Bangkok

Bitter pill: an antiretroviral that protects babies can leave their mothers resistant to treatment. Credit: A. ZIEMINSKI/AFP

Doctors should provide more treatment for pregnant women with HIV — not less. So argued scientists last week, after a controversial statement by the South African health minister at the XV International AIDS Conference in Bangkok.

The row focused on studies of a treatment that reduces the risk of women transmitting HIV to their babies during childbirth; some 700,000 children were born with HIV last year. Scientists already know that the treatment — a single dose of a drug called nevirapine (sold as Viramune) given to the mother during labour — can encourage drug-resistant viruses to grow in the mother's body. On 11 July, Gonzague Jourdain, with his Thai and French colleagues, announced that women with such drug-resistant viruses respond less well to the antiretroviral nevirapine when it is used to treat their disease later in life. The team published its work last week (Jourdain et al. New Engl. J. Med. 351, 229–240; 2004).

South African health minister Manto Tshabalala-Msimang told delegates that her country would stop recommending nevirapine based on this evidence. Scientists called her statement misguided. A sudden ban of the drug would unnecessarily cause disease in children, they say, because no other treatment is available in most poor countries. They add that the week-long controversy has overshadowed the real importance of the work, which could save the lives of mothers and children.

“This is not the Titanic sinking, where we have to save the mother or the child,” says Marc Lallemant, an author of the study from the IRD, a Paris-based research institute for sustainable development. “We are putting lifeboats all around, so everyone — mothers and children — can get out.”

The women who were most affected in Jourdain's study were also the least healthy to begin with. So the lesson, says Jourdain, is that sickly mothers should be given better care before labour, which could include taking a drug in combination with nevirapine that reduces both the chance of the baby getting HIV and the chance of resistance developing in the mother. “We should improve what is in place already,” says Jourdain, who works at the Harvard School of Public Health.

Another team of researchers at the conference presented similar conclusions about resistance in South African women. Infectious-disease specialist James McIntyre of the University of Witwatersrand in Johannesburg reported that if women were given nevirapine before labour and a two-drug combination therapy just afterwards, far fewer carried strains of virus resistant to nevirapine — resistance was cut at least fivefold. Jourdain called the study “preliminary, but encouraging”.

In Bangkok, world health officials spoke out against Tshabalala-Msimang's stance on nevirapine. By the end of the week, the South African government had decided that although it did not recommend using nevirapine alone, it would not immediately stop dispensing it. On 14 July, the World Health Organization said that single-dose treatments should not be undermined, but alternatives should be considered where possible.

All of this spells good news for mothers and their unborn children. But many at the conference still worry about the possible effects of Tshabalala-Msimang's comments on drug policies in Africa and Asia. “The confusion our minister sows is undermining prevention programmes around the world,” says activist Zackie Achmat of the South African group Treatment Action Campaign.