The Treatment Action Campaign (TAC) has welcomed the announcement of a new national protocol for the Prevention-of-Mother-to-Child-Transmission of HIV (PMTCT), but has also raised serious questions regarding some of the details.
The long-awaited guidelines were released last week following increasing pressure from the TAC and various other civil society groups. The department had initially promised to release the guidelines in December last year.
Will save lives
Central to the new policy is the introduction of dual-antiretroviral prophylaxis, consisting of nevirapine plus AZT, for preventing mother-to-child-transmission of HIV rather than the single-dose nevirapine regimen recommended in the Department’s 2003 PMTCT protocol.
"The revised PMTCT protocol will help to reduce the number of unnecessary infant HIV infections thereby saving many lives. We call on all healthcare workers, provincial health officials and community organisations to implement these protocols," the TAC said in a statement.
Effective treatment overlooked?
However, the TAC said they regret that the Department of Health’s new protocol, "while better than the 2003 one, is still out of sync with the World Health Organisation’s (WHO) strongest recommendations for the prevention-of-mother-to-child-transmission of HIV."
"Specifically, the revised protocol fails to include any mention of the antiretroviral drug lamivudine (aka 3TC), a safe, effective and inexpensive addition to AZT. The 2006 WHO guidelines for preventing HIV infection in infants recommend that lamivudine be administered to the mother, in conjunction with AZT, both during birth as an HIV prophylaxis as well as postpartum as a means of reducing the risk of nevirapine resistance," the TAC said.
They also said that the Minister of Health Tshabalala-Msimang has on several occasions publicly expressed her concern about possible nevirapine resistance in women who have participated in PMTCT programmes.
"It therefore makes little sense that an effective, scientifically-proven method of reducing the likelihood of a mother developing resistance to nevirapine, a seven-day postpartum course of AZT and lamivudine (known as the ‘cover-the-tail’ strategy), has been actively decided against in the new national protocol," the statement said.
"The 'cover-the-tail' strategy was strongly recommended by expert HIV paediatricians who advised the Department of Health on the new protocol; we are disappointed that this well-founded recommendation has been ignored," the TAC said.
Trailing international best practice
Another serious shortcoming in the new PMTCT policy guidelines, according to the TAC, is that pregnant women who test positive for HIV will only be started on antiretroviral therapy once their CD4 count has dropped to/below 200 cells/mm3.
"Once again this puts the new guidelines out of step with current international best practice. Compelling scientific evidence points to significant health advantages for pregnant women who initiate antiretroviral therapy at CD4 cell counts of 350 cells/mm3 rather than 200 cells/mm3. US and European treatment guidelines now recommend that all patients, including pregnant women, with a CD4 cell count of 350 cells/mm3 or below should start anti-HIV treatment. This was also recommended by expert HIV paediatricians who advised the Department of Health on the new protocol," said the TAC.
Who may prescribe?
According to a department of health press release, "the two drugs used in the programme - AZT and nevirapine - are schedule 04 medicines and they therefore have to be prescribed by a medical officer after an appropriate assessment of the patient."
The TAC expressed their concern that the term 'medical officer' as it is used by the Department of Health may prevent nurses and midwives from being allowed to routinely and easily administer AZT and nevirapine for the purposes of PMTCT.
"Given the acute shortage of doctors in the public health sector, if nurses and midwives are prohibited from prescribing antiretroviral drugs the national PMTCT programme will face severe difficulty in reaching the targets set by the National Strategic Plan," they said. – (Health24)
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