention, care and treatment. Formula feeding reduces the risk of transmission through breastmilk by one-third. But this option is another obstacle, as it requires a constant supply of clean water and firewood to ensure sterile feeding. Family pressure to breastfeed is strong, and mothers who formula feed are viewed with suspicion. Rose Mushabe (not her real name) is an HIV-positive doctor who gave herself an injection to dry up her milk but, when her family visited, she would pretend to breastfeed unsuccessfully. "I did three months of acting from fear of disclosing," she told PlusNews. The alternative is exclusive breastfeeding for the first three to six months, followed by quick weaning, as mixed feeding can damage the baby's fragile gut lining, increasing the risk of infection. UNICEF initially offered free formula in the country, but only one out of three mothers chose to use it. Free formula was discontinued and exclusive breast-feeding recommended. "Sometimes we are quick to offer solutions, like Nevirapine or condoms, without thinking through all the problems for all the people," noted Captain Stephen Talugende, coordinator of the National Forum of Networks of People with AIDS. Anglican priest Gideon Byamugisha and his wife Pamela were among the first HIV-positive parents to enrol on the PMTCT programme. Their three-year-old daughter Elizabeth is HIV-negative. An emerging problem is the mounting evidence that single-dose Nevirapine used in PMTCT may increase resistance to the drug when it is later used as treatment. During the International AIDS conference held in Bangkok earlier this year, South Africa's health ministry announced that for this reason, the use of a single dose of Nevirapine for PMTCT was under review. The alternative is a combination of other antiretrovirals, which if taken regularly from mid-pregnancy and boosted by nevirapine during labour, can cut transmission by two-thirds. But this drug regimen requires regular attendance at antenatal clinics and is more complex and expensive. Drug manufacturer Boehringer-Ingelheim currently supplies Nevirapine free to poor countries. Meanwhile, UNAIDS, UNICEF and the Elizabeth Glaser Paediatric AIDS Foundation have issued a statement supporting single-dose Nevirapine use where there are no other options. "Nevirapine is not the silver bullet we had hoped for," Odola-Ochongo commented. But for many pregnant women, it is still their only hope - despite the drawbacks.