African Physicians Speak Out

Vertical HIV Transmission in South Africa: Translating Research into Policy and Practice [Karim SA et al. Lancet 2002;359:992]: This is a statement from the Southern African HIV Clinicians Society dealing with vertical transmission and its prevention in South Africa. The following facts are emphasized:

• The rate of perinatal transmission of HIV in South Africa is 19-36% depending on breast feeding (AIDS 2001;15:379).
• Prevalence of HIV in antenatal clinics for public health services in 2000 was 24.5%.
• The South African government claims that interventions cannot be implemented due to cost, toxicity, drug resistance, breast feeding, and inadequate health service capacity.
• Antiretroviral drugs have now become much cheaper. Nevirapine, is being given free for the next five years to countries in Africa for reduction of vertical transmission. Thus, the costs are those of establishing voluntary counseling and testing at antenatal clinics. Cost analysis for South Africa has shown that antiretroviral therapy is cost-effective (BMJ 1999;318:1650; S Afr Med J 2000;90:794).
• Short course regimens with AZT show safety and efficacy (JAMA 1999;281:151). A decision analysis model has shown that nevirapine is beneficial even if the toxicity is 42 times greater than demonstrated in clinical trials (Am J Public Health 2002;92:365).
• Nevirapine resistance mutations may occur with a single dose, but this probably represents variants that are present at low frequency prior to antiretroviral therapy indicating HIV selection rather than new mutations. These resistant strains do not reduce efficacy of preventing transmission, the resistant strains are apparently not transmitted to the infant, and resistance tends to decrease over time in the mother in the absence of the drug (AIDS 2001;15:1951).
• Breast-feeding is an important mechanism of HIV transmission, and alternative options for feeding should be considered, including formula feeding. Breast-feeding should not negate the potential value of nevirapine.
• The capacity to implement a nevirapine prophylaxis program has been established in several health care facilities; for settings with less capacity for testing, alternative strategies could be considered, such as universal nevirapine without HIV testing.
• The public health experience in South Africa has been very uneven. The government has an exemplary record on providing free immunizations for children under six years of age, but the lack of a similar program to prevent the most common lethal perinatally transmitted infection is bothersome. This denial has been addressed in court, and the court's decision was that the government must provide a plan to deal with vertical transmission by March 31, 2002. This court order is now under appeal.
• The conclusion is that the scientific evidence to support the use of antiretroviral agents to reduce vertical transmission is strong. The challenge is to translate these research findings into policy and practice.

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