PMTCT: HIV no longer a death sentence

One bare foot slowly steps in front of the other. Her left hand presses against the wall for support, while her right holds her pregnant belly as she limps toward the nursing station. “It’s not about me anymore, it’s about my child,” she repeats to herself to get through the pain. Nthuthu Mxalisa, who has been living with HIV for 12 years, remembers how she stubbornly left her bed during labour to remind the nurses to administer her medication. She was told she needed to receive the antiretroviral (ARV) drug, AZT, every three hours during labour, and she was going to make sure she did. “The nurses told me I was a pain,” she says with a smile, “but I had to do everything I could to prevent my child from contracting the virus.” Nthuthu had always known that she wanted to have a child and, with the advances in treatment, HIV would not stop her. When she gave birth four years ago she received dual therapy treatment where she received AZT during labour and her daughter received another ARV, nevirapine, for the first six week of her life. This all paid off when Nthuthu received her daughter’s test results. She was negative. Since then there has been more advancements in this field. The roll out of prevention of mother to child transmission (PMTCT) treatment began a few years ago and has been a great success. A recent report, issued by Human Rights Watch, brought to light shocking information regarding maternal care in some Eastern Cape health facilities. Along with general negligence, patients have reported incidents of verbal and physical abuse. Some women have experienced nurses berating them for “getting pregnant knowing they were HIV positive”. Instead of condescending nurses, Nthuthu found a similar reaction from one of her co-workers. “One day when I broke the news she asked me, how can you do that? What kind of message are you sending?” Nthuthu had worked as an HIV counsellor for a number of years and knew better than anyone that, as a woman, she had the right to have a child. PMTCT has created a way for HIV infected women to empower themselves and stand up for their rights against the stigma of the disease. Professor Hoosen Coovadia, one of South Africa’s foremost PMTCT experts, says, “This virus has been the cause of a lot of gloom and doom in the country but it is time to focus on the success stories.” He believes that PMTCT is one of these stories and Nthuthu agrees, “HIV is no longer a death sentence.” When he worked in anti-natal clinics in the 90s he witnessed a different situation, “Out of every hundred mothers about 32 babies were positive but now it’s down to less than three.” He believes that it is simply the failure of our health system that is to blame for the remaining three percent. Our health system has numerous problems including a shortage of adequate care and resources. This has influenced the way PMTCT treatment has been implemented. Nthuthu realised this when seeking advice about her pregnancy. She had learned that a Caesarean section held less risk than natural birth in terms of transmission. When she asked whether this option was available to her, the nurse replied with a question, “What shoe size are you?” Puzzled, Nthuthu replied, “Six or Seven.” The nurse smiled, “Well then you will have no problem delivering your baby, you are going the natural way. We don’t have the resources.” Nthuthu need not have worried because with ARV treatment before, during and after birth, the risk of transmission is miniscule: even if you ‘go the natural way’. On the subject of ‘natural’, breast feeding has been a contentious issue regarding PMTCT. Four years ago, at the time of her pregnancy, Nthuthu was told to use formula as it was much safer than breast milk. In more recent years this view has largely been accepted as untrue. Through PMTCT the transmission rate through exclusive breast feeding (where the child is only fed breast milk) is around one percent. According to Coovadia the protective properties of breast milk are crucial in the third world context. “It has been observed that in the developing world as soon as you stop breast feeding three things happen: the child become malnourished, contracts infections and diarohea.” According to Coovadia, C-sections and formula feeding belong to developed countries as many people in South Africa simply do not have these options. “Now, through PMTCT, we can get the benefits of breast milk and minimise transmission.” This information was not available to Nthuthu when she was pregnant but, as an HIV and PMTCT counsellor (working at the Raphael Centre in Grahamstown) she helps to create awareness. Nthuthu only began taking ARVs for her own health at the beginning of this year. Now, instead of Nthuthu reminding the nurses to give her, her ARVs, her daughter reminds her every evening. “She is the best treatment supporter you could ever find.” Grey box How does PMTCT work? There are three possible points of transmission of HIV from a mother to her child. Accordingly, there are three interventions on the PMTCT programme. 1. Transmission in the womb: ARVs are administered to the mother during pregnancy if her CD4 count is below 350. The CD4 count is an indication of the strength of someone’s immune system. ARVs increase the CD4 count and reduce the chance of transmission. 2. Transmission during birth: ARVs are administered to the baby for first 6 weeks to reduce the chance of being infected during the birth process. 3. Transmission during breast feeding: ARVs are administered to the mother for the duration of breastfeeding (optimal time frame is 18 months) to reduce transmission through the breast milk.