Since the introduction of a prevention of mother-to-child HIV transmission (PMTCT) programme in August 2007 at Port Sudan Hospital in Sudan's northeastern Red Sea State, 1,620 pregnant women have received information about HIV and the offer of an HIV test; only 24 have taken up the offer.
The numbers are an indication of the long road ahead for Sudan's AIDS prevention efforts. Mother-to-child HIV infection is almost completely preventable - one dose of the antiretroviral (ARV) drug, nevirapine, can halve the chances of a mother infecting her child during delivery.
More sophisticated combinations of ARVs, combined with replacement feeding, can eradicate the risk almost entirely, yet African governments have struggled to implement PMTCT programmes, often taking years before the number of children infected is reduced.
These are early days in Sudan's PMTCT programme - Port Sudan Hospital is one of only seven health facilities in five states in northern Sudan that have been providing PMTCT services since August 2007. Besides these pilot programmes, pregnant women are not offered HIV tests and although free ARVs are slowly becoming available at some public health facilities, there are no PMTCT services for pregnant women.
Some pilot sites are doing better than others. At Saudi Hospital in Kassala State, on the border with Ethiopia and Eritrea in eastern Sudan, approximately 20 of 100 women using antenatal services there every week agree to an HIV test and the numbers are rising.
Severine Leonardi, HIV/AIDS manager for the UN Children’s Agency (UNICEF) in northern Sudan, which is supporting the pilot PMTCT programme, attributed the widely varying figures in Port Sudan and Kassala to their different approaches to testing.
"The policy is opt-out testing [in which women are routinely tested for HIV unless they expressly refuse]," she said, "but since it's a pilot, some of the teams still haven't implemented it, including Port Sudan."
Pregnant women at Port Sudan Hospital attend group information sessions on the availability of voluntary counselling and testing (VCT). Not surprisingly, few women take the initiative to go to the separate area where the VCT is conducted. Leonardi said the goal was for all pilot sites to offer opt-out testing by April 2008.
Malik Gaidoum, HIV/AIDS officer for UNICEF in Kassala, where testing is already routine, believes the biggest obstacle still preventing many women from agreeing to be tested are the high levels of stigma attached to HIV and AIDS in Sudan.
He said married couples would have difficulty talking about HIV with one another, making the decision to be tested even harder. "A Sudanese woman wouldn't want to discuss it with her husband."
Of the 24 women who agreed to take the test at Port Sudan Hospital, four were positive, a worryingly high figure in a country where data is scarce but national HIV prevalence is thought to be about 1.6 percent.
The four women were referred to Port Sudan's family planning centre, the only place in town where antiretroviral (ARV) treatment is available, but no one was sure that the women had received PMTCT treatment. "We haven't had any feedback," said one of the staff.
So far, the hospital in Kassala has identified only one pregnant woman from Ethiopia as HIV positive, who unfortunately could not receive PMTCT. "She refused treatment because her husband, who was a soldier, came with a pistol to take her away," said Youmis Menti, director of the hospital's PMTCT programme. "We tried to convince him she was negative and agreed she would come secretly for treatment, but then she ran away back to Ethiopia."
The story illustrates how carefully health officials need to tread in a country where culture, religion, a long conflict and high levels of illiteracy have left AIDS awareness efforts years behind most other countries in the region.
The more basic obstacle to the uptake of PMTCT programmes is that less than 50 percent of women in Kassala participating in a 2006 household health survey knew that women could transmit HIV to their children, and only a quarter of them knew how. Female volunteers at the Sudanese Red Crescent society have been going door-to-door in the area serviced by Saudi Hospital, educating women about HIV and the availability of PMTCT services.
Although more women are attending antenatal care clinics in Sudan, such services are still only available in towns. Rural women still give birth at home, with the help of traditional midwives and female relatives.
Menti said UNICEF had supported the Sudanese National AIDS Control Programme in teaching 120 traditional midwives in Kassala's rural areas about PMTCT in 2007, so they could pass on the information to their clients and encourage them to be tested for HIV.