London - Botswana's programme to prevent the transmission of HIV from mothers to their unborn babies is now integrated into all of the country's 634 public health facilities.
"A very high percent of pregnant women are tested and more than 90 percent of those who test positive are enrolled into the programme," the London-based AidsMap organisation said in its October newsletter.
"Despite this coverage, the programme still has its challenges and the national infant mortality rate remains high," AidsMap's Theo Smart said.
One is how optimise the antiretroviral (ARV) drugs used for prevention of mother to child transmission (PMTCT).
For women who do not yet qualify for ART for their own health, AZT currently is the cornerstone of the programme and is now given from week 28 of pregnancy onwards to HIV-positive women with CD4 counts over 200.
Single-dose nevirapine is also currently given to women during labour, but because of concerns about the development of nevirapine resistance this is under review.
Also under review is to increase the CD4 threshold at which the pregnant women can themselves qualify for ARV, currently 200.
ARV therapy is the norm for all HIV-infected pregnant women in most of Europe and the US, but adopting it in resource-limited settings would be expensive and difficult, the researchers say.
"According to Professor Sheila Tlou, Botswana's Minister of Health," Smart writes, "Botswana is definitely moving in the direction of raising the CD4 threshold for ART for pregnant women with HIV - to at least 250 and perhaps higher.
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There are also concerns about tracking the progress of babies born to the HIV-infected women. The women do not present their babies to be tested until they are very ill.
"We are losing the gains of the PMTCT programme," the researchers say.
"The programme has been putting emphasis on getting the mother to be tested, but not enough on following the baby."
There are two efforts to address this. Botswana has developed new 'Under-5 Cards' for infants, on which details of mother's PMCT treatment will be recorded.
When the children go to child health clinics, they will be easily identifiable.
"More ambitious," writes Smart, "there are plans to test infants for HIV at six weeks, using a dry blood spot test. The dried blood spots are easier to collect - just a prick to the heel or toe - store and transport than liquid blood samples, and the test results are just as reliable.
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The programme had been piloted successfully at 11 clinics and one referral hospital.
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