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The roll out of Aids drugs in KwaZulu-Natal
Mother to child transmission of HIV has been under the spotlight in KwaZulu-Natal with the recent announcement by Premier Lionel Mtshali that the province will start to make the anti-retroviral drug Nevirapine available to HIV-positive pregnant mothers in state hospitals. Mtshali said that the KwaZulu-Natal government was under obligation to supply anti-retroviral drugs to pregnant mothers who are HIV-positive. "While it is accepted that Nevirapine does causecomplications, it is the pregnant woman's prerogative to save her child from contracting the Aids virus. A mother who is already afflicted by an incurable disease should not have to contend with ahopeless situation of her unborn child facing the same affliction if it can be prevented," thepremier said. The programme to prevent mother-to-child transmission of HIV began in KwaZulu-Natal in June 2001. Although two sites were identified for the pilot programme, the sites included severalhospitals and clinics in the Pietermaritzburg and Durban areas. The programme has also subsequently been launched in the Hlabisa area in Zululand. It is being run by the local healthservice with the Africa Centre, which is a research institute funded by the Wellcome Trust. TheHlabisa programme is fully operational in seven of the 14 clinics in the district, in two mobile units In the period from June to December 2001 12 151 women received pre-test counselling at the Pietermaritzburg and Durban sites. Of these 76% consented to testing and 40% of those tested positive for HIV. Of the 3 683 women who were tested, 74% were informed of their results and70% of those (1 905) received the single dose of Nevirapine. Of those, 66% of the womendelivered at the designated centres and 99% of the babies received the single dose of Nevirapine. Half of the mothers chose to formula feed, while 40% chose to breastfeed. No records wereavailable for the other 10%. Pressure has been put on the department of health and clinicians to roll out the programme to atleast some, if not all health facilities in KwaZulu-Natal. However, the clinicians in particular have emphasised that the issue is not simply about the provision of the Nevirapine drug, but ratherabout the rolling out of the entire programme. Particular weaknesses identified in the programme during the first six months included a lack ofmentorship programme for counsellors, inadequate counselling facilities at many centres, poorfollow up services of women and infants and a lack of understanding of infant feeding practices and decision making. The programme in Hlabisa has experienced similar problems, particularly the Perspectives on KwaZulu-Natal was published by Profile KwaZulu-Natal cc in 2001 and 2002. All rights reserved. No editorial material published in Perspectives on KwaZulu-Natal may be reproduced in any form without prior written permission from, and acknowledgement to, Cheryl Goodenough. Perspectives on KwaZulu-Natal was proofread by Donna Hornby from Absolute Proof. Copyright Profile KwaZulu-Natal cc, 2001, 2002 shortage of counselling space at clinics. In some cases counsellors have had to conduct sessionsunder trees, but portable office tents have been bought to overcome this problem. KwaZulu-Natal health minister Zweli Mkhize said that the studies at the pilot sites have aimed todetermine the cost implications, particularly related to support services, of extending theprogramme to areas where it is currently not available. Key areas requiring attention, according tothe minister, were training of lay counsellors and provision of physical facilities to enhanceconfidentiality in counselling of HIV positive mothers. "The research sites have indicated that the major costs are related to logistics and human resources, the provision of space, health personnelnamely counsellors, nurse, doctors, etc. The selection, training and in-service experience requires about six months to provide a reliable counsellor. For the best results, one to one counselling is ideal," said Mkhize. A further problem that Mkhize said needs to be addressed was concerned with infant feeding.
"Many women attend ante-natal clinics without their partners and receive counselling on feeding options alone resulting in tensions at home with relatives or partners. This makes it hard for thewoman to maintain her status in confidence and for her to feed her baby exclusively on the optionshe has chosen whether to breastfeed or formula feed." While the ideal is to formula feed, this should only be done where it can be safely sustained. Inmany parts of KwaZulu-Natal this is not possible and studies have suggested that the bestalternative is to exclusively breastfeed for six months. The most risky method is mixing breastfeeding with other supplements. Mkhize has questioned how this issue can be approached particularly in light of the cost of formulafeed which makes up 50% of the implementation budget. The social stigma associated with HIV infection is a significant factor. This stigma is evident whenone considers that as many as 46% of HIV positive women tested do not return to collect theirresults. Mkhize said: "This seems to be due to the difficulty women may have to seek support andunderstanding of their husbands who may be healthy looking. Invariably women are accused ofspreading the virus or infecting their partners merely as a result of being the first to be diagnosedHIV positive. In a patriarchal society such as ours the women's fear of rejection is real; so is their inability to influence (their) partners risky sexual conduct." While the clinicians running the programme are still determined to address as many of theproblems as possible, Mkhize has announced that up to 20 hospitals in KwaZulu-Natal could be distributing Nevirapine within six months. The better-resourced hospitals will be brought on board first, after which another 40 remaining hospitals will be phased in over time. Perspectives on KwaZulu-Natal was published by Profile KwaZulu-Natal cc in 2001 and 2002. All rights reserved. No editorial material published in Perspectives on KwaZulu-Natal may be reproduced in any form without prior written permission from, and acknowledgement to, Cheryl Goodenough. Perspectives on KwaZulu-Natal was proofread by Donna Hornby from Absolute Proof. Copyright Profile KwaZulu-Natal cc, 2001, 2002

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