Botswana: A winning recipe for PMTCT but few follow it

Gabarone/Johannesburg - A success story, at last: Botswana has lowered the rate of mother-to-child transmission of HIV to less than four percent, coming close to developed countries that have almost eliminated paediatric AIDS.

In Europe and the USA, fewer than two percent of babies with HIV-positive mothers are born with the virus; without intervention, the risk of an HIV-positive pregnant woman passing on the virus to her baby is between 30 percent and 35 percent, according to health specialists.

In Lesotho, transmission rates from mother to child are still as high as 37 percent; in Zimbabwe, 100 babies become HIV infected every day.

So how did Botswana do it? It was one of the first countries in Africa to establish a national antiretroviral therapy programme in 2002, and with a population of over 1.7 million people, optimal use of existing resources and a relatively sound health infrastructure, it was always going to be easier to get results.

Dr William Jimbo, chief advisor on prevention of mother-to-child transmission (PMTCT) of HIV at the Botswana/USA health partnership (BOTUSA), also attributed the low rate of transmission to an effective cocktail of political commitment and bold policy decisions.

More than three years ago, the government introduced a policy of routine testing for HIV as part of its strategy for encouraging more people to be tested and access treatment.

All pregnant women attending a health facility are now routinely offered an HIV test unless they decline; those found to be HIV-positive receive immediate counselling and are put on a long course of zidovudine, also known as AZT, at 28 weeks, and given a single dose of nevirapine during labour. The infant is given four weeks of AZT and a single dose of nevirapine.

"Most other countries in the region are still piloting the programmes," Jimbo told IRIN. The World Health Organisation guidelines for PMTCT advise using combination therapy where possible, but the rest of southern Africa has been slow to move away from using mono-therapy, in which mother and child are each given a single dose of nevirapine.

Governments have only recently begun to introduce the newer and more effective combination medication, which can reduce the risk of transmission to as little as five percent.

In Zambia, for example, combination therapy for PMTCT is only available in urban areas, while rural areas continue using mono-therapy. Dr Max Bweupe, national coordinator for the government's PMTCT programme, told IRIN that the new drug regimen was being rolled out in phases, as healthcare workers require training on the new dosages.

Malawi will be switching to a triple combination drug regimen in October 2007, while South Africa has yet to indicate when it will make the change.

According to Jimbo, implementing a new method of collecting and testing blood samples from infants as early as six weeks of age, has also helped. The most commonly used HIV-antibody test - the rapid test - cannot distinguish between maternal and child antibodies in infants, because HIV antibodies can cross the placenta and stay in the child's bloodstream for 18 months.

Babies need a Polymerase Chain Reaction (PCR) test, which can detect small quantities of viral protein in the blood, to establish their status. Although the PCR technology has been available in Botswana since 2002, it could only be performed at the two referral hospitals where specially trained doctors are available to perform phlebotomy (draw whole blood from veins) on infants.

However, the introduction of the dried blood spot test has made it possible to train health workers at all clinics to obtain blood from infants, using a simple method of pricking the heel, toe or finger. The dried blood spot is cheaper and faster, and requires less skill than the liquid blood PCR tests. One a child is identified as HIV-positive, it's health can be better managed.

"There is no refrigeration required and there are no blood samples to carry in vials over long distances, and samples can be collected from a clinic anywhere in the country and transported immediately to remote laboratories," said Jimbo.

"During the past two years, we have been working on early infant diagnosis, taking it out to all rural districts in the country, so that even the most distant health post can effectively collect a sample for testing and send it through to a central laboratory for testing," said Dr Molly Smit, a BOTUSA PMTCT advisor in the northern town of Francistown.

Last week, health minister Sheila Tlou said that if the country kept at the same pace, their PMTCT programme could eventually reach levels of HIV transmission of below one percent.

"For the rest of Africa - they are still struggling. In some African countries the uptake is only 30 percent, and they often wonder how we managed to do it."