Prevention Of Mother-to-child Transmission Implementation Research Articles

Understanding rapid implementation from discovery to scale: Rwanda’s implementation of rotavirus vaccines and PMTCT in the quest to reduce under-5 mortality

BackgroundOver the last eight decades, many evidence-based interventions (EBIs) have been developed to reduce amenable under-5 mortality (U5M). Implementation research can help reduce the lag between discovery and delivery, including as new EBIs emerge, or as existing ones are adapted based on new research. Rwanda was the first low-income African country to implement the rotavirus vaccine (RTV) and also adopted Option B+ for effective prevention of mother-to-child transmission (PMTCT) before the World Health Organization’s (WHO) recommendation. We use implementation research to identify contextual factors and strategies associated with Rwanda’s rapid uptake of these two EBIs developed or adapted during the study period.MethodsWe conducted a mixed methods case study informed by a hybrid implementation research framework to understand how Rwanda outperformed regional and economic peers in reducing U5M, focusing on the implementation of health system-delivered EBIs. The research included review of existing literature and data, and key informant interviews to identify implementation strategies and contextual factors that influenced implementation outcomes. We extracted relevant results from the broader case study and used convergent methods to understand successes and challenges of implementation of RTV, a newly introduced EBI, and PMTCT, an adapted EBI reflecting new research.ResultsWe found several cross-cutting strategies that supported the rapid uptake and implementation of PMTCT, RTV, and leveraging facilitating contextual factors and identifying and addressing challenging ones. Key implementation strategies included community and stakeholder involvement and education, leveraging of in-country research capacity to drive adoption and adaptation, coordination of donors and implementing partners, data audit and feedback of coverage, a focus on equity, and integration into pre-existing systems, including community health workers and primary care. The availability of donor funding, culture of evidence-based decision-making, preexisting accountability systems, and rapid adoption of innovation were facilitating contextual factors.ConclusionImplementation strategies which are generalizable to other settings were key to success in rapidly achieving high acceptability and coverage of both a new and an evolving EBI. Choosing strategies which leverage their facilitating factors and address barriers are important for other countries working to accelerate uptake of new EBIs and implement needed adaptations based on emerging evidence.

Analysis of the Level of Knowledge and Perceptions of Pregnant Women Regarding the PMTCT Program in Antenatal Services in Bukittinggi City

The problem with Prevention of mother to Child Transmission (PMTCT) among pregnant women in Bukittinggi City is that there are still many pregnant women who do not carry out HIV tests. In 2021 K1 coverage is 95% but HIV screening coverage is only 45%, this shows that there are still many pregnant women who do not know their HIV status even though they have visited a health service facility. The aim of this research is to analyze the relationship between the level of knowledge and perceptions of pregnant women regarding the implementation of PMTCT. This research is a mix method study with systematic random sampling of 100 respondents. The results of bivariate analysis show the level of knowledge (p = 0.199), perceived vulnerability (p = 0.054), perceived severity (p = 0.916), perceived benefits (p = 0.993), perceived barriers (p = 0.360), perceived threats (p = 0.669 ) is not related to the implementation of PMTCT. Perception of cues to action (p=0.035) and support from health workers (p=0.007) were related to the implementation of PMTCT. Meanwhile, the results obtained from the multivariate analysis showed that the most significantly related variable was health workers (p = 0.005). Conclusion: The support provided by health workers is socialization and counseling, but not all health workers providing antenatal care have implemented this. Suggestions for Community Health Centers to optimize the implementation of counseling before and after HIV testing and for the Health Service to actively monitor the implementation of integrated ANC for all health workers providing antenatal care. Keywords: Knowledge, perception, pregnant women

Barriers in Implementing the PMTCT in Moretele Sub-District, South Africa: An Exploratory Study.

The Prevention-of-Mother-To-Child Transmission (PMTCT) program was introduced to prevent vertical transmission of HIV from a mother to her infant through pregnancy, labor, and breastfeeding. Therefore, it is critical for the program to be accessible in primary health care facilities across the globe to increase treatment uptake and to eliminate child and maternal mortality rates caused by HIV infections. However, barriers are still being experienced by some nurses while implementing PMTCT around Moretele sub-district in the North West Province (NWP). Hence, this qualitative study explored and described the factors influencing the implementation of PMTCT. A qualitative, exploratory-descriptive design was followed. Ten participants were selected purposively, and each participant was interviewed individually using WhatsApp video calling. All participants were made aware of their voices being recorded; data saturation was reached on the eighth participant as no new information evolved. Data were analyzed using Tesch’s method of qualitative data analysis. The findings revealed that factors that influenced PMTCT implementation were due to patient, management, and staff-related factors. Moreover, these factors impacted the provision of effective patient care. The findings of this study show that much still needs to be done to achieve and sustain the PMTCT implementation goal. Therefore, the training of nurses should be of paramount importance. They should be provided and equipped with the necessary resources, support, and encouragement to offer and ensure quality health care. Furthermore, the government should ensure that policies and guidelines are regularly monitored and evaluated.

Integrating gestational diabetes and type 2 diabetes care into primary health care: Lessons from prevention of mother-to-child transmission of HIV in South Africa - A mixed methods study.

BackgroundImplementation of the programmes for the Prevention of Mother to Child Transmission (PMTCT) of Human Immunodeficiency Virus (HIV) into antenatal care over the last three decades could inform implementation of interventions for other health challenges such as gestational diabetes mellitus (GDM). This study assessed PMTCT outcomes, and how GDM screening, care, and type 2 diabetes (T2DM) prevention were integrated into PMTCT in Western Cape (WC), South Africa.MethodsA convergent mixed methods and triangulation design were used. Content and thematic analysis of PMTCT-related policy documents and of 30 semi-structured interviews with HIV/PMTCT experts, health care workers and women under PMTC diagnosed with GDM complement quantitative longitudinal analysis of PMTCT implementation indicators across the WC for 2012–2017.ResultsProvincial PMTCT and Post Natal Care (PNC) documents emphasized the importance of PMTCT, but GDM screening and T2DM prevention were not covered. Data on women with both HIV and GDM were not available and GDM screening was not integrated into PMTCT. Women who attended HIV counselling and testing annually increased at 17.8% (95% CI: 12.9% - 22.0%), while women who delivered under PMTCT increased at 3.1% (95% CI: 0.6% - 5.9%) annually in the WC. All 30 respondents favour integrating GDM screening and T2DM prevention initiatives into PMTCT.ConclusionPMTCT programmes have not yet integrated GDM care. However, Western Cape PMTCT integration experience suggests that antenatal GDM screening and post-partum initiatives for preventing or delaying T2DM can be successfully integrated into PMTCT and primary care.

Prevention of mother-to-child transmission (PMTCT) of HIV: a review of the achievements and challenges in Burkina-Faso.

BackgroundBurkina-Faso’s HIV/AIDS program is one of the most successful in Africa, with a declining HIV prevalence and treatment outcomes that rival those of developed countries. Prevention of mother-to-child transmission (PMTCT) guidelines in Burkina-Faso, initiated in the year 2000, were revised in 2004, 2006 and 2010. The guideline document has since undergone several stages of improvement, largely based on recommendations from WHO, with adaptations by local experts in the field. Option B+ adopted since August 2014 in Burkina-Faso has enabled maintenance of mothers on longer treatment and increasing their survival and that of their children. Through this review, we describe the achievements and challenges of HIV PMTCT programs in Burkina-Faso.Aims of studyThis study had the following objectives: 1) describing the historical perspective of PMTCT implementation in Burkina-Faso; 2) presenting the effectiveness of interventions at improving PMTCT service delivery and promoting retention of mothers and babies in care; and 3) determining the impact of male partner involvement on PMTCT in Burkina-Faso.MethodologyA literature search was conducted in PubMed and Google. Search terms included the following keywords: “HIV testing”; “prevention”; “mother”; “child”; “male partner”; “counseling”; “involvement”; “participation”; and the grouped terms “PMTCT and partners”; “VCT”; “barriers and/or factors”; “Male involvement in PMTCT”; and “Burkina-Faso”. Data collection took place from May to October 2015. The search was limited to articles published between January 2002 and December 2015. UNICEF and UNAIDS web sites were also used to find relevant abstracts and documents.ResultsStudies have revealed that with PMTCT, HIV transmission rate moved from 10.4% in 2006 to 0% in 2015. The PMTCT program remains the best way to care for HIV-infected pregnant women and their babies. The current PMTCT policy is based on evidence that male partner involvement is associated with women’s completion of PMTCT.ConclusionThis study shows that the reduction in mother to child transmission of HIV in Burkina-Faso over the years is mainly due to the improvement of PMTCT programs. Efforts still need to be made about the involvement of male partners.

Comparative Assessment of Zero-Inflated Models with Application to HIV Exposed Infants Data

In a typical Kenyan HIV clinical setting, there is a likelihood of registering many zeros during the routine monthly data collection of new HIV infections among HIV exposed infants (HEI). This is attributed to the implementation of the prevention of mother to child transmission (PMTCT) policies. However, even though the PMTCT policy is implemented uniformly across all public health facilities, implementation naturally differs from every facility due to differential health systems and infrastructure. This leads to structured zero among reported positive HEI (where PMTCT implementation is optimum) and non-structured zero among reported positive HEI (where PMTCT implementation is not optimum). Hence the classical zero-inflated and hurdle models that do not account for the abundance of structured and non-structured zeros in the data can give misleading results. The purpose of this study is to systematically compare performance of the various zero-inflated models with an application to HIV Exposed Infants (HEI) in the context of structured and unstructured zeros. We revisit zero-inflated, hurdle models, Poisson and negative binomial count models and conduct the simulations by varying sample size and levels of abundance zeros. Results from simulation study and real data analysis of exposed infant diagnosis show the negative binomial emerging as the best performing model when fitting data with both structured and non-structured zeros under various settings.

Implementation of Prevention of Mother to Child Transmission of HIV Program in South Jakarta

Even though Prevention of Mother to Child Transmission (PMTCT) program has been running in Indonesia since 2006, the proportion of human immunodeficiency virus (HIV)-infected pregnant women remains high in some districts in Indonesia. The PMTCT program aims to reduce transmission of HIV from mother to child. Thus it requires an examination of the PMTCT program implementation. The study was a qualitative study on PMTCT program implementation in South Jakarta, Indonesia, whereas the proportion of children with HIV positive in the area was quite high. The analysis used domain analysis by looking the implementation of PMTCT as a system consisting of input, process and output. PMTCT strategy is based on a comprehensive four-pronged strategy. This study found that scaling-up communication and education about PMTCT program from health provider to community was needed. In the first prong, there was no specific health provider for PMTCT program, it was still integrated with the MCH staff. PMTCT program did not disseminate information to the community.Therefore, it seemed that it was underutilized. In the second prong, implementation of HIV testing and counseling for couples of women living with HIV remained a bottleneck because women living with HIV felt fear to inform their HIV status to their partners. Thus, counseling and HIV testing for couples have not benefited at all. These women were unsatisfied with the quality of counseling, and the failure to provide antiretroviral treatments. This study found the low coverage and less responsiveness of PMTCT program to build a network of partners with various elements of government.

Barriers and opportunities for implementing prevention of mother to child transmission (PMTCT) in Bangli District

Background and purpose: HIV testing among pregnant women can reduce the risk of mother to child HIV transmission. The implementation of prevention of mother to child transmission (PMTCT) program in Bangli District is suboptimal. This study aims to explore challenges and opportunities for implementing PMTCT program from both user and provider perspectives.Methods: A qualitative approach was conducted in Bangli District between April and May 2016. Data were collected using in-depth interviews with 18 informants. All informants were purposively selected and covered of 10 pregnant women, two counsellors, two laboratory analysts, two head of community health centres, one disease control officer from Bangli District Health Office and one officer from Bangli District AIDS Commission. Data were analysed using thematic method.Results: Pregnant women chose to have ANC service at private midwife and obstetrician instead of  public health centre. From health providers’ perspectives barrier of PMTCT implementation included lack of health human resources and a high level of stigma and discrimination related to HIV/AIDS in the community. This study revealed that there was an opportunity for PMTCT implementation in Bangli District due to positive attitudes and supports from husband and health provider toward HIV testing. Another opportunity is to involve village health cadres and community leaders in promoting HIV testing among pregnant women.Conclusions: Implementation of PMTCT program in health centre should include network of private practitioner and enhance village health cadres’ and community leaders’ participation.

The Achilles’ heel of prevention to mother-to-child transmission of HIV: Protocol implementation, uptake, and sustainability

The Joint United Nations Programme on HIV and AIDS proposed to reduce the vertical transmission of HIV from ∼72,200 to ∼8300 newly infected children by 2015 in South Africa (SA). However, cultural, infrastructural, and socio-economic barriers hinder the implementation of the prevention of mother-to-child transmission (PMTCT) protocol, and research on potential solutions to address these barriers in rural areas is particularly limited. This study sought to identify challenges and solutions to the implementation, uptake, and sustainability of the PMTCT protocol in rural SA. Forty-eight qualitative interviews, 12 focus groups discussions (n = 75), and one two-day workshop (n = 32 participants) were conducted with district directors, clinic leaders, staff, and patients from 12 rural clinics. The delivery and uptake of the PMTCT protocol was evaluated using the Consolidated Framework for Implementation Research (CFIR); 15 themes associated with challenges and solutions emerged. Intervention characteristics themes included PMTCT training and HIV serostatus disclosure. Outer-setting themes included facility space, health record management, and staff shortage; inner-setting themes included supply use and availability, staff–patient relationship, and transportation and scheduling. Themes related to characteristics of individuals included staff relationships, initial antenatal care visit, adherence, and culture and stigma. Implementation process themes included patient education, test results delivery, and male involvement. Significant gaps in care were identified in rural areas. Information obtained from participants using the CFIR framework provided valuable insights into solutions to barriers to PMTCT implementation. Continuously assessing and correcting PMTCT protocol implementation, uptake and sustainability appear merited to maximize HIV prevention.

The effectiveness of interventions to improve uptake and retention of HIV-infected pregnant and breastfeeding women and their infants in prevention of mother-to-child transmission care programs in low- and middle-income countries: protocol for a systematic review and meta-analysis.

BackgroundDespite recent improvements, uptake and retention of mothers and infants in prevention of mother-to-child transmission (PMTCT) services remain well below target levels in many low- and middle-income countries (LMICs). Identification of effective interventions to support uptake and retention is the first step towards improvement. We aim to complete a systematic review and meta-analysis to evaluate the effectiveness of interventions at the patient, provider or health system level in improving uptake and retention of HIV-infected mothers and their infants in PMTCT services in LMICs.Methods/DesignWe will include studies comparing usual care or no intervention to any type of intervention to improve uptake and retention of HIV-infected pregnant or breastfeeding women and their children from birth to 2 years of age attending PMTCT services in LMICs. We will include randomized controlled trials (RCTs), cluster RCTs, non-randomized controlled trials, and interrupted time series. The primary outcomes of interest are percentage of HIV-infected women receiving/initiated on anti-retroviral prophylaxis or treatment, percentage of infants receiving/initiated on anti-retroviral prophylaxis, and percentage of women and infants completing the anti-retroviral regimen/retained in PMTCT care. The following databases will be searched from inception: Ovid MEDLINE and EMBASE, The WHO Global Health Library, CAB abstracts, EBM Reviews, CINAHL, HealthSTAR and Web of Science databases, Scopus, PsychINFO, POPLINE, Sociological s, ERIC, AIDS Education Global Information System, NLM Gateway, LILACS, Google Scholar, British Library Catalogue, DARE, ProQuest Dissertation & Theses, the New York Academy of Grey Literature, Open Grey, The Cochrane Library, WHO International Clinical Trials Registry, Controlled Clinical Trials, and clinicaltrials.gov. Reference lists of included articles will be hand searched and study authors and content experts contacted to inquire about eligible unpublished or in progress studies. Screening, data abstraction, and risk of bias appraisal using the Cochrane Effective Practice and Organization of Care criteria will be conducted independently by two team members. Results will be synthesized narratively and a meta-analysis conducted using the DerSimonian Laird random effects method if appropriate based on assessment of clinical and statistical heterogeneity.DiscussionOur findings will be useful to PMTCT implementers, policy makers, and implementation researchers working in LMICs.Systematic review registrationPROSPERO CRD42015020829Electronic supplementary materialThe online version of this article (doi:10.1186/s13643-015-0136-x) contains supplementary material, which is available to authorized users.

S10.3 Sti control in china: what accounts for political priorities?

Introduction Despite a large and growing burden of mother-to-child transmission (MTCT) of syphilis in China over the past 20 years, the issue received far less attention and fewer resources than prevention of MTCT (PMTCT) of HIV, which has a substantially lower burden. China’s Ministry of Health issued the first national plan for syphilis control in 2010, aiming to integrate PMTCT of syphilis and HIV. Our study aimed to identify: 1) why PMTCT of syphilis had a lower political/resource priority than PMTCT of HIV before 2010; and 2) what actions would improve the prospects of successful implementation of dual PMTCT. Methods A comparative policy analysis was undertaken, based on informant interviews, documentation review, and nonparticipant observation of relevant meetings/trainings, to investigate priority-setting prior to 2010. Policy data were analysed by using a nine-factor framework which assesses political prioritization across three categories: transnational influence; domestic advocacy; and national political environment. Results Several factors contributing to the lower priority accorded to PMTCT of syphilis were identified: 1) relative neglect at a global level; 2) dearth of international financial and technical support; 3) poorly unified national policy community with weak accountability mechanisms; 4) insufficient understanding of the epidemic and policy options; and 5) a prevailing negative framing of syphilis that resulted in significant stigmatization. Conclusion The goal of dual PMTCT of syphilis and HIV will only be achieved when equal priority is accorded to both infections. This will require stronger cohesion and leadership from the syphilis policy community. The community will also need to reframe the issue so as to overcome stigmatization against those affected by the illness, organize focusing events to attract political attention, and work more closely with the HIV policy community in order to enhance the recognition of the need to control syphilis on both the national and sub-national agendas.

P13.05 Prevention of mother-to-child transmission of syphilis and hiv in china: what drives political prioritisation and what can this tell us about promoting dual control?

Introduction Despite a large and growing burden of mother-to-child transmission (MTCT) of syphilis in China over the past 20 years, the issue received far less attention and fewer resources than prevention of MTCT (PMTCT) of HIV, which has a substantially lower burden. China’s Ministry of Health issued the first national plan for syphilis control in 2010, aiming to integrate PMTCT of syphilis and HIV. Our study aimed to identify: 1) why PMTCT of syphilis had a lower political/resource priority than PMTCT of HIV before 2010; and 2) what actions would improve the prospects of successful implementation of dual PMTCT. Methods We undertook a comparative policy analysis, based on informant interviews, documentation review, and nonparticipant observation of relevant meetings/trainings, to investigate priority-setting prior to 2010. We used a nine-factor framework developed by Shiffman et al . which assesses political prioritisation across three categories: transnational influence; domestic advocacy; and national political environment. Results We identified several factors contributing to the lower priority accorded to PMTCT of syphilis: 1) relative neglect at a global level; 2) dearth of international financial and technical support; 3) poorly unified national policy community with weak accountability mechanisms; 4) insufficient understanding of the epidemic and policy options; and 5) a prevailing negative framing of syphilis that resulted in significant stigmatisation. Conclusion The goal of dual PMTCT of syphilis and HIV will only be achieved when equal priority is accorded to both infections. This will require stronger cohesion and leadership from the syphilis policy community. The community will also need to reframe the issue so as to overcome stigmatisation against those affected by the illness, organise focusing events to attract political attention, and work more closely with the HIV policy community in order to enhance the recognition of the need to control syphilis on both the national and sub-national agendas. Disclosure of interest statement This study was funded by the Department of Reproductive Health and Research, World Health Organization during the period from September 2011 to August 2012. The views expressed are not necessarily those of UNAIDS.

Timing of Maternal HIV Testing and Uptake of Prevention of Mother-to-Child Transmission Interventions Among Women and Their Infected Infants in Johannesburg, South Africa

By 2011, South African prevention of mother-to-child transmission (PMTCT) of HIV programs had reduced perinatal HIV transmission at 6 weeks of age to 2.7%. We investigated the profile of newly diagnosed vertically infected children and their mothers to identify shortfalls in the PMTCT program. In this operational follow-up study, fieldworkers enrolled mothers of newly diagnosed HIV-infected children up to 2 years of age at 5 major health care facilities in Johannesburg. Structured questionnaires and clinical record reviews were conducted and analyzed to describe the population and assess factors associated with PMTCT uptake. Two hundred eighty-nine mother-child pairs were enrolled. Timing of maternal HIV diagnosis influenced PMTCT access and feeding choices and was associated with infants' age at HIV diagnosis (7 vs. 11 vs. 31 weeks where mothers tested before, during, or after the pregnancy, respectively; P < 0.0001). Women diagnosed before pregnancy (12%) were older (median, 31 years) than those diagnosed during the index pregnancy (53%; median, 27 years). Women diagnosed after delivery (35%) were younger (median, 25 years, P < 0.0001), of lower parity, and less likely to be South African citizens. In 81 cases (29%), late maternal diagnosis precluded any PMTCT access. Where women were diagnosed during or before pregnancy, the recommended PMTCT guidelines for mother and infant were followed in 86 (61%) pairs. Failure to diagnose maternal HIV infection before delivery was the main reason for missing PMTCT prophylaxis and early infant testing. Timely maternal diagnosis enables PMTCT uptake, but implementation and follow-up gaps require attention to improve infant outcomes.

Elimination of mother-to-child transmission of HIV in South Africa: Rapid scale-up using quality improvement

South Africa (SA) is committed to achieving the goal of eliminating mother-to-child transmission (MTCT) of HIV by 2015. To achieve this, universal coverage of quality antenatal, labour, delivery and postnatal services for all women has to be attained. Over the past decade, the prevention of mother-to-child transmission (PMTCT) programme has been scaled up to reach all healthcare facilities in the country. However, challenges persist in achieving 100% coverage and access to the programme. We describe the process undertaken by the National Department of Health (NDoH), in collaboration with partners, to develop, implement and monitor a data-driven intervention to improve facility, district, provincial and national PMTCT-related performance. Between 2011 and 2013, the NDoH developed and implemented an intervention using data-driven participatory processes to understand facility-level bottlenecks to optimise PMTCT implementation and to scale up priority PMTCT actions nationally. There was remarkable improvement across all key indicators in the PMTCT cascade over the 3 years 2011-2013. Simple monitoring tools such as a visual dashboard and data for action reports were successfully used to improve the performance of the PMTCT programme across SA. MTCT has shown a significant downward trend. It is feasible to implement district-level, data-driven quality improvement processes at a national scale to improve the performance of the PMTCT programme at the local level.

Improving a Mother to Child HIV Transmission Programme through Health System Redesign: Quality Improvement, Protocol Adjustment and Resource Addition

BackgroundHealth systems that deliver prevention of mother to child transmission (PMTCT) services in low and middle income countries continue to underperform, resulting in thousands of unnecessary HIV infections of newborns each year. We used a combination of approaches to health systems strengthening to reduce transmission of HIV from mother to infant in a multi-facility public health system in South Africa.Methodology/Principal FindingsAll primary care sites and specialized birthing centers in a resource constrained sub-district of Cape Metro District, South Africa, were enrolled in a quality improvement (QI) programme. All pregnant women receiving antenatal, intrapartum and postnatal infant care in the sub-district between January 2006 and March 2009 were included in the intervention that had a prototype-innovation phase and a rapid spread phase. System changes were introduced to help frontline healthcare workers to identify and improve performance gaps at each step of the PMTCT pathway. Improvement was facilitated and spread through the use of a Breakthrough Series Collaborative that accelerated learning and the spread of successful changes. Protocol changes and additional resources were introduced by provincial and municipal government. The proportion of HIV-exposed infants testing positive declined from 7.6% to 5%. Key intermediate PMTCT processes improved (antenatal AZT increased from 74% to 86%, PMTCT clients on HAART at the time of labour increased from 10% to 25%, intrapartum AZT increased from 43% to 84%, and postnatal HIV testing from 79% to 95%) compared to baseline.Conclusions/SignificanceSystem improvement methods, protocol changes and addition/reallocation of resources contributed to improved PMTCT processes and outcomes in a resource constrained setting. The intervention requires a clear design, leadership buy-in, building local capacity to use systems improvement methods, and a reliable data system. A systems improvement approach offers a much needed approach to rapidly improve under-performing PMTCT implementation programmes at scale in sub-Saharan Africa.

An audit of PMTCT services at a regional hospital in South Africa

SA Fam Pract 2009;51(6):492-495 Prevention of mother-to-child transmission (PMTCT) is a major intervention world-wide in the fight against the HIV pandemic, and has resulted in markedly reduced rates of mother-to-child transmission rates in well-resourced countries. However, it seems that barriers to implementation of the programme exist at all levels of health care at all facilities providing maternal care. Aim: To conduct a clinical audit of the PMTCT programme at a regional hospital in Pietermaritzburg, KwaZulu-Natal, South Africa. Methods: Data was collected from an analysis of antenatal and medical records of women who attended antenatal care and delivered at the regional hospital between January and December 2007. Only pregnant women who attended antenatal care at this regional hospital and delivered in its facilities were selected for the study. Patients eligible for review were identified using the labour ward delivery log book. Results: Of the 499 records analysed, 479 women (96%) were offered testing, of which 473 accepted. Of those tested, 227 (48%) were HIV positive. Only 15 (6.1%) of the 246 who tested negative were re-tested. CD4 counts were done for only 159 (70%) of the 227 HIV-positive women. More importantly, only 134 (84.3%) received their results. Of the 227 HIV-positive women, only 131 (57.7%) were given 200 mg nevirapine at ≥ 28 weeks gestation (to take home and swallow once they had strong labour pains); 185 (81.5%) took nevirapine before delivery (i.e. the total number of both those that took NVP 2hrs) 143 (77.3%) took nevirapine > 2 hours before delivery and 84 (37%) took nevirapine < 2 hours before delivery. Of the babies, 208 (91.6%) were given nevirapine within 72 hours. Discussion: This audit shows that progress has been made in the implementation of PMTCT of HIV at this regional hospital by the high uptake of HIV testing; however, barriers to full implementation are caused by the lack of integration of testing, counselling and obtaining CD4 count results.

The impact of scaling‐up prevention of mother‐to‐child transmission (PMTCT) of HIV infection on the human resource requirement: the need to go beyond numbers

Although the mother-to-child transmission (MTCT) contributes only 5% of transmission of HIV infection, its impact has reversed the decline in infant and child mortality rates. With antenatal service coverage of over 90%, the integration of prevention of MTCT (PMTCT) of HIV infection into the Reproductive and Child Health (RCH) services in Tanzania, this is likely to overstretch the staff capacity and undermine the already compromised quality of health care services. A retrospective study was conducted to assess the impact of integrating and scaling-up PMTCT of HIV infection into routine RCH services, on the magnitude of staff workload in RCH clinics. The study was conducted in 60 health facilities identified from five regions that had participated in the pilot phase of PMTCT implementation in the Mainland Tanzania. The average staff workload was calculated from staff-load obtained from attendance records and activity-time obtained by direct observation; and staff-time from records that were kept at the clinic. The average staff workload was found to be 50.5% (8-147%) for facilities providing PMTCT of HIV infection and 37.8% (11-82%) for facilities without PMTCT services. The average staff workload was computed on the assumption that all clients attending various antenatal clinics received PMTCT services from trained staff only and the result revealed staff workload of 87.2%. This study concludes that services for PMTCT of HIV infection can easily be scaled-up and integrated into RCH services using the already existing staff. In the wake of the human resource crisis in the health sector in developing countries, strategies to address the problem will need to go beyond numbers to address issues of staff productivity and their distribution.

The Time to Treat the Children Is Now

As the HIV pandemic spreads through regions of the world it takes a particularly discouraging toll on children and young adults-our collective future. Infants and children born to HIV-infected parents face a double threat: if they escape the 25%-40% risk of HIV infection through perinatal and breast-feeding exposure they remain at high risk for losing one or both parents to the disease. Of the 39.5 million people estimated to be living with AIDS globally as of December 2006 2.3 million were < 15 years old with ~530000 youngsters (1500/day) newly infected during the past year. Perhaps the greatest advance in HIV-related public health has been the use of antiretrovirals (ARVs) for the prevention of mother to child transmission (PMTCT). The initial report of the complex use of zidovudine by mother-infant pairs in the landmark AIDS Clinical Trials Group 076 study and the subsequent report of a simple single-dose nevirapine regimen used in HIV Network for Prevention Trial 012 and of many useful variations on these 2 models that followed have transformed PMTCT practices. Although partnerships between governments and nongovernmental organizations have developed broad PMTCT implementation programs significant limitations regarding penetration and uptake on a population scale remain to be solved. The result is a constant expansion of the ranks of HIV-infected children with recently infected newborns and young infants. (excerpt)

Antenatal HIV testing in rural eastern Uganda in 2003: incomplete rollout of the prevention of mother-to-child transmission of HIV programme?

BackgroundUganda began to implement the prevention of mother-to-child transmission (PMTCT) of HIV programme in 2000, and by the end of 2003 it had expanded to cover 38 of the 56 districts including Mbale District. However, reports from Mbale Hospital showed that less than 10% of pregnant women accepted antenatal HIV testing. We therefore conducted a study to determine the proportion of pregnant women who tested for HIV and the gaps and barriers in PMTCT implementation.MethodsThe study was a cross sectional household survey of women aged 18 years or more, with children aged one year or less, who resided in Mbale Town or in the surrounding Bungokho County. We also conducted in-depth interviews with six health workers in Mbale Hospital.ResultsIn 2003, we interviewed 457 women with a median age of 24 years. The prevalence of antenatal HIV testing was 10 percent. The barriers to antenatal HIV testing were unavailability of voluntary counselling and testing services (44%), lack of HIV counselling (42%) and perceived lack of benefits for HIV infected women and their infants. Primipara (OR 2.6, 95% CI 1.2–5.8), urban dwellers (OR 2.7, 95% CI 1.3–5.8), women having been counselled on HIV (OR 6.2, 95% CI 2.9–13.2), and women with husbands being their primary confidant (OR 2.3, 95% CI 1.0–5.5) were independently associated with HIV testing.ConclusionThe major barriers to PMTCT implementation were unavailability of PMTCT services, particularly in rural clinics, and poor antenatal counselling and HIV testing services. We recommend that the focus of the prevention of mother-to-child transmission of HIV programme should shift to the district and sub-district levels, strengthen community mobilization, improve the quality of antenatal voluntary counselling and HIV testing services, use professional and peer counsellors to augment HIV counselling, and ensure follow-up care and support for HIV positive women and their infants.