Rift Over AIDS Treatment for Mother-To-Child Transmission Lingers in South Africa, NVP+AZT vs One Drug therapy and Affordability
Mariella Furrer for The New York Times
Mpumelele, who is H.I.V. positive, regularly receives antiretroviral medicines. His mother was given only nevirapine before his birth in 2006. She said she was never told that a second drug might have helped prevent her son's infection.
By CELIA W. DUGGER
Published: March 9, 2008
KWANGWANASE, South Africa - Colin Pfaff, a slight doctor imbued with Christian zeal, had reached a moral crossroads.
Dr. Pfaff knew that giving H.I.V.-positive women and their newborns two anti-AIDS drugs instead of one would reduce the odds that mothers would pass the virus to their babies. For months, he and doctors from other hospitals pleaded with provincial health authorities for permission to use the approach, in a province where a staggering 4 in 10 pregnant women were infected.
"We cannot sit in silence any longer," they wrote last May.
But South Africa had not yet adopted the two-drug strategy, as recommended by the World Health Organization, and the doctors' request was rebuffed.
So, Dr. Pfaff made his choice. He raised the money on his own.
Then a week after the national health department said in January that it would begin requiring the use of both drugs, health authorities here in KwaZulu-Natal Province charged Dr. Pfaff with misconduct for raising money from a British charity and carrying out the very same preventive treatment "without permission."
Dr. Pfaff's case has stirred a furious reaction from rural doctors and advocates on AIDS issues, raising questions not only about a doctor's duties in the public health system, but also about why it took so long for South Africa, a country with more H.I.V.-positive people than any other in the world, to act.
The evidence that two drugs together - AZT plus nevirapine - work better than one has been accumulating since a clinical trial in Thailand was published in 2004 in The New England Journal of Medicine.
Even here in South Africa, the approach has worked. The Western Cape Province has deeply reduced mother-to-baby H.I.V. infection rates since 2004 - to less than 5 percent from 22 percent - by using both drugs.
AIDS advocates are celebrating the government's new policy. Still, they contend that South Africa, the region's economic powerhouse, should have put it into practice long ago, but lacked the political will.
Sibani Mngadi, a spokesman for South Africa's Health Department, disagreed, saying the government took the time needed to review the data and consult various players after the W.H.O. issued its recommendation in 2006. "There were a number of issues to be debated," he said.
For years, the country's political leaders have faced harsh international criticism for their resistance to providing antiretroviral medicines. Only after a 2002 court order did the government begin providing nevirapine to prevent women from infecting their babies.
In years past, President Thabo Mbeki defended the country's consultation of dissident scientists who denied that H.I.V. causes AIDS, while Health Minister Manto Tshabalala-Msimang has promoted indigenous remedies, including diets of garlic, beetroot and African potatoes.
Rural doctors in this district say babies were needlessly infected as a result of the government's slow pace.
"You can't uninfect them once they're infected, can you?" said Dr. Victor Fredlund, who has been at the hospital in Mseleni for 27 years.
In this remote, northeastern corner of the country, with its heart-stoppingly big skies and lush coast, doctors see grieving mothers carry babies with AIDS - feverish, vomiting and miserable - back to the hospitals where they were born.
In the doctors' letter to the provincial authorities in May, Dr. Pfaff, acting medical manager at Manguzi Hospital here, said they thought it was unethical to withhold a treatment used so successfully elsewhere. "We know better options are available and that we have the capacity to deliver them," he wrote.
In an e-mail message, Dr. Sandile Buthelezi, a provincial health official, acknowledged that the mother-to-baby transmission rate in KwaZulu-Natal, where only nevirapine was used, was 23 percent, while it was less than 5 percent in the Western Cape.
But he also wrote that nevirapine was still the nationally approved regimen and that the cost of adding AZT was not yet factored into the budget. "I am wary of us undermining national just because of what other provinces are doing," he wrote.
After Dr. Pfaff was charged with misconduct for using the two-drug regimen at Manguzi, advocacy groups took up his cause, as did the political opposition, which seemed only to further rile provincial officials.
"We will not allow anyone to pull vulturistic theatrics to mystify this matter for their own political gain," the provincial health department said in a Feb. 11 press release.
Peggy Nkonyeni, the African National Congress politician who is the health minister here, visited Manguzi Hospital after the charges were filed. Her spokesman, Desmond Motha, said she told the staff that antiretroviral medicines were not a cure for AIDS, "that the medicine they receive is indeed toxic and that's why people need to be counseled."
The Treatment Action Campaign, the country's most influential AIDS advocacy group, met last month with Mrs. Nkonyeni. Its spokesman, Nathan Geffen, said they were horrified to notice that the minister's desk had on it only a notepad and a book, "End Aids! Break the Chains of Pharmaceutical Colonialism," by Dr. Matthias Rath, whose ideas have been denounced by many medical groups and experts.
On his Web site, Dr. Rath contends that antiretroviral drugs attack and destroy the immune system and accuses multinational companies of using poor countries as a marketplace for their "toxic and often deadly drugs."
Mrs. Nkonyeni's spokesman said a member of the Treatment Action Campaign disrespectfully told his boss "she should put the book in the dust bin."
"It's her right to read the book," Mr. Motha said angrily
As protests mounted, the Pfaff case became an embarrassment to the governing A.N.C., which in December ousted Mr. Mbeki as its president. The party's new leaders seem to be seeking to reduce the acrimony between the party and AIDS advocacy groups. It has already reached out to the treatment campaign.
"That's a huge move forward," said Nozizwe Madlala-Routledge, who was fired by Mr. Mbeki in August as deputy health minister but was often credited with pushing for scientifically based action against AIDS.
Mr. Geffen said that he hoped that the Pfaff case was "the last kick of a dying horse" and that the A.N.C.'s new leaders would take a fresh approach to AIDS.
So it was perhaps not surprising that days after meeting with members of the treatment campaign, the provincial health department confirmed that Mrs. Nkonyeni had decided to withdraw the misconduct charges against Dr. Pfaff.
Her spokesman, Mr. Motha, said Mrs. Nkonyeni managed a program to provide drugs to people with AIDS and would carry out the new guidelines to give both nevirapine and AZT to pregnant women.
Those new rules will be important to Phiwili Ntuli, who is now five months pregnant and working in a sweltering phone shop for $80 a month to support her 19-month-old, H.I.V.-positive son, Mpumelele.
Ms. Ntuli was given nevirapine only when she went into labor in Manguzi Hospital in July 2006. The drug did not work.
Her affectionate son, who is still unable to stand or walk on his own, endured months of sickness before he began taking antiretroviral medicines he will probably need for the rest of his life.
Ms. Ntuli said she was never told that a second drug might have prevented her son's infection. "Using just one drug makes them guilty," she said of South Africa's leaders. "They're not thinking of the people."
S.Africa worried about affordability of AIDS fight
Friday, March 7, 2008; 9:51 AM
CAPE TOWN (Reuters) - South Africa, which has one of the world's highest rates of HIV/AIDS, is worried a national programme to fight the disease could founder on a lack of financial resources, it said in a report to the United Nations.
An estimated 500,000 people in South Africa are infected with HIV/AIDS each year and close to 1,000 die of related ailments every day.
Figures from the department of health said the national strategic plan (NSP), which aims to give 80 percent of HIV-positive people access to antiretroviral therapy by 2011, would cost about 6 billion rand ($747 million) to implement in 2008, rising to 11 billion rand ($1.37 billion) in 2011.
"If the NSP target of 80 percent of HIV-positive people receiving antiretroviral therapy (ART) was achieved, this would exceed 20 percent of the health budget," said the report, posted on the Web site of U.N. agency UNAIDS.
"This poses a challenge for both the affordability and sustainability of the NSP," added the report, which was approved by South Africa's cabinet this week.
President Thabo Mbeki's government has been criticized for not doing enough to halt the spread of the disease despite the heavy economic and human toll.
But in its strategic plan which runs from 2007 to 2011, the government has significantly ramped up spending and increased access to life-saving antiretroviral drugs.
The report said there has been an encouraging trend showing lower HIV prevalence among young pregnant women in South Africa aged below 20 years and those aged between 20 and 24.
"This could be the beginning of the long-awaited downward trend on prevalence among pregnant youth in South Africa," it said.
But exorbitant prices for antiretroviral drugs and a dire shortage of skilled medical personnel remained major challenges.
"It is estimated that at current prices the provision of antiretroviral therapy will account for about 40 percent of the total cost of the national strategic plan," said the report.
"This much-needed service will soon be unaffordable at current drug prices."
During 2007 only 42 percent of 889,000 people requiring ARV drugs were able to access them, figures show.
(For full Reuters Africa coverage and to have your say on the top issues, visit: http://africa.reuters.com/)
(Reporting by Wendell Roelf; Editing by Mark Trevelyan)