Friday, August 14, 2009

Mbeki's Legacy

The August issue of Obstetrics and Gynecology contains a chilling report on the impact of HIV treatment (or lack thereof) on maternal mortality in a Johannesburg hospital over five years. The news is grim: HIV-infected pregnant women faced a mortality risk more than six times higher than that of women who didn't carry the HIV virus. HIV was the leading cause of maternal mortality, responsible for nearly half of the deaths reported in the study. Even worse -- many of these deaths could have been prevented through the use of antiretrovirals, which became available at the hospital only in 2004. Only two of the HIV-positive women in the study initiated antiretroviral treatment, demonstrating the need to integrate treatment with prenatal care and pursue more active follow-up processes. Perhaps more importantly, over 40% of the women were "of unknown HIV status", meaning that they had not taken an HIV test. The legacy of Mbeki's AIDS policy is clear: the late introduction of antiretrovirals and the missed opportunity for a public health campaign to educate pregnant women about the need for testing and treatment have contributed to an unacceptably high maternal death rate.
An article in last December's Journal of Acquired Immune Deficiency Syndromes paints an even starker picture:
At the peak of the [HIV/AIDS] epidemic, the [South African] government, going against consensus scientific opinion, argued that HIV was not the cause of AIDS and that antiretroviral (ARV) drugs were not useful for patients and declined to accept freely donated nevirapine and grants from the Global Fund. . . More than 330,000 lives or approximately 2.2 million person-years were lost because a feasible and timely ARV treatment program was not implemented in South Africa. Thirty-five thousand babies were born with HIV, resulting in 1.6 million person-years lost by not implementing a mother-to-child transmission prophylaxis program using nevirapine. The total lost benefits of ARVs are at least 3.8 million person-years for the period 2000-2005.
In September 2003, I visited Lusikisiki, a rural town in South Africa's Eastern Cape, where a Médecins Sans Frontières program was awaiting the government's decision as to whether it could provide antiretrovirals. Approval came a month later, and the project's final report demonstrates significant success -- for example, voluntary counseling and testing during pre-natal care visits increased from 26% in 2003 to 89% in 2006. Lessons to be drawn from that study include the importance of adherence counsellors and community support as well as service user empowerment. It's not too late to undo Mbeki's legacy, though the human cost has already been far too high.


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