Expanding government’s nevirapine programme
It will be difficult for government to expand its prevention of mother-to-child transmission (PMTCT) sites overnight if the complex programme is to be sustainable.
Yet with about 70 000 HIV positive babies born in South Africa every year – and nevirapine offering the chance to prevent half of these from getting HIV – expansion is crucial.
When a pregnant woman goes to an antenatal clinic, she needs to be told about the nevirapine programme. Then she has to be encouraged to take an HIV test. If she agrees, she should be counselled before and after the test.
If HIV positive, the woman gets a tablet of nevirapine during labour, while her baby gets half a teaspoon of nevirapine syrup within 72 hours of birth.
Thereafter, the mother needs to be helped to decide whether to breast or bottlefeed her baby. Breast milk can transmit HIV to babies, but poorly prepared formula milk can also kill a baby.
Getting pregnant women to accept the programme, training staff and volunteers and finding the space in which to run the programme all takes time.
In a report assessing Government’s 18 PMTCT sites, the Health Systems Trust (HST) found that sites that were carefully prepared before the programme started were more likely to be successful.
Ideal site preparation started with solid planning, staff training, the recruitment of lay counsellors, the training of lay counsellors, community mobilisation and the establishment of adequate and appropriate space.
According to HST, setting up the 18 pilot sites involved:
- The development of a PMTCT protocol which includes a set of clinical and patient care guidelines;
- Financing, budgeting and buying medicines, HIV testing kits, staff and formula milk;
- Ensuring appropriate supply, distribution and storage of drugs and formula.
- Training clinical and management staff;
- The creation of new posts at the provincial level to support the programme;
- The recruitment and deployment of lay counsellors;
- The development of a routine information and monitoring system.
HIV testing and counselling is difficult and time-consuming. Suggested minimum standards for counselling advise an average of 60 minutes of initial pre- and post-test counselling, together with two further ante-natal counselling sessions of about 30 minutes each.
At present, staff time constraints mean that pre-test counselling takes about 10 minutes and the post-test counselling around 20 minutes.
“There is no way in which existing staff, with other clinical and public health duties, can cope with such an increase in workload,” the HST report said.
Because of this, the employment of lay counsellors to support health workers is a cornerstone of the PMTCT programme.
But lay counsellors are currently barred from performing the rapid on-site HIV diagnostic test because they are not nurses. This takes about 30 minutes per client, and has to be done by the nurses.
A significant challenge, according to HST, is overcoming the lack of space and furniture to provide counselling in a comfortable and private manner.
In hospitals it is possible to identify spare rooms that can be used. But many clinics resort to counselling in inappropriate places such as in a car, a kitchen, a public room or under a tree.
Record-keeping plays a central role in ensuring that all HIV positive women have access to the drug when in labour, and are followed up once their babies are born.
The national PMTCT protocol stipulates that pregnant women should be given a nevirapine tablet from their 28th week of pregnancy in case they go into labour.
There needs also to be a good supply of nevirapine tablets and syrup (for babies) with a secure place to store it.
Nurses and doctors also need to be trained in safer delivery methods. There are certain obstetric practices that can minimise the risk of transmission of HIV from mothers to babies. These include avoiding the artificial rupture of membranes, minimising the length of active labour and avoiding instrumental or assisted vaginal deliveries.
The supply of baby formula, the most expensive and controversial part of the programme, needs to be ensured. Women need to be counselled on how to make informed choices about what the best feeding method is for their babies taking into consideration factors such as access to clean, safe water.
Despite all these hurdles, many researchers, doctors, nurses, members of civil society and now the courts, are struggling to find good reasons for delaying a phased expansion of PMTCT services in all provinces.
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Expanding government’s nevirapine programme
by Anso Thom, Health-e News
April 4, 2002