The Challenge of Preventing Mother-to-Child Transmission of HIV in South Africa

The echoes of the sheep’s guttural death moans have finally ceased to reverberate among the emerald green, sugarcane-covered bluffs. The only sound now is that of the butcher’s rusted knife, sawing through sinew.

A feast is being prepared.

As the local men drink from golden bottles of beer in the murky shade of a wall, the silence is broken by women who begin to sing joyfully in a tent in the middle of the homestead.

The celebratory slaughter and song are in honor of Cynthia Mkhize. Soon, she will be married.

The woman steps carefully across the sinuous stream of blood, the crimson gash in the animal’s throat bleeding red rivulets into the rich black soil.

“It is a fat one!” she gleefully exclaims, admiring the glassy-eyed carcass.

Mkhize has been living here, at Kwanyuswa village, in the Valley of a Thousand Hills in South Africa’s KwaZulu-Natal province, all her life. She’s 34 years old. She’s the mother of six children.

KwaZulu-Natal is home to the country’s Zulu people. It’s one of South Africa’s poorest areas, with high rates of unemployment and malnutrition. It’s also the epicenter of the nation’s war against HIV/AIDS.

South Africa is suffering one of the most severe AIDS epidemics in the world. Almost six million people live with HIV in the country, with about 1,000 people dying from AIDS-related illnesses every day. Many are children. Their HIV-infected mothers pass the virus on to them in the womb, during labor or through breastfeeding. Antiretroviral drugs have long been available to stop this from happening, but few HIV-infected South African women have access to the life-saving medicines, and tens of thousands of babies continue to be born with the lethal virus.

In KwaZulu-Natal, one in four people has HIV. Mkhize is one of them.

The province’s graveyards are filled with the bodies of those who have succumbed to AIDS-related sicknesses. “It’s a curse!” Mkhize spits, carrying her five-year-old son, Bongamusa - a Zulu name meaning ‘Thank the Lord.’

Mkhize contemplates, “But for now, I am okay. It is up to God to decide when to take me….”

She explains that she was “sick a lot” when she fell pregnant with Bongamusa. “I went to the counselors. They told me I was HIV-positive. My heart was broken,” she whispers. “I thought it was over for me, but the doctors told me they could save me. They gave me the anti-HIV drugs.”

Mkhize was given two antiretroviral drugs during her pregnancy, and this protected Bongamusa from HIV-infection.

“I am very happy that my child is HIV-negative. If I did not listen to the advice of the nurse, and take the drugs to prevent the virus from going into Bongamusa, none of us would be safe right now. Now we all have life,” she smiles.

But Patience Mavata, a nurse and clinic manager in the valley, maintains that Mkhize’s story is an unusual one. Mavata says one in three mothers who fall pregnant in the district is HIV-infected and many pass the virus on to their babies.

“Small battles are being won here and there, but the war is being lost. Some people now call this area ‘the valley of a thousand deaths,’” the young nurse says dejectedly.

The war Mavata speaks of is being fought on several fronts in KwaZulu-Natal. It’s raging against certain aspects of culture that ensure that HIV is easily spread, against poverty that forces women into risky behavior and against discrimination that results in people refusing to be tested for HIV.

No drugs

Prof. Hoosen Coovadia, one of South Africa’s eminent HIV scientists, says 60,000 HIV-positive babies are born every year in the country. “Many of them are dying. Simple. And tragic. But that’s the truth,” he says.

Most fatalities occur in South Africa’s most impoverished provinces, like KwaZulu-Natal.

Coovadia’s frustrated.

“It’s easy to save all these kid’s lives, with just basic planning and correct allocation of resources,” he maintains.

South Africa’s the richest country in Africa. It has the 25th highest GDP in the world. Yet its response to HIV/AIDS has thus far, according to Coovadia, been “embarrassing” when compared to efforts mounted against the disease in far poorer countries.

The pediatrician says, “There’s been no political will in South Africa to really battle this epidemic.”

However, the country’s Health Minister, Aaron Motsoaledi, who’s been in the job for just over a year, is inspiring hope with a range of new policies regarding HIV/AIDS - including promises of a new, sustained focus on prevention of mother to child HIV transmission.

He’s also introduced new treatment guidelines for HIV-positive pregnant women. According to these, HIV-infected pregnant women with CD4 counts of 350 are given lifelong access to ARVs. A CD4 count is a measure of the strength of an individual’s immune system. Previously, the drugs were only given to HIV-infected women with CD4 counts of 250. Medical experts credit Motsoaledi’s reforms with saving the lives of many women and children in South Africa.

A few years ago, the United States President’s Emergency Plan for AIDS Relief, PEPFAR, gave Coovadia funds to test combinations of antiretroviral drugs (ARVs) in KwaZulu-Natal. He found the medicine reduced mother to child transmission of HIV to as low as one percent.

Coovadia says the drug combination needed to stop babies getting HIV costs “only a few dollars.” Yet HIV-positive mothers in many parts of South Africa don’t have access to it. The country’s Center for Actuarial Research has found that in some provinces, only one out of every ten HIV-infected pregnant women who need the medicines that would prevent their babies from being infected with HIV, are getting the drugs.

‘It’ll make you weep….’

For the president of the South African HIV Clinicians Society, Dr. Francois Venter, the answer to the question of why so many children are still being born HIV-positive in his homeland lies in the recent past.

“It’s a legacy of our previous health minister, where she did everything in her power to create obstacles to access to antiretrovirals,” he bluntly states.

South Africa’s former health minister, Manto Tshabalala-Msimang, insisted that ARVs were “poisonous.” Instead, she promoted a diet of fruits and vegetables for HIV-infected people. AIDS activists, and a study done by Harvard University, say the South African government’s initial refusal to provide the drugs in state clinics was responsible for the deaths of hundreds of thousands of HIV-infected people.

In 2004, the government began dispensing antiretrovirals after a successful court action by South African activists.

Coovadia says there are also other “massive deficits” in the country that result in HIV-positive pregnant women not getting medication, and passing the virus to their babies.

“The key problem in Africa as a whole and in this country is the lack of infrastructure – which is sufficient clinics to provide coverage, or sufficient, professional personnel to run these clinics.”

In the Valley of a Thousand Hills, nurse Mavata bemoans the fact that her clinic is “always so overburdened” with patients. Nevertheless, she’s thankful, saying, “At least we do have something, rather than to have nothing, because there are areas where they’ve got nothing.”

Mavata says clinics in KwaZulu-Natal are “few and far between. Many people spend all day walking to and from” the facilities. “I don’t know why the state doesn’t build more. Ask them,” she says.

Coovadia’s convinced that mismanagement of the few health facilities there are also contributes to high HIV infection and death rates in South Africa.

“We don’t have competent managers. They can’t run hospitals. I have lived here all my life, and it’s a disaster. They put people in positions of power, and if I told you the stories of what they get up to, it’ll make you weep!” he exclaims.

Mavata’s emphatic that the “number one” reason for so many pregnant women being infected with HIV, and subsequently giving it to their offspring, is extreme poverty. Some people, she says, don’t even have the “few cents” needed for transport fare to get to clinics. They therefore remain untreated in their home villages.

Mavata adds that even if the women do get to the clinics to receive drugs, they live in such poor conditions that the medicine often becomes ineffective. Antiretrovirals must be kept cool…. But the tiny huts, with no electricity, are often heated by fire.

She says, “If the medicine is exposed to too much heat, it might not work by the time the person is using it. The women end up using useless medication.”

Women are ‘slaves’ to men…. And circumstance

Mavata explains that a lot of men in rural KwaZulu-Natal move to the urban centers to work, or to search for jobs, leaving the women alone in the villages. In the cities, the men have sex with other women.

“Our men, they prefer skin-on-skin sex…. Condoms they find less pleasurable,” Mavata says.

The nurse knows of a wealthy man in the valley who is HIV positive, but “hates” condoms. “The man is a businessman. He’s got power, he’s got money. How many women does he sleep with to fulfill his desires?” she asks.

But Mavata stresses it’s not only the men who are spreading HIV in the province. She says the women here are “totally economically disempowered” and are thus forced to rely “completely” on men for their needs. When their husbands or partners are away, the women require money for essentials and will look to other men to fulfill these needs.

“The women, because of poverty, they are looking for men that they can con, in order for them to live day by day,” she comments. And this “con,” says Mavata, “equates to sex. Women exchange sex for food, for presents, for a roof over their heads.”

The nurse stresses that poverty encourages “dangerous” promiscuity, which in turn fuels the epidemic.

Mavata tells the story of a local woman who recently consulted her, and said, “I’ve got five men in my life. One is the father of my children. Two is the one that is giving me money for clothes. Three is the one that I enjoy sex with. Four is the one who helps me go on holiday. Five is the one who is popping up cash for my education.”

In desperation, Mavata screeches, “It’s all unprotected sex! How can we stop the spread of HIV in this context?”

When the women become HIV-infected, she says, they don’t tell any of their male partners, because they fear rejection and consequent loss of income. When a man demands sex without a condom, Mavata explains, the women yield and don’t inform the man that they’re HIV-positive. And so the virus is transmitted “over and over and over again.”

Many HIV-positive pregnant women in the valley also refuse to attend clinics where they could be counseled on preventing transmission of the virus to their babies, because, says Mavata, “they know that as soon as they enter that clinic, people will know they are HIV-positive. Then I tell them, ‘Don’t let your feelings get in the way of saving your baby’s life.’”

Some heed the nurse’s advice. “Others don’t,” she sighs.

‘Pregnant mothers are not the drivers of this epidemic!’

For Prof. Hoosen Coovadia, there’s one “obvious” way to decrease the numbers of children being born with HIV in South Africa. “You should start with the HIV-negative mother. If you kept women negative, there’s going to be no babies [born] positive,” he states.

The scientist says for the first time in South Africa, it’s now possible to eliminate transmission of HIV to babies, with highly-active antiretroviral therapy (HAART). “But a lot more work needs to be done. We need trained counselors and more facilities. The money for this is there in state coffers, but it’s not being used,” Coovadia laments.

He maintains that unless the South African government improves health services, to enable more HIV-positive pregnant women to get drugs, thousands of children will continue to be born with the virus.

“How are we going to manage with all these children, say from two months [of age]?” Coovadia asks. “Can you imagine feeding this baby drugs - if it was your child - until the baby dies as an adult, for 20 years or 30 years? My God, it beggars the imagination. I don’t know how we’re going to manage it.”

He’s adamant that giving drugs to people, for a country with resources like South Africa, is the “easy part” of its response to HIV/AIDS…. The crucial and most complex challenge to the nation, the doctor insists, is ensuring that South Africans practice safer sex.

“Pregnant mothers are not the drivers of this epidemic! The big problem is heterosexual transmission. We can eliminate mother to child transmission, and not affect transmission of HIV from men to women and women to men, one iota!” Coovadia exclaims.

AIDS experts agree that South Africa has the scientific knowledge and the budget to prevent and treat HIV.

But, as Coovadia says, “you can throw all the money and knowledge in the world at the problem, but unless you have good political leadership, to ensure proper planning, you are finished. And unless we have somebody with imagination and dedication and understanding at the top, who drives this process, we’ll have many, many unnecessary deaths.”

Those embroiled in the battle against HIV/AIDS in South Africa are continually looking to Minister Motsoaledi to radically revamp what they say has so far been a dire response to the pandemic.

But at the homestead at Kanyuswa village, the politics of South Africa’s HIV/AIDS strategy is far from Cynthia Mkhize’s mind, as she laps up the attention of women ululating in her honor. The HIV-positive bride-to-be smiles shyly. She thanks God again that her son has been born HIV-free. But then, unexpectedly, Mkhize whispers some words that destroy the assumption that hers will be a story with a happy ending.

“The man I am to marry, he is sure that he is HIV-positive. But he refuses to go for the HIV test. He says he will kill himself if he’s positive. He now eats my pills….”

If this situation persists, Mavata asserts, then Mkhize and her future husband won’t ingest the levels of medication needed to enable them to fight off opportunistic illnesses. And her HIV-free children remain at high risk of being orphaned. If this happens, they’ll be left to fend for themselves in the unforgiving climate that reigns in the Valley of a Thousand Hills.

“It won’t happen, it won’t happen,” Mkhize forcefully shakes her head. “God is looking after us,” she whispers again, stroking her slumbering son’s cheek.