Archive for December, 2009

On the eve of World AIDS Day, the World Health Organization (WHO) is releasing new recommendations on treatment, prevention and infant feeding in the context of HIV, based on the latest scientific evidence.

WHO now recommends earlier initiation of antiretroviral therapy (ART) for adults and adolescents, the delivery of more patient-friendly antiretroviral drugs (ARVs), and prolonged use of ARVs to reduce the risk of mother-to-child transmission of HIV. For the first time, WHO recommends that HIV-positive mothers or their infants take ARVs while breastfeeding to prevent HIV transmission.

“These new recommendations are based on the most up to date, available data,” said Dr Hiroki Nakatani, Assistant Director General for HIV/AIDS, TB, Malaria and Neglected Tropical Diseases at the World Health Organization.  “Their widespread adoption will enable many more people in high-burden areas to live longer and healthier lives.”

An estimated 33.4 million people are living with HIV, and there are some 2.7 million new infections each year. Globally, AIDS is the leading cause of mortality among women of reproductive age.

New treatment recommendations

In 2006, WHO recommended that all patients start ART when their CD4 count (a measure of immune system strength) falls to 200 cells/mm3 or lower, at which point they typically show symptoms of HIV disease. Since then, studies and trials have clearly demonstrated that starting ART earlier reduces rates of death and disease. WHO is now recommending that ART be initiated at a higher CD4 threshold of 350 cells/mm3 for all HIV-positive patients, including pregnant women, regardless of symptoms.

WHO also recommends that countries phase out the use of Stavudine, or d4T, because of its long-term, irreversible side-effects. Stavudine is still widely used in first-line therapy in developing countries due to its low cost and widespread availability. Zidovudine (AZT) or Tenofovir (TDF) are recommended as less toxic and equally effective alternatives.

The 2009 recommendations outline an expanded role for laboratory monitoring to improve the quality of HIV treatment and care. They recommend greater access to CD4 testing and the use of viral load monitoring when necessary. However, access to ART must not be denied if these monitoring tests are not available.

Preventing mother-to-child transmission and improving child survival

In 2006, WHO recommended that ARVs be provided to HIV-positive pregnant women in the third trimester (beginning at 28 weeks) to prevent mother-to-child transmission of HIV. At the time, there was insufficient evidence on the protective effect of ARVs during breastfeeding. Since then, several clinical trials have shown the efficacy of ARVs in preventing transmission to the infant while breastfeeding. The 2009 recommendations promote the use of ARVs earlier in pregnancy, starting at 14 weeks and continuing through the end of the breastfeeding period.

WHO now recommends that breastfeeding continue until the infant is 12 months of age, provided the HIV-positive mother or baby is taking ARVs during that period.  This will reduce the risk of HIV transmission and improve the infant’s chance of survival.

“In the new recommendations, we are sending a clear message that breastfeeding is a good option for every baby, even those with HIV-positive mothers, when they have access to ARVs,” said Daisy Mafubelu, WHO’s Assistant Director General for Family and Community Health.

National health authorities are encouraged by WHO to identify the most appropriate infant feeding practice (either breastfeeding with ARVs or the use of infant formula) for their communities. The selected practice should then be promoted as the single standard of care.

Benefits and challenges

An earlier start to antiretroviral treatment boosts the immune system and reduces the risks of HIV-related death and disease. It also lowers the risk of HIV and TB transmission.

The new prevention of mother to child transmission (PMTCT) recommendations have the potential to reduce mother-to-child HIV transmission risk to 5% or lower. Combined with improved infant feeding practices, the recommendations can help to improve child survival.

The main challenge lies in increasing the availability of treatment in resource-limited countries. The expansion of ART and PMTCT services is currently hindered by weak infrastructure, limited human and financial resources, and poor integration of HIV-specific interventions within broader maternal and child health services.

The recommendations, if adopted, will result in a greater number of people needing treatment. The associated costs of earlier treatment may be offset by decreased hospital costs, increased productivity due to fewer sick days, fewer children orphaned by AIDS and a drop in HIV infections.

Another challenge lies in encouraging more people to receive voluntary HIV testing and counselling before they have symptoms. Currently, many HIV-positive people are waiting too long to seek treatment, usually when their CD4 count falls below 200 cells/mm3. However, the benefits of earlier treatment may also encourage more people to undergo HIV testing and counselling and learn their HIV status.

WHO, in collaboration with key partners, will provide technical support to countries to adapt, adopt and implement the revised guidelines. Implemented at a wide scale, WHO’s new recommendations will improve the health of people living with HIV, reduce the number of new HIV infections and save lives.

Malawi mums need support

Mary Donohoe warns that when we recruit healthcare providers to Ireland from developing countries where shortages exist, we cause deaths

The Rose Project is an Irish non-governmental organisation, founded in 2003 by former nurse Mary Donohoe. The organisation has raised significant sums of money and supports locally led healthcare programmes in Malawi.

Malawi is a landlocked country in southern Africa and ranks among the most densely populated and least developed countries in the world. With the majority of people living on less than $2 a day, life is a challenge.

Travelling around the capital city of Lilongwe and its rural surroundings, one is struck by the sinister poverty, with lack of healthcare being a major contributing factor.

HIV positive
According to official figures, 15 per cent of the population is HIV positive; however speaking with hospital staff and healthcare professionals generally, it is estimated to be considerably higher in urban areas.

Prior to the advent of HIV, the healthcare system in Malawi was severely challenged; with its arrival, it has been brought to its knees. Efforts to increase access to healthcare and to maintain and improve the quality of care are being severely hampered, due to the acute shortage of health workers and appalling conditions in the hospitals and health centres.

In relation to healthcare workers, the situation is at crisis level, with only one doctor per 100,000 people and 56 nurses. Nowhere is this more evident than in the area of maternal and infant mortality.

Malawi has the highest rate of maternal mortality for a non-conflict country, with one in 14 women losing their life in childbirth. The country also has one of the highest levels of vertical HIV transmission in Africa, resulting in 30,000 babies being born HIV positive each year. Few of these infants reach their second birthday.

To exacerbate the above, Malawi has one of lowest ratios of healthcare professional per patient in east Africa. The Rose Project is addressing all three problems.

Last month, Dr Mary Robinson and the Vice President of Malawi, Ms Joyce Banda, opened a new maternity hospital in Lilongwe on behalf of the Rose Project. This hospital replaces a shed-like building which was constructed in 1939 to facilitate 4,000 annual deliveries.

There are now 12,000 annual deliveries. Many of the women at the old hospital delivered their infants onto stone floors due to overcrowding and unassisted due to lack of staff. In addition, 25 per cent of the expectant women are HIV positive, many with AIDS. This places enormous pressures on existing services.

State-of-the-art facility
While the new hospital is a state-of-the-art facility and the first of its kind in Africa to afford each couple a private room for the birth of their baby, it still has only has only one resident obstetrician and three qualified midwives for 12,000 annual births. To place this in context, the National Maternity Hospital in Dublin has 9,000 annual deliveries with 18 obstetricians and 138 midwives. The challenge is enormous.

Thirty thousand infants are born HIV positive in Malawi each year. This is preventable, however the greatest challenge is the shortage of healthcare workers to implement the necessary initiatives.

In 2006, the Rose Project funded the Lighthouse AIDS Clinic in the centre of Lilongwe. Prevention of HIV transmission from mother to child has been central to the care provided at this facility.

Co-funded by Irish Aid
In 2008, in an effort to bring PMTCT (preventing-mother-to-child transmission) to the rural areas The Rose Project awarded a three-year grant to Lighthouse Clinic. To date, the clinic has successfully implemented PMTCT at 30 of the 40 healthcare centres. This programme, which is being co-funded by Irish Aid, is working well but has serious challenges due to the shortage of healthcare workers at the centres.

Finally, many healthcare workers are themselves unwell having been infected in the workplace with TB/HIV or succumbed to the virus themselves. These individuals need to be cared for in a confidential and safe environment.

Wellness centres for healthcare workers are an initiative of the International Council of Nurses in Geneva and have been proven most successful in halting the attrition rate of healthcare workers in Lesotho and Swaziland, where they have been in operation for some time.

Critical shortage
Last month the Rose Project funded a new Wellness Centre in Lilongwe, which was opened by the Vice President of Malawi. Undoubtedly, the principal challenge to safe motherhood in Malawi is the critical shortage of healthcare professionals.

Africa has 25 per cent of the global disease burden with only 2 per cent of the global workforce. No one denies that developing countries, including Malawi, need to take the lead in providing solutions to this acute shortage of healthcare workers.

Despite limited resources, the Malawian government is attempting to do this; however given the huge level of illness created by the AIDS pandemic, they are keen for international support.

Ireland has one of the most highly skilled medical and nursing workforces in the world. According to UNICEF’s latest figures, Ireland is the safest place in the world to have a baby. Given this remarkable achievement, surely there is a great opportunity and an urgent need for individuals, medical and nursing institutions to become involved in what is now acknowledged to be one of the greatest tragedies of our time — the level of maternal and infant mortality in the developing world.

As a country we have benefited and continue to benefit from foreign healthcare workers, in some cases to the detriment of local healthcare systems. How much of this recruitment is ethical is questionable.

Everyone has a right to access the global labour market; however it is important to remember that few of these workers wish to leave their families and countries. They do so out of need. This need often fills gaps in healthcare systems in rich countries where investment in training has been insufficient.

We need to understand that the recruitment of healthcare workers from developing countries, where critical shortages already exist, is causing deaths. If recruitment must continue, it should be carried out in a fair and equitable manner in consultation with local governments; after all, for the most part they are funding the undergraduate training.

The Rose Project
Over the past 6 years the Rose Project has funded 28 HIV-related programmes in six east African countries, reaching approximately 200,000 people with treatment and care, including five new healthcare centres, medical/nursing training and salaries, large scale prevention programmes, nutrition, drugs and transport.

Mary Donohoe trained as a nurse in Saint Vincent’s University Hospital Dublin and is a governor of the National Maternity Hospital Dublin

For further information please visit: www.roseproject.org