PMTCT, and National's - Health Systems Trust

An Evaluation of the Prevention of Mother-to-child Transmission
(PMTCT) of HIV Initiative in South Africa:
Lessons and Key Recommendations
WRITTEN BY:
Tanya Doherty, Mitchell Besser, Steven Donohue, Nelson Kamoga, Norah Stoops, Louisa
Williamson and Ronel Visser
REVIEWED BY:
Lilian Dudley, Peter Barron, David McCoy and Jaine Roberts
September 2003
ISBN#: 1-919743-75-8
This publication is also available on the Internet
www.hst.org.za
This report has been produced by the Health Systems Trust for the National Department of
Health. The research and this report were funded by the National Department of Health (South
Africa).
Health Systems Trust
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The information contained in this publication may be freely distributed and reproduced, as long
as the source is acknowledged, and it is used for non-commercial purposes.

Acknowledgements: This report would not have been possible without the co-operation
and support of many individuals in the national and provincial Departments of Health. Provincial
and District PMTCT co-ordinators facilitated access to the research sites and were co-operative
and supportive of the evaluation. To the many health workers who allowed us to visit facilities and
evaluate the programme, your dedication to PMTCT and willingness to share your experiences is
deeply appreciated. Individuals from the national Department of Health, especially Dr Nono
Simelela and Ms Sesupo Makakole-Nene, have been supportive and have provided valuable input
at various stages of the research. We would also like to acknowledge the support received from
the HST research sub-committee; namely Dr Zola Njongwe, Professor Craig Househam and
Professor Eric Buch.
The national PMTCT evaluation and research framework was developed by Dr David McCoy
together with the National Department of Health. This framework made provision for two evaluations
of the PMTCT programme, a national PMTCT cohort study as well as a number of sub-studies.
Dr McCoy’s initiation and co-ordination of the PMTCT research studies has been key in ensuring
the successful completion of these projects.
The efforts of Candy Day and Halima Hoosen in the HealthLink programme in the final review
and layout of this report are greatly appreciated.
The infant testing component of section 6.3 (Infant Testing and Outcomes) was written by Dr Gayle
Sherman, Mr Grant Napier and Dr Wendy Stevens of the Department of Molecular Medicine and
Haematology, National Health Laboratory Service and University of the Witwatersrand.
Contributions to the section 6.6.2 (Management of Information for PMTCT) were received from
Louisa Williamson and Norah Stoops of the Health Information Systems Programme, University
of the Western Cape.
Abbreviations used in this publication:
ATICC
BFHI
CHC
CCLO
DoH
HIV
HST
HISP
IEC
ISDS
MCWH / MCH
MOU
NAPWA
NGO
NVP
PHC
PMTCT
PWA
SAINT
TAC
UNICEF
VCT
WHO
AIDS Training, Information and Counselling Centre
Baby Friendly Hospital Initiative
Community Health Centre
Chief Community Liaison Officer
Department of Health
Human Immunodeficiency Virus
Health Systems Trust
Health Information Systems Programme
Information, Education and Communication
Initiative for Sub-District Support
Maternal, Child (and Women’s) Health
Midwife Obstetric Unit
National Association of People With AIDS
Non-Government Organisation
Nevirapine
Primary Health Care
Prevention of Mother-to-Child Transmission
People living With AIDS
South African Intrapartum Nevirapine Trial
Treatment Action Campaign
United Nations Children’s Fund
Voluntary Counselling and Testing
World Health Organisation
Provinces:
EC
FS
GT
KZN
LP
MP
NC
NW
WC
Eastern Cape
Free State
Gauteng
KwaZulu-Natal
Limpopo
Mpumalanga
Northern Cape
North West
Western Cape

CONTENTS
1. Executive summary
2. Introduction
3. Methodology and Design
4. Overview of Sites
5. Description of Routine Indicators
6. Key Findings and Recommendations
6.1 Antenatal Counselling and Testing
6.2 Dispensing of Nevirapine to Mothers and Infants
6.3 Infant Testing and Outcomes
6.4 Maternal and Infant Follow Up
6.5 Infant Feeding
6.6 Health Care Infrastructure
6.6.1 Human Resources
6.6.2 Management
6.7 Scaling up and Integrating PMTCT Initiatives
Page Number
1
5
6
8
10
13
14
23
26
34
37
48
65

BACKGROUND TO THE REPORT
EXECUTIVE SUMMARY
A decision was made by the National Department of Health at the end of 2000 to implement
two PMTCT pilot sites in each province of South Africa. Health Systems Trust was subsequently
commissioned to evaluate progress with implementation in the pilot sites, and released a report
in February 2002 covering the period January to December 2001.
This second and final evaluation report on the PMTCT pilot sites builds on the previous one,
and describes progress made between January and December 2002 in the same 18 pilot
sites. This study forms part of the national research framework for the PMTCT programme,
and reference is made in sections of the report to work conducted in other components of the
overall PMTCT research.
The focus of this report is on the performance of the original pilot sites, but attempts are made
to describe the process underway in each of the provinces to expand this programme beyond
the pilot sites. This evaluation also assesses whether lessons learnt and problems identified
from the first evaluation have been addressed.
PERFORMANCE OF THE PMTCT PILOT SITES
Coverage
The 18 PMTCT pilot sites achieved a coverage of approximately 9% (84406/901882) of the
total antenatal bookings in the public sector in 2002, which represents the same coverage
in these sites as found in 2001. The total national coverage for PMTCT exceeds this figure as
some Provinces managed to extend PMTCT beyond the pilot sites during this same time period,
with KwaZulu-Natal and Western Cape achieving high levels of Provincial coverage. The 9%
figure therefore represents a conservative estimate of national PMTCT coverage in South Africa
in 2002.
Voluntary Counselling and Testing (VCT)
VCT provides an entry point to the PMTCT programme, and as PMTCT cannot be delivered
without effective VCT (including specialised counselling on the implications of PMTCT for both
mother and infant), it is assessed as a key component of implementation of PMTCT in the pilot
sites.
The uptake of HIV testing within the pilot sites has differed greatly, with some sites achieving
high uptake and others consistently low uptake. This has influenced overall programme
effectiveness in the provinces. The average testing uptake rate across the 18 pilot sites is 56%
(46910/84406), a slight increase on the 51% found in the first evaluation period. There are
large differences between provinces in the uptake of HIV testing (ranging from 14% to 92%).
Several factors were identified which could have contributed to these differences, including
access to training, the availability of lay counsellors, and the quality of counselling provided.
HIV test results were received by 85% (39733/46910) of women who agreed to an HIV test.
This is very encouraging and suggests that rapid tests are being used and that results are most
likely available the same day as testing.
HIV prevalence
The average HIV positive rate amongst pregnant women tested in the pilot sites is 30%
(14340/46910), which is the same rate as found in the first evaluation period. This figure is
slightly higher than the National HIV sero-prevalence amongst women attending public
antenatal services of 26.5% in 2002 1 . These two rates cannot be compared as the methods
utilised to capture this information were different. The national antenatal sero-prevalence
survey is an anonymous, unlinked cross sectional survey, whereas in the PMTCT pilot sites
only women who consented to be tested for HIV were included in this data item. In addition,
the PMTCT pilot sites were specifically chosen because of their situation in high HIV prevalence
areas.
1

Dispensing of Nevirapine
Nevirapine was dispensed to an average of 55% (7853/14340) of HIV positive pregnant
women who booked at the PMTCT pilot facilities during 2002. The 2001 evaluation estimated
that nevirapine was dispensed to 30% of such women, suggesting an overall increase in
dispensing. This is unfortunately an unreliable indicator of nevirapine coverage as nevirapine
was dispensed in a variety of facilities and levels of care (antenatal clinics and hospital labour
wards) to which these women had access and for which data could not always be accessed.
Nevirapine administration to newborns was much higher with 99% (7932/7950) of infants
born to HIV positive women in the pilot sites receiving nevirapine. As nevirapine is usually
dispensed to the infant in the pilot facility or ward after delivery, this may provide a more
accurate reflection of antiretroviral coverage. However, it may also hide missed opportunities
as the indicator only includes women who were identified as being HIV positive in labour.
Given the low rate of dispensing of nevirapine to women, it is likely that a significant number
of women do not disclose their status to labour ward staff.
Infant Feeding
An average of 58% (4196/7237) of HIV positive women expressed an intention to practice
exclusive formula feeding, and an average of 42% (3041/7237) of HIV positive women
intended to practice exclusive breastfeeding. These rates differ substantially between provinces
and study findings suggest that these differences are influenced by institutional or facility
policies and staff training.
The finding in most provinces is that formula feeding intention rates have decreased since the
first evaluation. In the Free State formula feeding intention rates have decreased from 73%
to 36%. In KwaZulu-Natal a similar decrease has been seen from 53% to 41%. The only
province showing an increase in formula intention rates across both sites is the Eastern Cape
where the rate increased from 62% to 80%.
Study findings suggest that the decrease in intentions to formula feed and increase in the
intentions to breastfeed are due to more than one factor, including increased infant feeding
counselling training during 2002, as well as unreliable supplies of formula to facilities,
particularly feeder clinics in certain sites.
Infant Follow Up and Infant Testing
This cross sectional study was not intended or designed to follow up infants. However, attempts
were made to record follow up of infants delivered in these sites during the full period of
implementation of PMTCT to identify operational issues related to the ability of services to
follow up mothers and infants. Information is provided on follow up but must be interpreted
with caution. A cohort study is currently underway to assess vertical transmission and will be
reported on separately.
A total of 1907 live infants were born to HIV positive women in the sites between April 2001
and March 2002, and were due for follow up visits and testing (9 month and 12 month testing)
between January and December 2002. Of these a total of 949 infants were tested for HIV
in the pilot sites which translates to a follow up rate of 50%. Of these, 18% tested HIV positive.
However, this figure cannot be extrapolated to the full cohort, as no information is available
on the other 50%, for whom seroconversion could be vastly different for a variety of reasons.
No information is available either on infant feeding practices of the infants for whom follow
up tests were conducted.
2

HEALTH CARE INFRASTRUCTURE
Human Resources
Counselling
Lay counsellors are central to the PMTCT programme. Attempts have been made by all provinces
to employ lay counsellors; however, several difficulties have been experienced and some pilot
sites remain without counsellors. The employment conditions, remuneration, training and
supervision of lay counsellors differ greatly between provinces. Monthly salaries range from
R500 to R2900. It is evident from the results that provinces in which lay counsellors are better
paid, achieve higher testing uptake rates (e.g. KwaZulu-Natal and the Western Cape). In
addition, low counsellor salaries have resulted in high rates of counsellor turnover and the
need for constant re-training.
Health Worker Training
Provinces have adopted various approaches to training health workers on PMTCT. The most
widely used approach is the UNICEF/National DoH supported PMTCT and infant feeding
counselling course. This is a 5-day residential training course that focuses on infant feeding
counselling and filled a gap that other training courses neglected to cover adequately.
The Western Cape and the Free State developed an on-site training course focusing on the
PMTCT protocol and operational issues. Courses typically last 2 days. This approach enabled
more health workers to be trained on crucial operational issues in a short period of time. The
main difference between the two approaches is that the UNICEF/National DoH training aimed
to develop trainers and infant feeding counsellors whereas the Western Cape and Free state
aimed to prepare staff to implement services.
Management
Information management
The move from an intensive research oriented information system for the pilot sites to a limited
information system integrated into the national essential primary health care dataset for the
expanded programme is proving difficult. Many provinces are still collecting the full research
dataset using numerous registers. This has resulted in virtually no data being available outside
of the pilot sites as health workers are simply too busy to collect the information. Approval
has been given for PMTCT data to be incorporated into the national essential primary health
care dataset; however, implementation appears slow.
Management of drugs and supplies
The evaluation found evidence of disruptions in the supply of test kits, nevirapine and formula
milk in some provinces. This was due to a variety of reasons including the separation of PMTCT
drugs and supplies from other essential primary level medicines, inadequate district and
provincial capacity to manage this procurement, short expiry limits of nevirapine tablets and
syrup, and poor quality of one particular type of testing kit resulting in delays when stocks
had to be returned to the depots.
Nevirapine is currently not on the Essential Drug List. Although registered as a Schedule 4
medicine, it is handled as a controlled substance (Schedule 5) in all facilities offering PMTCT
services. This system is time-consuming for health workers, unnecessarily bureaucratic and
may limit access to the drug.
These problems influenced the number of women who participated in the programme. Greater
involvement of the National Health Laboratory Service is needed to ensure regular quality
control of rapid test kits. Furthermore, the planning for national antiretroviral treatment should
weigh the need for security and documentation against the need for systems that are convenient
and simple.
3

SCALING UP THE PMTCT PROGRAMME
There have been attempts to scale up the PMTCT programme beyond the pilot sites in all
provinces. The greatest coverage exists in the Western Cape and KwaZulu-Natal, where
comprehensive, phased expansion plans have been developed and additional funding allocated.
In other provinces, the focus has remained on improving the functioning of the pilot sites.
This has resulted in well-resourced provinces with access to technical and academic expertise,
wide NGO networks and strong local government, achieving success and rapid expansion,
whilst less resourced provinces continue to struggle to provide a basic service even at the pilot
sites. Human resources and facility infrastructure require ongoing investment to provide
communities with basic services. This report recognizes that many of the existing challenges
to the effective and wide-scale provision of PMTCT should be resolved through strengthening
the health system and human resource capacity at various levels. Moreover, a more planned
approach to scaling up of the programme would ensure greater sustainability and coverage
and allow PMTCT to serve as a vehicle for improving maternal and child health care.
KEY CHALLENGES AND RECOMMENDATIONS
1. The pilot sites have demonstrated that it is feasible to implement PMTCT in South Africa,
but have also identified numerous operational challenges for establishing and
expanding a PMTCT programme under routine health service conditions. These
challenges should be addressed as a matter of priority for the pilot sites, particularly
those that are not performing adequately. However, these challenges are not
insurmountable, and with the necessary leadership, planning and resource allocation,
can be addressed to make full expansion of PMTCT in South Africa a reality.
2. Strong leadership and management are needed at both provincial and national
levels, to address existing shortcomings in pilot sites, and for expansion beyond these
sites. Financial resources were made available by the National DoH to strengthen
provincial capacity for PMTCT, but often the appointments made were not at a sufficiently
senior level, and many had inadequate technical expertise required for this task.
Provinces and National DoH need to address this jointly to ensure that each province
has the required dedicated leadership and management capacity to support PMTCT
implementation.
3. A clear policy framework and updated national implementation guidelines are urgently
needed on key issues such as infant feeding, and infant testing. The evaluation has
provided insights into infant feeding choices, availability of free formula at facilities
and support systems to promote safe infant feeding. The continued supply of free
formula in a scaled up PMTCT programme needs re-consideration at national and
provincial levels, with specific attention to issues of equity, duration for which free
formula is provided, the quality of counselling provided, effects on the infant feeding
practices of HIV positive and HIV negative women and on child health outcomes.
4. Human resource capacity to provide the additional requirements for PMTCT, in particular
counselling and testing, and training and support of professional staff, needs to be
addressed. The availability of lay counsellors has in several of the pilot sites eased
the workload of nurses and improved the uptake of HIV testing amongst pregnant
women. National policy is required to clarify the role and responsibilities of, and the
employment and remuneration of lay counsellors for HIV care.
5. Completion of the data for the PMTCT pilot sites has been demanding on health service
providers, and has not necessarily provided useful data for local management and
service delivery. Essential PMTCT data, as approved by NHISSA, should be the only
items collected at all facilities. These items should be incorporated into the district
health information system, so that it can flow through the same channels as all PHC
data. The expanded research data items collected in the 18 pilot sites, should only
be collected for specific research purposes, and discontinued once this research has
been completed.
REFERENCES
1. National Department of Health. National HIV and Syphilis antenatal sero-prevalence
survey in South Africa 2002. Pretoria, National Department of Health, 2003.
4

INTRODUCTION
Implementation of a pilot programme for the prevention of mother-to-child transmission (PMTCT)
of HIV commenced in early 2001 in South Africa following a National government decision
in late 2000. A total of 18 pilot sites, two in each of the 9 provinces, were selected using
broad criteria including high HIV prevalence, representation of urban and rural health services,
and primary and secondary level facilities. These served as research and learning sites to
assess the feasibility of implementing this programme more widely. In May 2002, the
Constitutional Court of South Africa ruled that nevirapine should be available to all HIV positive
pregnant women and their infants, who give birth in any public sector facility. There has
subsequently been a gradual and steady expansion of the PMTCT programme beyond the
original pilot sites.
In February 2002, an ‘Interim evaluation report of the PMTCT pilot programme’ covering the
period January to December 2001, was released by the Health Systems Trust. The interim
evaluation focussed mainly on operational challenges involved with the implementation of the
pilot sites. The main challenges associated with programme implementation were found to
be health systems issues relating to poor infrastructure within the health system. It was
emphasised that any expansion of PMTCT activities should occur simultaneously with general
health system strengthening, particularly in rural, under resourced areas, to avoid widening
the inequities between provinces.
This report presents progress during the second year of the pilot programme, over the period
January to December 2002, and documents experiences and key challenges associated with
the pilot sites, and initial attempts to expand this programme beyond the pilot sites. A focus
of this evaluation has been to assess whether the lessons learnt and problems identified in the
first evaluation have been addressed.
The specific areas of programme functioning that this evaluation covers include:
• National and provincial leadership and management
• Human resource management
• PMTCT training
• PMTCT programme uptake
• Information management
• Infant feeding
• Maternal and infant follow up
This report draws on the experiences of the pilot sites and is specifically structured to highlight
the strengths and weaknesses of the provincial programmes in order for best practices to be
identified and for the report to serve as a basis for improvement. Specific areas of programme
functioning were selected for discussion in order to develop key recommendations.
5

AIM OF THE EVALUATION
METHODOLOGY AND DESIGN
The overall aim of the evaluation was to assess the performance and uptake of the PMTCT
programme in the eighteen pilot sites and to describe the processes underway in the provinces
to expand the PMTCT programme beyond the original pilot sites.
SPECIFIC OBJECTIVES
• To assess implementation of the components of the programme in the original pilot
sites.
• To assess uptake of the programme components in the pilot sites.
• To analyse routine information collected in the 18 PMTCT pilot sites.
• To evaluate PMTCT management at the provincial and national level.
• To describe progress with the scaling up of PMTCT services in nine provinces.
• To make policy recommendations to enhance the functioning of PMTCT services.
RESEARCH DESIGN
The evaluation utilised a cross-sectional design that incorporated both qualitative and quantitative
research methods. The evaluation covers the period January to December 2002. Data was
collected at district, provincial and national levels by one HST staff member and three external
consultants. Two of the researchers were also involved in the first evaluation.
SAMPLING FRAME
In each of the nine provinces one pilot site hospital and one feeder clinic were visited. The
same hospital and clinic that were visited for the first evaluation (covering the period January
to December 2001) were selected for this repeat evaluation in order to assess progress over
time.
DATA COLLECTION METHODS
Data collection methods utilised in this evaluation included individual interviews, document
review, participant observation and review of routine monthly PMTCT data.
Two questionnaires were developed for the evaluation, one for the facility level, and the other
for the provincial level. The site questionnaire addressed management, training, counselling
and testing, antenatal care, infant feeding, monitoring and follow up, procurement of supplies
and community involvement. The provincial questionnaire addressed provincial management,
information management, plans for expansion of the programme, and expenditure.
At the facilities visited, individual interviews were conducted with health care workers (mostly
midwives) in contact with antenatal clients, lay counsellors, nutrition advisors, hospital matrons
and doctors. Individual interviews were conducted at the provincial level with the HIV director,
PMTCT co-ordinator, MCWH co-ordinator and information officers. A review of documentation
such as provincial roll-out plans, training plans, and financial reports was also undertaken.
In order to ensure standardisation amongst researchers, the same tools were used in all
provinces and the same categories of health workers were interviewed across all provinces.
6

In order to evaluate national and provincial management of the programme, ongoing participant
observation was undertaken through attendance at national and provincial level PMTCT
meetings throughout the period of the evaluation.
All routine data was collated by consultants from the Health Information Systems Programme
(HISP) who were sub-contracted by HST. This data was entered into and analysed using the
District Health Information System (DHIS) Software.
The research team met on three occasions during the course of the research in order to address
issues of quality control and to ensure consistency in the application of the tools and interpretation
of findings. In addition, every attempt was made to validate routine provincial data collected
by the HISP consultants. This was done through review of registers during site visits and
attendance at national steering committee meetings where provincial data was presented.
LIMITATIONS OF THE EVALUATION
1. Definitions of expansion differed between provinces and the information collected was
not always verifiable. Verifying provincial reports of expansion proved difficult, as the
researchers were unable to visit each facility that was considered by the province to
be a PMTCT site. Therefore, information provided by the provincial HIV directorates
had to be relied on. Furthermore, the definitions of expansion differed from province
to province, and this had to be accepted by the researchers. Some provinces considered
a facility with supplies of nevirapine to be offering PMTCT whilst others considered
a facility to be operational only once lay counsellors were employed, formula supplied
and staff trained.
2. The use of routine data for the evaluation also posed problems as there were many
difficulties with data quality. Data was collected through registers designed by the
National HIV Directorate and in some cases provincial HIV directorates. Registers
were completed by health workers at the sites and data was entered by district and
provincial information officers. The researchers had little control over the data collection
tools, data entry or data flow. Every attempt has been made to correct errors in the
data; however, given the constraints raised there may still be some inaccuracies.
7

OVERVIEW OF THE PMTCT PILOT SITES
*Sites highlighted in blue were visited for this evaluation
Province
Site
East London Complex
Frere Hospital and 29 clinics, Cecilia Makiwane Hospital and
19 clinics.
Umzimkulu Sub-district
Rietvlei Hospital and 12 clinics (many of which are small, isolated,
under-resourced and understaffed)
Virginia
Virginia Hospital and 8 clinics
Frankfort
Frankfort Hospital and 8 clinics
Natalspruit
Natalspruit hospital and J. Dumane CHC
Kalafong
Kalafong Hospital and Pretoria West antenatal clinic
Durban
King Edward VIII Hospital and Kwamashu Polyclinic, Prince
Mysheni Hospital and feeder clinics in section D and K, Umlazi
Pietermaritzburg
Grey’s Hospital, Northdale Hospital and Sabantu and Northdale
clinics, Edendale Hospital and Imbalenhle and Taylors Halt clinics,
Church of Scotland Hospital, Tugella Ferry.
Date PMTCT Services
Began
July 2001
July 2001
July 2001
August 2001
May 2001
June 2001
June 2001
July 2001
Average number of first
antenatal bookings in
the pilot sites per month,
2002
1252
83
211
152
558
226
1100
450
Average number of
first antenatal
bookings in the
province per month
10 725
4794
11 152
20 200
KwaZulu-Natal
Gauteng
Free
State
Eastern
Cape
8

Mankweng
Mankweng Hospital and 19 clinics (many of which are small,
isolated, under-resourced and understaffed)
Siloam
Siloam Hospital and 17 clinics (some of which are small, isolated,
under-resourced and understaffed).
Shongwe
Shongwe Hospital and 23 surrounding clinics (many of which
are small, isolated, under-resourced and understaffed)
Evander
Evander Hospital, Lebohang CHC and Embalenhle clinic
Thlabane
Thlabane Health centre and 4 clinics
Lehurutshe
Lehurutshe District Hospital and 21 surrounding clinics
Galashewe
Galashewe Day Hospital, Kimberley Hospital, Masakhane clinic
and Roodepan clinic
De Aar
De Aar Day Hospital, Motana clinic, Amalia clinic, Nomzwakazi
clinic and one CHC
Guguletu
Guguletu MOU and 8 clinics in Nyanga district
Paarl
Paarl Hospital, T.C Newman CHC and 17 surrounding clinics
Aug 2001. Service started
in 6 clinics. Extended to 13
clinics in December 2001
Mid-Nov 2001
Sept 2001 at Shongwe
hospital. Few of the clinics
have counselling and
testing services due to lack
of counsellors
October 2001
July 2001
July 2001
August 2001
August 2001
Jan 2001
May 2001
508
256
30
158
851
306
166
50
338
289
11 475
6904
6321
1631
7507
Western
Cape
Northern
Cape
North
West
Mpumalanga
Limpopo
9

DESCRIPTION OF ROUTINE PMTCT INDICATORS
PRESENTED IN THIS REPORT
Indicator
HIV testing rate
amongst
pregnant
women
HIV test results
received rate
HIV positive rate
amongst
pregnant
women tested
Formula for calculation
Num: Number of
pregnant women who
have an HIV test
Den: Number of first
antenatal visits / bookings
Num: Number of
pregnant women who
receive an HIV test result
Den: Number of
pregnant women who
have an HIV test
Num: Number of HIV
positive test results
Den: Number of
pregnant women who
have an HIV test
Definition
This indicator measures the proportion
of antenatal clients who agree to be
tested for HIV. It should also include
women tested post partum prior to
discharge.
This indicator measures the proportion
of antenatal clients who are tested
for HIV that receive their test results
(it includes both positive and negative
test results).
This indicator measures the proportion
of pregnant women who test positive
for HIV from amongst those who
accept to be tested.
Explanatory notes
The determination of first ANC visits in urban sites is complex
as many cases are referred after booking, thus in some sites,
first visits can represent the first time a women accessed testing
rather than the first antenatal visit.
In terms of policy, HIV testing is only done after pre-test
counselling, thus low testing rates may be indicative of poor
counselling infrastructure.
Although the data in this report indicates a high proportion
of test results received, staff were generally concerned about
the lack of organisational infrastructure to ensure that women
received test results.
The prevalence rates amongst women attending the pilot sites
are in many instances higher than the rate in the annual
antenatal sero-prevalence survey. It is important to note that
the pilot sites were selected because they are in high HIV
prevalence areas therefore these high rates are not totally
unexpected.
10

Nevirapine
(NVP)
dispensing rate
to HIV positive
pregnant
women
Num: Number of
nevirapine tablets
dispensed to pregnant
women with HIV
Den: Number of
antenatal clients testing
HIV positive
This indicator measures the
proportion of HIV positive pregnant
women who receive nevirapine.
This indicator is a rather inaccurate measure of nevirapine
coverage of to pregnant women with HIV. No distinction
has been made between NVP dispensed in the antenatal
clinic setting and NVP administered in the labour ward
setting therefore double counting can occur. The denominator
for this indicator is the number of HIV positive test results,
however, many of the women who test positive for HIV may
not deliver in the same month therefore it is not possible to
accurately measure whether nevirapine was actually taken
by each HIV positive woman in labour. This indicator is
simply a broad measure of nevirapine tablets utilised in
the system and it should not be used as a measure of
programme effectiveness. The data should be derived from
pharmacy inventory records rather than clinic and hospital
registers.
11

Nevirapine
(NVP)
dispensing rate
to newborns
Num: Doses of
nevirapine syrup
dispensed to newborns of
HIV positive women.
Den: Number of live births
to HIV positive women
Breastfeeding
intention rate
Num: Number of HIV
positive women intending
to exclusively breastfeed
Den: Number of live births
to HIV positive women
Formula feeding
intention rate
Num: Number of HIV
positive women intending
to exclusively formula feed
Den: Number of live births
to HIV positive women
This indicator measures the
proportion of newborns who receive
nevirapine syrup
This indicator measures the
proportion of HIV positive women
who indicate at the time of discharge
that they intend to exclusively
breastfeed their infants. This is not
a measure of actual practice.
This indicator measures the
proportion of HIV positive women
who indicate at the time of discharge
that they intend to exclusively formula
feed their infants. This is not a
measure of actual practice.
It is important to note that this represents treatment coverage
only in infants of women who have been identified as being
HIV positive, therefore missed opportunities are not included.
This rate will be inaccurate when two doses of nevirapine
are administered to babies born to mothers that are untreated
or inadequately treated or when mothers delivering at home
bring their babies to the labour ward or postpartum ward
for treatment. In these situations proportions in excess of
100% may be found.
Data collected for these elements demonstrated a limited
understanding of their use, thus they must be treated with
caution
Quantitative data collection of intention is of limited value as
it is simply a measure of intentions.
12

KEY FINDINGS AND RECOMMENDATIONS
This section presents the key findings of this evaluation and discussion relating to the main
challenges. The topics covered in this section were chosen because they were identified in the
provincial evaluations as requiring further exploration and discussion. Where appropriate,
examples are drawn from provincial experiences in order to highlight lessons and challenges.
Key recommendations are given at the end of each discussion area.
13

6.1 Antenatal Counselling and Testing
This chapter attempts to highlight the key findings from this evaluation that relate to counselling
and testing services for pregnant women and to raise specific areas that require further
discussion and in some instances policy guidance. Specific issues relating to lay counsellors
will be discussed in a subsequent chapter.
The interim evaluation of the PMTCT programme made specific recommendations about
counselling and testing for PMTCT. These included:
• The creation of a cadre of generic lay health workers with standardised employment
conditions including fair salaries.
• The creation of adequate space within facilities for HIV counselling.
• The broadening of the notion of counselling to include ongoing support beyond the
initial period of testing, and the promotion of couple counselling.
KEY FINDINGS FROM THE EVALUATION
PMTCT Counselling
In most of the facilities visited for this evaluation, antenatal clients are introduced to the
components of the PMTCT programme during a group information session. All first antenatal
clients are therefore informed about the PMTCT programme together. However, in some facilities
this is not done, due either to a shortage of staff, or a low client load which allows for individual
information sessions. In Limpopo, group information sessions are not given and nurses have
argued convincingly that they achieve better communication and testing uptake by concentrating
on one-to-one communication. A cause for concern was the finding that group information
sessions in many provinces include information on formula feeding. This should not be part
of group information to woman prior to testing as it may confuse the general public and
undermine breastfeeding practices.
Following the information session, in most facilities, individual pre-test counselling is offered
and women can decide whether or not to have an individual counselling session. In KwaZulu-
Natal individual HIV counselling is seen as compulsory in order for women to make an
informed choice regarding HIV testing. The presence of lay counsellors in every facility offering
PMTCT in KwaZulu-Natal allows this approach to succeed. The very high uptake of HIV testing
in this province may be related to the approach of providing individual counselling to every
antenatal client.
In many but not all of the facilities offering PMTCT, counselling is performed by lay counsellors.
In Mpumalanga, the Eastern Cape, North West and the Northern Cape there are still problems
with the employment of lay counsellors. In these provinces, most counselling is performed by
nurses with numerous clinical duties. The low uptake of HIV testing in these provinces may
be attributable to the lack of lay counsellors.
In addition to human resource support for counselling, the physical infrastructure of facilities
also impacts on the ability to provide individual, confidential counselling. As with the previous
evaluation, this evaluation found large differences between facilities with regard to physical
space to perform counselling. In some instances rooms have dual purposes, serving as storerooms
and counselling rooms. This results in frequent interruptions during counselling sessions.
Table 6.1.1 includes one facility from each province with an indication of the numbers of lay
counsellors, the numbers of dedicated counselling rooms and the testing uptake rate for 2002.
Clearly some facilities have insufficient dedicated space for counselling. This has implications
for client waiting times and the level of confidence in the ability of a facility to provide a
confidential service, both of which impact on decisions to take an HIV test. The table suggests
that the availability of space for private counselling influences the rate of testing uptake amongst
antenatal clients. In some facilities inadequate space for counselling has led to correspondingly
low rates of testing uptake. Facilities with sufficient space appear to achieve higher testing
uptake rates although the examples of Church of Scotland Hospital in KZN and Natalspruit
Hospital in Gauteng show that a high uptake of HIV testing is possible with constraints on
physical space.
14

Table 6.1.1: Physical space for counselling
Province Facility Average Number of lay
number of first counsellors/ nurse
antenatal visits counsellors
per month
Number of
dedicated
counselling
rooms
Testing
uptake
rate, 2002
Eastern
Cape
Rietvlei
Hospital
83
2 nurse counsellors/
no lay counsellors
2 rooms
86%
Free State
Virginia
Hospital
211
2 lay counsellors
Office used for
counselling
shared with
hospital coordinator
58%
Gauteng
Natalspruit,
Hospital
558
5 lay counsellors
4 rooms
79%
KwaZulu-
Natal
Church of
Scotland,
Hospital
275
4 lay counsellors
3 rooms
83%
Limpopo
Siloam
Hospital
256
3 lay counsellors
2 rooms
57%
Mpumala
nga
Shongwe
Hospital
30
2 nurse counsellors/
no lay counsellors
5 rooms
57%
North
West
Lehurutse
Hospital
306
5 lay counsellors
2 rooms
27%
Northern
Cape
Galeshewe
Day Hospital
(GDH)
166
8 lay counsellors
4 rooms
42%
Western
Cape
Paarl East
Day Hospital
289
5 lay counsellors
5 rooms
99%
HIV Testing
Antenatal testing
All facilities offering PMTCT services use rapid HIV tests. HIV test results are generally available
the same day except in cases of severe staff shortage or stock outs of rapid test kits.
Figure 6.1.1: SA HIV testing rate in the 18 pilot sites, 2002
100
%
80
60
40
20
0
NW EC LP NC FS MP GP WC KZN Average
Figure 6.1.1 shows the percentage of antenatal clients in the 18 pilot sites who agreed to an
HIV test during 2002. The average testing uptake rate across the 18 pilot sites is 56%
(46910/84406).
15

This rate has increased slightly since the first evaluation covering the period January to December
2001 where it was found to be 51%. The graph highlights the large differences between provinces
in the uptake of HIV testing (ranging from 14% in the North West to 92% in KwaZulu-Natal).
In addition to variation between provinces, much variation exists within provinces. For example
in the Eastern Cape, the testing uptake rate in the Rietvlei site is 86% (852/995) whilst the rate
in the East London site is 31% (4602/15025). Various reasons were found for the large differences
between provinces in testing uptake:
• The availability of lay counsellors
The provinces with the smallest drop off between first antenatal visits and women accepting HIV
testing, namely Gauteng, KwaZulu-Natal and the Western Cape, have all prioritised the utilisation
of lay counsellors, either by directly employing them or by contracting NGOs to employ them.
Provinces with low HIV testing uptake such as the North West (14%) and the Eastern Cape (34%)
are still struggling to employ lay counsellors and many of the pilot facilities still rely on nurse
counsellors.
• The counselling strategy adopted in provinces
In some provinces women are given the option to receive individual pre-test counselling whilst
in other provinces such as KwaZulu-Natal, individual counselling is seen as an integral part of
antenatal care and all women receive an individual session with a counsellor. Following this
session a woman can decide whether to be tested for HIV. It appears that this approach increases
the uptake of testing as it may normalise counselling as a part of antenatal care and not associate
it only with testing for HIV.
• Physical space available for counselling
As described above, facilities with insufficient space for counselling appear to have lower testing
uptake rates than facilities that do have sufficient space. This infra-structural constraint should
not be regarded as a reason not to implement PMTCT in a facility. Strengthening of facility
infrastructure should be seen as an ongoing priority to enable effective provision of PMTCT.
• Distribution and technical support for HIV testing
There have been interruptions in the supply of testing kits to many facilities particularly in the
Free State, Eastern Cape and Mpumalanga. These interruptions can result in missed opportunities
for HIV testing. Much of the procurement of supplies still takes place through the national HIV
directorate as they have tenders with specific manufacturers. As the programme expands more
rapidly it will be important for districts and sub-districts to procure their own supplies to avoid
interruptions in service delivery.
There have also been documented false negative results with the Efoora test kit from many
facilities. A decision has been taken by the national Department of Health not to renew the
tender with the manufacturer of this test kit. As the tender decisions have major implications for
delivery of PMTCT in all provinces, a thorough investigative process should be conducted prior
to allocation of tenders using the available expertise, and with the involvement of senior managers
in the National HIV/AIDS Directorate.
Figure 6.1.2: Receipt of HIV test results by clients, 2002
100
%
80
60
40
20
0
GT NW KZN FS MP EC WC LP NC Average
16

HIV test results were received by 85% (39733/46910) of women who agreed to an HIV test.
This is very encouraging and suggests that rapid tests are being used and that results are most
likely available the same day as testing. The reasons for the large proportion of clients who
do not received their test results in Gauteng and the North West should be investigated to
determine whether this is related to stock outs of test kits or a particular policy within these
provinces.
HIV testing in labour and postpartum
This evaluation found that very few facilities are offering HIV testing to women in early labour
or postnatally. This was found to be due in many cases to personal beliefs of nurses regarding
the appropriateness of testing in labour, as well as the lack of lay counsellors in labour and
postnatal wards. The National PMTCT Protocol for the pilot states that women who do not
attend antenatal care and report to a facility in labour should not have access to antiretroviral
drugs because they cannot be adequately counselled and tested. The policy does however
recommend early postpartum testing and infant prophylaxis. The policy regarding counselling
and testing in labour should be reviewed and postnatal testing should be actively encouraged
to prevent missed opportunities for treating infants.
Ongoing counselling and support
It was clear during this evaluation that PMTCT counselling is focussed around pre- and post-
HIV testing and that very little ongoing support is provided. This was due to a lack of human
resources and inability to cope with the demands of counselling for HIV testing. Initiatives do
exist, such as the ‘Mothers-to-Mothers-to-Be’ programme described in appendix 6.1, that have
developed innovative strategies to provide ongoing support to mothers using resources outside
of health facilities. Some facilities have also started support groups, which are dependent on
the availability of facilitators and a suitable venue.
The involvement of local NGOs in ongoing support appeared minimal at most facilities visited
except for the NGO management of facility-based lay counsellors. NGOs can serve as valuable
sources of support for home-based care, infant feeding support and ongoing counselling, and
their involvement in PMTCT services should be encouraged.
KEY ISSUES FOR DISCUSSION
Counselling in the context of PMTCT
For pregnant women to make informed decisions about reducing their risks of transmitting
HIV to their infants, they must know their HIV status. Therefore, counselling and HIV testing
is the entry point into the PMTCT programme. Making counselling and testing services available
in health centres and clinics is a key PMTCT programme objective. United Nations guidelines 1
recommend that all pregnant women receive voluntary counselling and testing for HIV.
Counselling in the context of PMTCT occurs in two phases:
• Counselling and informed consent for HIV testing
• Ongoing counselling and information during the antenatal and postnatal period to
support infant feeding and other decisions such as disclosing HIV status.
Counselling and testing for HIV has traditionally taken place in the context of existing illness
as clients are typically referred from services treating STIs, TB or other infectious diseases. In
the maternal and child health setting, counselling and testing has the potential to reach large
numbers of women who may not already be infected thereby providing an opportunity for
prevention through counselling to reduce high-risk behaviours.
17

Group education followed by individual pre- and post-test counselling is the model that has
been adopted for the PMTCT programme in most settings. The group education session is used
in most sites as a way to introduce women to the PMTCT programme and to the option of
individual counselling and testing. It has not been determined to what extent this method of
giving information may actually discourage women from opting for individual counselling.
Following the group education session, women are offered the option of individual counselling.
In order to fully integrate the PMTCT programme into maternal health services, there is the
belief among some health professionals that counselling should be compulsory and testing
voluntary. This approach has already been adopted in KwaZulu-Natal which has a testing
uptake rate of 92%.
In pregnancy, providing information about HIV testing is not optional. Without information,
there can be no informed choice. It is essential to provide information and to assist women
to make a decision as to whether to be tested for HIV. Provision of information and counselling
to pregnant women about HIV testing should be part of the current standard of care, such
as is information and counselling around family planning.
Therefore we should refer to this process as counselling and voluntary testing (CVT), which
in principle is no different from the informed choices that we give people in any medical care.
Support Requirements of Counsellors
During interviews with staff involved in PMTCT counselling, the issue of support for counsellors
was raised. Very few provinces have implemented measures to provide psychological support
to staff involved with HIV counselling. The Western Cape Metro region has committed additional
resources to employing professional counsellors to run regular sessions with staff at facilities
implementing PMTCT and VCT. KwaZulu-Natal has also employed full time mentors to provide
regular support and debriefing for lay counsellors. Where these measures have been taken,
they have often focussed on lay counsellors and not nursing staff who in many facilities have
to manage large counselling loads in addition to an already heavy clinical workload.
Greater attention should be paid to the needs of health workers and counsellors involved in
HIV counselling to prevent burn out and high staff turnover.
Testing for HIV
Rapid ELISA testing is offered as part of the PMTCT programme. This is currently performed
by nurses and the results are available within 15 minutes. The average uptake rate for HIV
testing in the 18 pilot sites in 2002 was 56%. This meets the World Health Organisation 2
suggested target that at least 50% of pregnant women counselled should be tested for HIV,
as part of their recommended routine PMTCT indicators. Although a nationally defined target
for the uptake of HIV testing has not been established, any site with a testing uptake rate of
>80% can be considered to be doing very well. A testing uptake rate of between 50-80% can
be considered to be reasonably good with room for improvement, and a testing uptake rate
of below 50% is considered to be unsatisfactory and those sites should be targeted for extra
support.
Provincial HIV Testing Uptake Rates
HIV Testing Rate
> 80%
50-80%

There are various factors that influence the uptake of HIV testing. These include both health
service and community factors. Health service factors include:
• Work flow arrangements
• HIV testing policies
Community factors include:
• Lack of awareness of HIV/AIDS and PMTCT
• Stigma and discrimination
• Fear of negative reactions from partners or relatives
Health service factors
• Work Flow
The organisational arrangement and workflow within facilities also impacts on the uptake of
HIV testing. Limiting antenatal bookings to certain days of the week may be beneficial in that
women would meet together as a group; however, it could also result in unacceptably high
work loads on those days and possibly long waiting times. Other issues such as the marking
of dedicated rooms for counselling may result in stigmatisation for clients seen to be entering
or leaving that room. The security of counselling and testing registers is also important to avoid
risks to client confidentiality.
• HIV Testing Policy
One possible reason why testing uptake in this programme is less than desired is the current
“opt-in” testing policy under which women must make a specific request to be tested. Two
alternative strategies are available. One involves routine HIV counselling with an opportunity
to “opt-in” for testing. A second alternative is to offer HIV testing as part of the routine series
of ANC tests and allow women to “opt-out” if so desired. Since there is little experience with
the opt-out strategy in Africa, many health service managers feel that further research is
needed to compare the acceptability and uptake in the ANC setting of the opt-out versus the
opt-in strategy.
A recent policy development with regard to rapid testing is the decision by the Health Professions
Council of South Africa taken in February 2003, to allow trained lay counsellors to perform
the initial screening test for HIV. The interpretation of the results of the test should still be
confirmed by a nurse. This could substantially reduce the workload of nurses given that
approximately 70% of women will test HIV negative and won’t require a confirmatory test to
be performed by a nurse.
Community factors
The risk of rejection, abandonment and fear of loss of support related to an HIV positive
diagnosis was expressed by many health workers interviewed as a serious limiting factor to
HIV testing. A woman is generally the first member of a couple to receive HIV testing and
know her status. Despite attempts by counsellors and nurses to offer VCT for couples, the
uptake of testing by partners continues to be poor. This data item was not collected as part
of routine data but anecdotal evidence from the sites suggests that less than 1% of partners
opt to be tested for HIV. The environment within antenatal clinics may alienate men, despite
the service being available.
A study of PMTCT services in Khayelitsha 3 found that despite high awareness of the presence
of HIV/AIDS in the community, it is still associated with stigmatisation and fear among
community members. Disclosure of HIV positive status was found in this study to be a very
isolating experience for mothers.
19

WHO 2 recommends that at least 50% of partners of antenatal clients should be tested for HIV.
This is quite an ambitious target given the current situation therefore serious attention should
be focussed on strategies to increase male involvement in this programme.
HIV testing in labour
Very few facilities offer counselling and HIV testing to women during labour. This is partly
because health workers do not feel that it is appropriate, and partly because lay counsellors
are not available in many delivery wards. An evaluation of obstetric services conducted by
HST 4 found that in most of the facilities surveyed, the physical layout of the labour ward made
privacy for counselling difficult. Women arriving in labour were usually separated from family
and/or friends, thus allowing questions about HIV status and nevirapine to be asked privately.
Confidentiality was more difficult when this initial evaluation occurred in a room occupied
by more than one patient – this occurred in 73% of the facilities surveyed. Nurses complained
that in rooms where beds are separated only by a curtain, even whispered conversations can
be overheard. A few sites offered counselling and testing to women in early labour, a service
provided by nurses and midwives. Some patients were given results immediately, others after
birth.
The policy regarding counselling and testing in labour should be revisited. However, it should
be emphasised that testing should be offered to all women of unknown status postpartum in
order for missed opportunities for treating infants to be avoided. Studies are planned to
compare the efficacy of post exposure nevirapine prophylaxis to infants only versus doses to
both mother and infant. These results may remove the dilemma regarding testing and treatment
during labour if the infant only prophylaxis proves as effective as doses to both mother and
infant.
Ongoing counselling and support
The South African National Protocol for the PMTCT pilot sites 5 states that counselling should
involve a pre-test session, post-test session and that HIV positive women should be offered
counselling at every subsequent antenatal visit. The purpose of these sessions is to assist women
to cope with the diagnosis and to make plans to prevent HIV transmission to the infant. Despite
this recommendation that counselling should occur beyond the context of testing, field visits
for this evaluation confirmed that little ongoing counselling is taking place.
The lack of ongoing support is of particular concern in relation to infant feeding counselling.
Infant feeding options are included in the post-test counselling session for HIV positive women
along with a host of other information. The time immediately following an HIV positive diagnosis
is one of confusion, perhaps anger and shock. Attempting to convey large amounts of
information during this time may often not seem appropriate or compassionate. However, due
to the shortage of staff in most facilities, which limits opportunities for ongoing counselling
and support, this is where issues such as infant feeding options are discussed. Ideally this
should be done in a follow up counselling session once the mother has had an opportunity
to deal with the initial impact of her HIV status.
Given the constraints to support at the facility level, strengthening of community links is essential
to provide follow up support for mothers both antenatally and postnatally. The care and support
links between facilities and local NGOs remain poor in many of the sites. Interviews during
site visits revealed that referrals from sites are made largely to secondary and tertiary medical
facilities, and not to NGOs to meet care and support needs. The involvement of NGOs appears
to be limited to supplying lay counsellors. Ongoing community support can assist with disclosure,
infant feeding practices, reducing stigma and linking individuals with community resources.
Support groups are also a valuable place where women can share their experiences with
others and gain from the group support. Unfortunately very few sites have been able to
implement PMTCT support groups. This is due to many reasons including:
• Lack of space within facilities
• Shortage of staff to facilitate the group
• Fear on the part of women of being identified as HIV positive
20

The entire burden of care and support for HIV positive individuals cannot rest on the health
system alone. Initiatives such as the one described in Appendix 6.1 fill an important gap and
they should be evaluated to determine the potential for their expansion.
Disclosure
For pregnant women known to be infected with HIV, the avoidance of re-infection during
pregnancy and lactation is important to lower the risk of MTCT. This can only be achieved if
their partners are involved in preventive interventions, particularly VCT and infant feeding
counselling. However, the uptake of VCT amongst partners as well as disclosure of test results
remains very low. Findings from this evaluation revealed that women were more likely to
disclose to other family members than to their partners.
A study conducted at a PMTCT site in the Western Cape 3 reported that women felt that being
diagnosed HIV positive would result in serious social and domestic consequences. This highlights
the impact of the stigma, blame and discrimination that characterises the HIV epidemic in
South Africa.
Counselling of women should include providing them with skills and support to discuss HIV
risk reduction and facilitate disclosure to partners or family members.
Recommendations
• Counselling within PMTCT programmes tends to be focussed around HIV testing. This
needs to be complemented much more with ongoing support during the antenatal and
postnatal period.
• The rapid expansion of VCT services should be accompanied by strategies to ensure
quality assurance, otherwise the programme will be of limited effectiveness as many
barriers to the uptake of counselling and testing will remain.
• Different models of peer and community support should be explored.
• Improved collaboration among clinics and NGOs should be encouraged to meet care
and support needs.
• Regular supplies of test kits should be ensured through improved management of supply
procurement. Procurement of supplies should be the responsibility of provinces and not
the national HIV directorate. Minimum re-order levels should be established so that
replacement orders can be made in good time to avoid stocks running out.
• Thorough communication needs to take place from the National DoH regarding the
new policy on lay counsellor testing to avoid confusion and tension at the level of
service delivery.
SUGGESTIONS FOR FURTHER RESEARCH
Health systems research
• Research is needed to explore the quality of counselling offered as part of the package
of care for PMTCT. This evaluation addressed issues such as physical space and staffing;
however, it was not able to assess the quality of individual counselling sessions and this
is necessary to guide future training efforts.
• The needs of health workers and lay counsellors involved in HIV counselling were not
explored during this evaluation. We would recommend that research be conducted to
assess the extent of counselling related burnout and to provide possible strategies to prevent
it.
• Models for community involvement in the PMTCT programme should be evaluated.
Social science research
• Research is also needed to understand the origins and pathways of stigma and ways
to measure it.
• Research is needed to explore the effective use of communication strategies to promote
VCT and PMTCT.
21

APPENDIX 6.1: EXAMPLE OF A PEER COUNSELLING AND SUPPORT STRATEGY
Mothers-to-Mothers-to-Be:
Peer Counselling, Education and Support for Pregnant Women in Cape
Town, South Africa.
Mothers-to-Mothers-to-Be (M2M2B) is a mentorship programme for HIV infected pregnant
women. Recently delivered HIV infected mothers who have passed through the antenatal
programme are invited to return to the antenatal clinic to act as mentors, educators, counsellors,
friends and confidants for recently diagnosed, HIV infected pregnant women. At the first
antenatal visit, a pregnant woman is matched with a woman who has recently delivered – a
mentor. This mentor sits with the pregnant woman – keeps her company, helps her with
questions, the logistics of negotiating the hospital, reinforces messages about taking nevirapine
and choosing a feeding method. At each appointment, the patient sees the same mentor.
The mentor-mothers also visit mothers in labour and the post-partum wards. Post-partum
education is so important for mothers going home with new babies. HIV positive mothers are
challenges by uncertainties about feeding regimes and they need to be certain about followup
care for themselves and their babies.
At a clinic, each day, different mentor-mothers are scheduled to be part of the care team. Ten
mothers provide care each week; each mother has her day so patients know when to come
back to see a familiar face. Each mentor-mother holds her position for six months. After six
months, the mothers graduate to be replaced by new mentor-mothers. The mentor-mothers
are paid a stipend for their work.
The first M2M2B programme was started at Groote Schuur Hospital in Cape Town in October
2001. M2M2B has subsequently opened in Khayelitsha’s Site B MOU, a primary care maternity
centre and at Mowbray Maternity Hospital, a district hospital. Additional sites in the Cape
Town area, Paarl, Kimberley, East London and Johannesburg are awaiting M2M2B programs.
The programme has been a tremendous success, with rapid expansion only limited by funding
constraints.
The programme has resulted in an increase in pre-natal visits, and an increase in knowledge
on the issues surrounding HIV and pregnancy resulting in greater adherence to therapies that
will reduce vertical transmission of HIV.
REFERENCES
1. UNAIDS. Counselling and voluntary HIV testing for pregnant women in high HIV
prevalence countries: Guidance for service providers. UNAIDS, 1999.
2. WHO/UNICEF/UNAIDS. Local monitoring and evaluation of the integrated prevention
of mother to child HIV transmission in low-income countries. Geneva: WHO, 2001.
3. Chopra M, Piwoz E, Sengwana J, Schaay N, Dunnett L, Sanders D. Effect of a motherto-child
HIV prevention programme on infant feeding and caring practices in South
Africa. SAMJ 2002; 92(4): 298-302.
4. Besser M, Dinat N, Paruk F. Changing obstetric practices in the context of HIV: an
evaluation of service provision in the national PMTCT learning sites. Durban: HST,
2002.
5. South African National Department of Health. Protocol for the eighteen PMTCT pilot
sites in South Africa. Pretoria: Department of Health, 2001.
22

6.2 Dispensing of Nevirapine to Mothers and Infants
DISPENSING OF NEVIRAPINE TO MOTHERS
The national PMTCT protocol for the pilot sites stipulates that HIV positive pregnant women
who are 28 weeks or more in their gestation should be given 200mg of nevirapine for selfadministration
at the onset of labour or rupture of membranes.
This evaluation found that an average of 55% of HIV positive pregnant women were dispensed
nevirapine in the pilot sites during 2002. This is an improvement from the first evaluation in
2001 where the percentage of HIV positive women receiving nevirapine was 30%.
This indicator is an unreliable measure of nevirapine tablets dispensed to pregnant women
with HIV. For various reasons this indicator can over or under estimate actual nevirapine
coverage. This routine data was collected in both the antenatal clinics and labour wards, and
not linked to patient identifiers. Total doses dispensed to HIV positive mothers in each setting
were recorded by staff, and used by researchers to obtain the overall coverage. Double
counting could therefore have occurred which would over estimate coverage.
Underestimation of the coverage could also have occurred if a woman chose not to disclose
her status to labour ward staff, yet self administered her nevirapine dose. This dose although
administered would not be recorded in the routine data. It was unfortunately not possible for
researchers to assess the extent of any over or under estimation of this figure.
The denominator for this indicator is the number of HIV positive test results, however, many
of the women who test positive for HIV may not deliver in the same month therefore it is not
possible to accurately measure whether nevirapine was actually taken by each HIV positive
woman in labour. This indicator is simply a broad measure of nevirapine tablets utilised in
the system and it should not be used as a measure of programme effectiveness. In future, the
data on dispensing should be derived from pharmacy inventory records rather than clinic and
hospital registers.
Despite the limitations of this indicator, it is lower than the WHO 1 recommended target that
at least 75% of HIV-infected women should receive an ARV during labour. However, in
comparison with other African countries, the estimated nevirapine coverage in South Africa
appears reasonable. In the nine African PMTCT sites supported by the United Nations, only
about 18% of the target population (HIV positive women) received antiretrovirals 2 . Wilfert 3
reports better results in the Elizabeth Glaser Pediatric AIDS Foundation supported sites in 10
African countries, with 37% of HIV positive mothers receiving treatment. Reasons for the low
uptake in these sites are related to both health service and community factors.
Provinces achieving the highest rate (>60%) of estimated nevirapine dispensing to HIV positive
pregnant women are the Northern Cape (92%), Eastern Cape (69%) and Mpumalanga (63%).
This may be due to the small number of HIV positive women identified in these provinces per
month. The average number of HIV positive women identified per month in the Northern Cape
is 19, and in Mpumalanga, the average is 37. This low average HIV positive client load,
together with the limited number of sites offering PMTCT services in these two provinces may
enable easier tracking of clients. In the Eastern Cape, the average number of HIV positive
women identified per month is far higher at 134. Further research should be performed to
determine the enabling factors that have resulted in high nevirapine coverage in these provinces.
This research should also assess whether the expansion of PMTCT services to more facilities
enables or hampers tracking of HIV positive mothers.
The lowest estimated nevirapine dispensing rates are seen in KwaZulu-Natal (49%) and the
Western Cape (48%). The extensive expansion of PMTCT services in these provinces may have
resulted in more difficult tracking of monthly cohorts of HIV positive women. It is possible that
women may receive antenatal care at a clinic, yet deliver their infants at a hospital. The
accumulation of nevirapine data from these different settings, which may not even be in the
same district, may be difficult.
23

Figure 6.2.1: Nevirapine dispensing to HIV positive women in the pilot sites, 2002
100
%
90
80
70
60
50
40
30
20
10
0
WC KZN NW LP FS GT MP EC NC Average
There are a number of problems with the dispensing of nevirapine to HIV positive pregnant
women:
1. Inadequate patient information regarding correct nevirapine administration
There were reports from some sites that women did not adequately understand the
regimen for nevirapine administration. This resulted in some women taking the tablet
antenatally at the time it was dispensed and requiring a second dose when in labour.
Some sites reported a high number of women who required nevirapine to be dispensed
in the labour ward which suggests that tablets are not correctly self-administered or
are lost, or that women forget to take the tablet when they go into labour.
2. Lack of clarity regarding the dispensing of repeat doses to women
The national PMTCT protocol for the pilot sites stipulates that in the case of false or
prolonged labour nevirapine can be taken again 24 hours after the first dose at a
subsequent onset of labour. A study conducted in South Africa showed that giving two
doses of nevirapine to mothers results in a much higher rate of nevirapine resistance
than one dose 4 . A circular dated 16 th of April 2002 was sent from the national
Department of Health to provinces informing them, amongst other things of the revised
nevirapine regimen. The circular states that women in prolonged or false labour should
not receive a repeat dose of nevirapine. This evaluation found that in many facilities,
midwives were not aware of the change to the protocol and this information did not
appear to have been transmitted from provincial management to the facility level.
3. Difficulties identifying HIV positive women in the labour ward due to non-disclosure
The dispensing of nevirapine to HIV positive women in labour relies on the presence
of a unique patient identifier or on the willingness of the woman to disclose her status
to health workers. HIV positive women may be reluctant to reveal their HIV status in
delivery rooms that lack privacy, or to staff that have not been involved in their antenatal
counselling and care. This can result in missed opportunities for nevirapine coverage
of HIV positive pregnant women.
24

NEVIRAPINE ADMINISTRATION TO INFANTS
Figure 6.2.2: Nevirapine dispensing rate to newborns in the 18 pilot sites, 2002
100
%
80
60
40
20
0
NW LP FS GP MP WC EC NC KZN Average
Nevirapine administration to newborns is a more accurate reflection of antiretroviral coverage
as it is usually dispensed in one facility and sometimes one ward. However, it is important to
note that this indicator represents treatment coverage only in infants of women who have been
identified as being HIV positive therefore missed opportunities are not included. This rate will
also be inaccurate when two doses of nevirapine are administered to babies born to mothers
that are untreated or inadequately treated or when mothers delivering at home bring their babies
to the labour ward or postpartum ward for treatment. In these situations proportions in excess
of 100% may be found.
The national PMTCT protocol for the pilot sites stipulates that all infants born to HIV-infected
women should receive a single dose of nevirapine suspension between 24 and 72 hours after
delivery.
Figure 6.2.2 shows that an average of 99% of infants born to HIV positive women in the pilot
sites received nevirapine. This rate is extremely high across all provinces although this only
reflects coverage of infants born to HIV positive women who were identified as being HIV positive
during labour. Given the low rate of nevirapine dispensing to mothers, it is likely that a significant
number of HIV positive women do not identify themselves as being HIV positive in labour.
RECOMMENDATIONS
1. There needs to be a distinction made between pharmacy stock control of nevirapine
and monitoring to determine nevirapine coverage. In order to improve the accuracy
of this indicator, nevirapine dispensing should be recorded in one place, preferably
the labour ward. Nevirapine dispensing in the antenatal setting can be controlled by
the pharmacy.
2. Greater efforts should be made to identify HIV positive women in the labour ward
setting to prevent missed opportunities for nevirapine coverage of mothers and infants.
Staff should not rely on tracking numbers on patient cards or folders to identify HIV
positive status; this should be done by asking women in privacy.
3. The change in the clinical protocol for nevirapine dosage should be communicated
to all facilities to ensure that repeat doses are not given.
REFERENCES
1. WHO/UNICEF/UNAIDS. Local monitoring and evaluation of the integrated prevention
of mother to child HIV transmission in low-income countries. Geneva: WHO, 2001.
2. Chopra M. Personal communication, July 2003.
3. Wilfert C. Prevention of mother to child transmission of HIV: reflections on implementation
of PMTCT in the developing world. Acta Paediatrica 2002; 91:863-865.
4. Moodley D, Moodley J, Coovadia H, Gray G et al. A multicenter randomised controlled
trial of nevirapine versus a combination of zidovudine and lamivudine to reduce
intrapartum and early postpartum mother to child transmission of human
immunodeficiency virus type 1. Journal of Infectious Diseases 2003; 187: 725-35.
25

6.3 Infant Testing and Outcomes
BACKGROUND
One of the anticipated aims of the national PMTCT pilot programme was to assess the effectiveness
of this programme in reducing mother-to-child transmission of HIV. A great deal of public
anticipation of the “results” from these pilot sites has therefore been generated. It is important,
however, to clarify that the design of the pilot sites allowed for an evaluation of the operational
issues associated with providing PMTCT care but was not appropriate for determining transmission
rates. A prospective cohort study has been commissioned by the National Department of Health
in order to measure vertical transmission rates. However, important lessons can be learnt from
this evaluation relating to operational issues associated with the testing of infants.
The primary objective of the PMTCT programme is to reduce the transmission of HIV from a
mother to her infant. The national PMTCT protocol for the pilot sites stipulates that all children
should be tested for HIV 12 months after delivery. If the infant tests positive at 12 months they
should be retested at 15 months to ensure that the 12-month test was not a false-positive test
due to residual maternal antibodies in the infant. For mothers continuing to breastfeed after 12
months, an HIV test should be performed at least 3-months after the mother ceases breastfeeding.
This section will present key findings from the evaluation that relate to infant testing as well as
presenting an alternative testing strategy to improve the follow up component of PMTCT.
KEY FINDINGS FROM THE EVALUATION
Uptake of Infant HIV Testing
This evaluation found fairly low uptake of infant HIV testing at 12 months across most provinces.
Table 1 displays the infant testing rates in all 9 provinces. It is difficult to draw conclusions from
this data as some provinces test infants at 9 months and others at 12 months. In addition, some
provinces changed their testing protocol from 9 months to 12 months during 2002 and the
researchers were not always able to determine exactly when this change occurred. Specificity
of the rapid HIV ELISA test at 9 months and 12 months is only 59% and 89% respectively 1 .
Approximately 40% of truly negative infants would therefore test positive at 9 months, making
the data which includes 9 month test results an unreliable indicator of HIV transmission.
A large proportion (50%) of the infants born to mothers who received nevirapine, were not
followed up and tested. The HIV status of these infants is therefore unknown and could potentially
vary substantially from the results of infants that were followed up and tested. It is therefore not
possible to draw any conclusions on impact or effectiveness of the programme from this data.
Table 6.3.1: Infant testing rates
Province
Number of live births
Number of infants tested
for HIV
HIV testing
rate
Number of
infants testing
HIV positive
Eastern Cape 1
Free State 1
Gauteng 2
KwaZulu-Natal 2
Limpopo 1
Mpumalanga 2
North West 1
Northern Cape 1
Data only available for
GDH site
Western Cape 3
TOTALS
305 (Sept 01 – March 02)
129 (Aug 01 – March 02)
403 (May – Dec 01)
470 (Sept – Dec 01)
45 (Nov 01-March 02)
55 (Sept –Dec 01)
11 (July 01 – March 02)
65 (Aug 01 – March 02)
424 (April 01-March 02)
1907
76 (June – Dec 02)
56 (May-Dec 02)
40 (May – Dec 02)
368 (Sept – Dec 02)
17 (Aug – Dec 02)
12 (Sept –Dec 02)
44 (April –Dec 02)
25 (May-Dec 02)
311 (Jan-Dec 02)
949
25%
43%
10%
78%
38%
22%
39%
38%
73%
50%
4
21
3
38
3
3
8
17
73
170 (18%)
Note: 1. Province changed infant testing policy from 9 to 12 months during 2002
2. Province tests infants at 12 months
3. Province tests infants at 9 months
26

Impressive infant follow up rates have been achieved in the Western Cape (73%) and KwaZulu-
Natal (78%) possibly due to the extensive coverage of these provinces with PMTCT services
enabling easier follow up of infants at the clinic level. A further factor enabling improved
follow up of infants in the above provinces is the expansion plan which focused on geographical
areas and referral systems rather than sites and facilities. This facilitates improved tracking
of mothers and infants between delivery centres and feeder clinics.
The Western Cape tests infants at 9 months despite the national PMTCT protocol for the pilot
sites calling for 12 month testing. The province is concerned that delaying testing until 12
months will result in higher loss to follow up. As a result of this policy, approximately 40% of
infants are testing false positive at 9 months and have to have a repeat test at 15 months. The
province is planning to change to early PCR testing of infants to improve both follow up and
clinical management.
In the other seven provinces the follow up rates are low. This may be due to the fact that in
many of these provinces, particularly in Gauteng and Mpumalanga, PMTCT services have not
been extended to many feeder clinics as expansion has been focused primarily on hospitals.
Mothers therefore have to return to the primary PMTCT site, usually a hospital, in order for
their infants to be tested for HIV.
The low rate of follow up occurs for a variety of reasons that include:
• Inadequacies in the routine monitoring system
• Poor referral networks between hospitals and clinics
• Limited numbers of clinics offering the PMTCT programme
• Tracking/coding systems using patient-held records not implemented or ineffective
• Mothers reluctance to disclose their HIV status to health workers
The high loss to follow up rate means that those infants born to HIV positive women involved
in the PMTCT programme, the majority will have their HIV infection status determined for the
first time when they present with HIV disease and are not receiving routine medical care
recommended for HIV infected children (viz, prophylactic co-trimoxazole under 12 months.
They also do not access other medical interventions that might benefit their health such as
nutrition support and multivitamins in the case of growth faltering.
Out of the 949 infants in the pilot sites (excluding the De Aar site) that were tested for HIV,
170 tested HIV positive (18%). It is important to note that over half of the infants tested were
from the Western Cape and KwaZulu-Natal, the number of infants tested in the other 7
provinces is extremely small. Given the small number of infants tested and the testing method
used, (antibody test between 9 and 12 months) this figure can not be considered an accurate
reflection of the vertical transmission rate amongst this group of infants.
In order to determine transmission rates in infants receiving care through the PMTCT programme
and to facilitate improved clinical management of infants born to HIV positive women, either
the follow up of infants to 12 months needs to be drastically improved, or an alternative
method of determining infant HIV status needs to be adopted. Such an alternative testing
recommendation is discussed in this chapter.
Counselling for the infant HIV test
Pre and post test counselling is also required when testing infants for HIV. This evaluation
found that health workers were generally unsure as to how to counsel mothers for their infant’s
HIV test. There was also lack of clarity regarding who could be given the infant HIV test result;
the mother, father or a caregiver. The current PMTCT protocol provides no guidelines in this
regard.
There are many issues that should be discussed at the time of the infant’s HIV test including
the implications of the test result, requirements for further follow up care of the infant including
prevention of opportunistic infections in the case of a positive diagnosis and care and support
of the mother. This component of the programme should receive as much time and attention
as the counselling associated with maternal testing. Ongoing training of clinic nurses may be
necessary to familiarise them with the follow up needs of mothers and infants.
27

DISCUSSION
HIV Diagnosis in Infants
The purpose of testing perinatally exposed infants is three fold: firstly, on an individual level
to determine an infant’s true HIV infection status in order to make clinical management
decisions; secondly, to determine the relative efficacy of various interventions to reduce vertical
transmission; and finally, at a population level, to evaluate the effectiveness of the PMTCT
programme.
The diagnosis of HIV infection in infants requires careful timing of the initial HIV antibody
based (ELISA) diagnostic test (including the Abbott Determine HIV-1/2 and other rapid tests
which are currently used at PMTCT sites). This is due to the presence and persistence of
maternal HIV-specific antibodies in all perinatally exposed infants for many months after birth.
Sero-reversion may occur as early as 9 months (40-60%) but maternal HIV antibodies have
been shown to persist for up to 18 months 2 . To accurately assess the effectiveness of the PMTCT
programme, accurate, affordable and timeous infant HIV diagnostic protocols are required.
General Principles of HIV Testing in Infants
1. Diagnosis needs to be made in the clinical context of the case, with knowledge of the
various test options and their interpretation depending on the age of the child.
2. Different protocols may be needed for different areas depending on accessibility to
laboratory tests. However, data presented here proposes that where testing can be
centralized to a reference laboratory, an HIV DNA PCR test is recommended.
3. Infant feeding must be taken into consideration. In the case of a woman who has chosen
to breastfeed, early HIV testing (using an HIV DNA PCR) to determine status may serve
as (a) an incentive to stop breastfeeding if child is negative or (b) encouragement to
continue breastfeeding if the child is already positive, or (c) a guide to considering relactation
if the woman has not been breastfeeding and the child is already positive.
CURRENTLY AVAILABLE INFANT HIV TESTS
Antibody Tests
A. Serum HIV ELISA Tests
These tests include onsite rapid tests and laboratory based analyzer assays. The later in life
they are performed in infants the more accurate the results, but this means longer periods of
follow up of large numbers of HIV exposed children, most of whom will be negative. To date
this has resulted in enormous loss to follow up.
The Abbott Diagnostics Determine HIV-1/2 Rapid Test can be purchased at US$0.85/test or
provided free of charge through the company’s PMTCT support programme. Confirmatory
Rapid tests like Unigold which confirm initial rapid positive results cost about R25.00. Less
than1% of these rapid tests are discordant. Laboratory based HIV-1/2 ELISA tests requested
from the NHLS cost the state R33.50/test. The advantage of rapid tests is that they can be
performed on site rapidly by both lay counsellors (the screening test) and nurses, and do not
require specimen transport to a laboratory except in the case of ELISA confirmation.
B. Oral fluid Based HIV ELISA Tests
Oral fluid contains lower concentrations of antibodies, including anti-HIV antibodies, than
serum. Waning maternal anti-HIV antibodies at 12 months of age in HIV uninfected children
are therefore less likely to give false positive HIV ELISA tests results when measured in oral
fluid as compared to serum. Oral fluid tests are currently not recommended for diagnostic
purposes and have not been evaluated in children under 13 years of age. Both sensitivity and
specificity on 204 patients using OraSure is 94%.
28

Nucleic Acid Tests (NAT)
Nucleic Acid Testing involves detection of the specific HIV nucleic acid either DNA or RNA.
A. HIV DNA PCR
This has been shown to be highly sensitive and specific at 6 weeks, 3 months and later (using
the Roche Amplicor 1.5 assay- see Table 2 below 3 ). The test can be performed earlier but
sufficient sensitivity data at earlier time points is not available nor is it practical to test earlier
since a mother’s first scheduled clinic return visit is normally 6 weeks (well baby check and
immunization), hence the 6 week timing of the test is perfect. The cost/test is R225. Utility of
this assay has been well defined in key MTCT clinical trials namely the PETRA and SAINT
studies. A DNA PCR at 6 weeks of age in 293 infants attending the Coronation hospital PMTCT
clinic concurred with the 3 month PCR result in all cases 4 . It needs to be emphasized that the
v1.5 test, in use since 2000, has yielded significantly better sensitivity and specificity than the
previous version assay and it is recommended that the v1.5 test is used.
Table 6.3.2: Sensitivity and specificity for DNA PCR tests
Age
< 48 hours
48 hours – 7 days
8 days – 1 month
1-4 months
4-6 months
Sensitivity (95% CI)
0.55 (0.32, 0.76)
0.75 (0.36, 1)
0.81 (0.62, 0.95)
0.98 (0.87, 1)
0.95 (0.82, 0.99)
Specificity (95% CI)
1 (0.99, 1)
1 (0.97, 1)
1 (0.99, 1)
1 (0.99, 1)
1 (0.99, 1)
Note: CI = confidence interval
Source: North Caroline Retrovirology Laboratory
B. HIV RNA (Viral load based assays; PCR, bDNA, NASBA)
Similar to DNA PCR but detects and quantifies levels of HIV-1 RNA. These tests do not offer
any significant advantages and are more expensive. RNA may be detected early in infection
(< 6weeks). However, this gain does not justify almost 2-3 times the cost of an HIV DNA PCR
assay. Some local research has been done into qualitative + quantitative “home-brew” HIV
RNA PCR tests using customized reagents on real-time based PCR instruments. These assays
have not yet been standardized and therefore should not yet be recommended for wide-scale
use. They may provide cost advantages and therefore should still be pursued.
C. p24 Antigen Assay
This uses Schupbach’s method of signal-amplification-boosted ELISA. Several centers are
showing good results with this assay but further research is required. This assay could replace
the HIV DNA PCR test if there is a significant cost saving.
29

Current Status of Infant Testing
Currently National DOH Guidelines for infant testing in PMTCT pilot sites indicate that an
ELISA test should be performed at age 12 months. Previously HIV antibody assays were being
performed between 9-12 months but this has shown to generate a large number of false
positives particularly when testing at around 9 months, due to persistence of maternal HIV
antibodies.
A study conducted at King Edward Hospital (KZN) site of the PETRA study showed HIV ELISA
test specificity at 9 months and 12 months of only 59% and 89% respectively 1 . The low specificity
at 9 months suggested the change in policy to delay the rapid test to 1 year (with a repeat
test at 15 months in the event of a positive result). Provincial departments have been asked
to stop testing at 9 months and to ensure that the 1 st antibody HIV test is performed on a child
1 year or older. Despite this recommendation, some provinces such as the Western Cape
continue to test infants at 9 months.
Some experts think that a rapid test at 12 months may still be too early 5 . A study conducted
at the Coronation Hospital in Gauteng showed that 40% of HIV uninfected children tested HIV
ELISA positive at 12 months of age with a lab based ELISA test 4 . Delaying testing further,
however, may be impractical and result in further loss to follow up.
Problems with the Current Testing Protocol
The delay of 1 year in being able to make a reasonably accurate diagnosis in infants has the
following repercussions:
• Unacceptable rates of loss to follow up (in some provinces >50%)
• Inability to adequately evaluate the effectiveness of the PMTCT programme
• Inability to provide appropriate clinical and social support to families
• Immeasurable emotional costs to families waiting for the HIV status of an infant
• Direct and indirect costs of providing co-trimoxazole to HIVnegative babies
• Large numbers (70-94%) of HIV negative babies treated as HIV positive for the first
year of life.
Advantages of Earlier Testing
There are numerous benefits to performing early nucleic acid testing of HIV exposed infants,
which clearly have enormous social implications and will affect management of HIV in these
children, their families, and society. Using earlier NAT would have the following benefits:
• Reduction in the loss to follow up
By offering testing of infants at 6 weeks this would provide some incentive for mothers to
adhere to this follow up visit and they may be more willing to disclose their status in order
for their infant to be tested. Women who learn that their infants are positive at this early
stage may be more motivated to return for frequent clinic visits in order to maintain the
health of their infants and to benefit from ongoing care.
• Improved monitoring of the effectiveness of the PMTCT programme
Earlier testing of infants would enable the National Department of Health to have more
accurate records of HIV transmission rates in which to evaluate programme effectiveness.
This is an important monitoring tool as unacceptably high vertical transmission rates may
be due to problems in other aspects of the programme such as poor uptake of nevirapine,
inappropriate obstetric practices or poor infant feeding counselling.
• Reducing the numbers of children requiring long term follow up by 90%
The HIV status of infants could be tested at a 6 week visit and HIV uninfected children
discharged from specific HIV follow up as early as 10-14 weeks of age with certain provisos.
Only HIV infected children (about 10% of the total HIV exposed, non breastfed children)
would require specific further follow up and prophylaxis for opportunistic infections.
30

• Reduction in Mother/Family anxiety
Early infant diagnosis relieves the majority of HIV positive mothers of the emotional burden
of having infected their children (since between 70-94% of babies will be born negative).
The emotional and human value of this is beyond measure.
• Informed formula feeding choice
Early knowledge of the HIV status of an infant may enable mothers to make a more informed
decision regarding feeding choices. Mothers who have been breastfeeding may want to
change to formula milk if they know that their infants are negative or women opting for
formula may want to consider relactation in the event that the infant is HIV positive. This
would still need to occur within the context of adequate infant feeding counselling and an
assessment of the individual home circumstances.
• Reduction in cost of and use of co-trimoxazole
All infants born to HIV positive mothers are given co-trimoxazole from age 6 weeks until
12 months. Since the large majority of these infants do not require this, some saving and
a reduction in side effects experienced from the drug can be achieved.
• Earlier entry into infant hiv management protocols
Holistic medical management of an HIV infected child requires that the child’s HIV infection
status be established as early as possible. Prevention of opportunistic infections, treatment
of intercurrent infections and emotional support for the child and family, derived from
counselling and peer groups, improve the child’s quality of life even in the absence of
antiretroviral therapy.
Diagnostic algorithm for the use of nucleic acid testing in the public sector
Guidelines for infant HIV diagnosis, both internationally 6 and in the local private sector 7 ,
recommend 2 PCR tests before 12 months of age (the 2 nd PCR is done primarily to confirm
the first PCR result). International experience is that the sensitivity of the DNA PCR at 6 weeks
of age in a non breastfeeding population approaches 98% 3 . Local experience in the Coronation
PMTCT infant diagnostic study suggests that a single DNA PCR at 6 weeks, together with a
clinical assessment, yields accurate results 4 . Assuming that the large numbers of HIV affected
children in SA make 2 HIV PCR tests per child unaffordable, an alternative diagnostic protocol
that offers a vast improvement on the current situation is required.
Taking all this into consideration, the following recommendation for infant HIV diagnosis is
made, irrespective of infant feeding status. It is based on the assumptions:
• That visits to the clinics for HIV diagnosis should be timed with routine clinic/immunization
visits, making it cost effective and practical for both the state and families.
• That HIV results can be given before starting the co-trimoxazole prophylaxis to eliminate
unnecessary long term prophylaxis of HIV negative babies.
• That a concise diagnostic algorithm that is merely an add on to current paediatric
management guidelines (IMCI) can be effectively communicated to all primary care
personnel enhancing its application and effectiveness (HIV diagnosis should be one
component of overall child health care).
• That this algorithm would enhance follow-up, care of HIV negative and HIV infected
infants and allows for measurement of the effectiveness of the PMTCT programme.
• That primary health care nurses understand the limitations of a single PCR test at 6 weeks
of age (due to possible sample mix ups and post natal transmission of HIV), and that they
are able to perform basic clinical assessments that would alert them to the need for further
age-appropriate HIV testing.
31

Proposed Infant HIV Test Timelines
6 weeks 1 st well baby clinic visit
Clinical assessment
HIV DNA PCR test
10 or 14 weeks Timing of 2 nd and 3 rd immunization visit
Clinical assessment
HIV DNA PCR result
• PCR positive – child is HIV infected – refer for HIV specific
care, reinforce infant feeding choices + start co-trimoxazole
• PCR negative – mother counseled that child is HIV uninfected
at present and educated on feeding practices
Note: test not infallible as breastfeeding and other exposure would mean
possible window period infection status {+ specimen mix up possible but
limited (12 months age
AND
• >3 months after breastfeeding has ceased
Positive Children
If no ART and no HIV stigmata
• Confirm HIV status by rapid HIV test at 18 months
Note: this test would pick up any children misdiagnosed as positive probably by
specimen mix up at 6 weeks.
Note: It is envisaged that this diagnostic protocol would enable the majority of children (>97%)
to be correctly diagnosed at 6 weeks of age. By reducing the number of children requiring
follow up for HIV by approximately 90% at 10-14 weeks of age, scarce health care resources
can be focused on HIV infected children. Child health care workers would need to maintain
a high index of suspicion in HIV exposed children who present with clinical stigmata of HIV
later on in life in order to diagnose post natal transmission of the virus and to refer these
children for appropriate medical management.
Practical Issues Surrounding Implementation of NAT Testing for PMTCT follow-up
• The DOH and NHLS need to work more closely to leverage their significant, but
currently inefficiently employed, resources to make this diagnostic method deliverable.
• Provinces should be able to decide when to implement alternative testing strategies
depending on their capabilities. In places where rapid tests are not yet available this
should be implemented prior to nucleic acid testing as a basic requirement.
• The same problems experienced already with rapid testing such as stocks running out,
poor quality control, and inadequate staff training will occur with an alternative form
of testing. These logistical and infrastructural issues should therefore be addressed
before a new method of testing is made widely available otherwise this could worsen
existing services.
• Thorough investigation is needed to determine the adequacy of transport systems to
facilities to enable this form of testing to be undertaken.
• The NHLS laboratory network (>150 nationwide) needs to be exploited and staff
trained at all clinics on how to use this system. Currently the NHLS has links to all
antenatal clinics and systems in place for transport of specimens to tertiary centers
that have NAT capability. The decision to use NAT would require these logistics to be
effectively mobilized. Currently NAT capability exists in Cape Town, Durban, Bloemfontein,
Johannesburg and Pretoria. Consideration to use dried blood spots vs EDTA collection
tubes would need to be investigated. This is a separate discussion that should be held
with the relevant team from the NHLS but is definitely achievable.
32

RECOMMENDATIONS
It is recommended that consideration be given to changing the infant testing policy from rapid
testing at 12 months to nucleic acid testing at 6 weeks. This could be performed utilizing dried
blood spot methods (RNA-PCR) in areas where access to laboratories is difficult. However,
in areas where access to laboratories is not problematic, whole blood should be utilised for
DNA-PCR testing as this is less expensive. The following health systems and technical issues
should be addressed in the process of planning for this policy change:
Health Systems Recommendations
a) Thorough cost analysis of benefits of earlier testing using NAT compared to the current
test system for the PMTCT programme. This is currently underway through Coronation
Hospital, and data should be available in late 2003.
b) Analysis and implementation of logistics around supporting NAT testing through the
NHLS to all clinic sites using either whole blood collection or dried blood spots.
c) Assess the impact of effectively utilising NHLS infrastructure and how it will, at the
same time, put in place the systems for viral load monitoring to support government
treatment sites, as the same NAT testing centers and logistics would be required for
viral load and CD4 monitoring.
d) The counselling associated with the infant HIV test requires greater attention as the
purpose of this test is not simply to determine HIV status but to make decisions regarding
further care and support for families.
e) Until such a policy decision can be made, further attention must be given to improving
follow up of infants at routine clinic visits for immunizations and other child health
services utilizing the IMCI model.
Technical Recommendations
a) Further comparison of sensitivity and specificity of dried blood spots as compared to
whole blood for DNA PCR.
b) Further investigation of the p24 Ag assay by local research groups.
REFERENCES
1. Moodley D, Moodley J. Rapid Testing for Perinatal HIV in Developing Countries.
Unpublished paper, 2002.
2. Centers for Disease Control. Revised Classification System for Human Immunodeficiency
Virus Infection in Children Less than 13 Years of Age. MMWR 1994; 43: 1-10.
3. Benjamin DK. Integration of statistical theory and practical clinical expertise. Polymerase
chain reaction testing of the HIV-exposed infant. Minerva Pediatr. 2002;54(2):105-11.
4. Sherman G. Unpublished data, 2003.
5. Report on the National Scientific Consultative Forum on HIV/AIDS, August 2002.
6. Centers for Disease Control. Revised Guidelines for Prophylaxis Against Pneumocystis
carinii Pneumonia for Children Infected with or Perinatally Exposed to Human
Immunodeficiency Virus. 1995; 44 (RR-4): 1-11.
7. Webber LM et al. Diagnosis of Perinatal HIV-1 infection in South Africa. Southern
African Journal of HIV Medicine 2001:5:21-6.
33

6.4 Maternal and Infant Follow Up
INTEGRATING HIV CARE INTO PRIMARY HEALTH CARE
The national PMTCT protocol stipulates that care must extend beyond the point of delivery for
both mother and child. All women are advised to return for a post-natal care visit within 3-
14 days after discharge, every two weeks in the first month and once a month thereafter. The
purpose of these visits is to assess the woman for signs of infection, to provide multivitamins
and prophylaxis against opportunistic infections, to provide support for exclusive breastfeeding
if this is the chosen feeding method and to provide guidance on safe formula feeding and
formula milk supplies to women who have selected to formula feed. These recommendations
for maternal care are based on the DoH Guidelines for Maternity Care in South Africa.
The recommendations for follow up of infants in PMTCT pilot sites are based on the South
African DoH IMCI clinical case management guidelines, which were adapted in 2001/2 to
include care of children infected or affected by HIV/AIDS. This suggests that infants should
be followed up weekly during the first month of life, and monthly thereafter, until the age of
twelve months. The purpose of these visits is for growth monitoring, assessment of feeding
difficulties, provision of prophylaxis against opportunistic infections, assessment for clinical
signs suggestive of AIDS, routine immunizations according to the South African EPI schedule,
and HIV testing.
Despite the presence of comprehensive guidelines for follow up care, this evaluation found
that very few of the sites are able to provide the appropriate postnatal care required for
women with HIV and their families. The challenges to providing follow up care are numerous,
and include:
• Difficulties identifying HIV positive women and their infants at clinics due to inadequate
tracking mechanisms.
• Many women opting not to disclose their status to clinic staff.
• Poor access to health facilities due to long distances and a lack of affordable transport
All facilities were able to provide routine MCWH services, however, additional follow-up care
such as co-trimoxazole prophylaxis, infant testing, support groups, multivitamins, and AIDS
care were more difficult, and very few facilities are at a stage where they have integrated
these components into primary health care services.
Provinces that have achieved success in following mothers and infants, namely the Western
Cape and KwaZulu-Natal, have implemented an expansion plan that targets geographical
areas and referral systems rather than sites and facilities. This enables a hospital and its
surrounding feeder clinics to implement PMTCT before the service is extended to other hospitals.
This strategy strengthens referral networks within sub-districts to allow for continuity of care
between delivery centers and clinics.
Both of these provinces have hired dedicated PMTCT staff to assist existing staff with the
additional demands of this service. In the Paarl site in the Western Cape, the co-ordinator
sends a list to the clinics each month notifying them of the infants due for HIV testing. If these
infants do not attend the clinic during the expected month, a home visit is conducted to trace
these infants. In KwaZulu-Natal the use of community health workers to improve the follow
up of infants is being explored. These are both strategies that are human resource intensive
however; the benefits in terms of monitoring the effectiveness of the programme and improved
clinical management of mothers and infants may outweigh the costs.
This evaluation found that women who had opted for formula feeding received more frequent
postpartum care than women who chose to breastfeed because they attend health facilities
more frequently to receive formula supplies. However, women opting for breastfeeding seem
to only attend clinics for infant immunizations; they are not routinely followed up for infant
feeding care and support and to maintain breast health. A key factor hampering follow up
efforts is the reluctance of many PMTCT clients to disclose their status to health workers. In
many areas the facility in which initial antenatal HIV testing occurs (frequently a community
health centre), is different from the facility in which well child-care occurs (mostly a clinic
setting). Women may have established a trusting relationship with their lay counsellor in the
antenatal setting and may not want to risk disclosing their status to a new group of health
workers in a different setting.
34

TRACKING OF CLIENTS ACROSS SERVICES
This programme collects anonymous, aggregated data. It is therefore difficult to track HIV
positive clients across sites rendering antenatal, delivery and child health services while
respecting the need for confidentiality and avoiding stigmatisation.
A variety of approaches are being piloted in the respective provinces to improve the tracking
of clients across facilities and services. Most pilot sites developed a single tracking number
format for monitoring both mother and baby across all feeder clinics in a sub-district. The
problem with this approach is that districts used different tracking systems and patients could
therefore not be identified outside of their local health facilities. In addition, the tracking
number/code soon became recognisable as a sign of HIV infection and some clients defaced
their cards or failed to bring them for appointments to avoid stigmatisation.
Our findings were that most of the methods used to track clients, despite being attempts to
protect the confidentiality of women, actually served to reinforce stigma and silence and further
prevented health workers from identifying HIV positive women.
With expansion of an integrated PMTCT service across the country, a national unique patient
identifier for tracking of clients while maintaining confidentiality must be developed. Limpopo
province has implemented a coding and tracking system across the province that has worked
effectively. The code provides a mechanism to facilitate continuity of care and anonymised
identification of HIV status. This approach should be evaluated to determine its applicability
at a national level.
THE ROLE OF POSTNATAL CARE AND SUPPORT
Postnatal care of HIV positive women is important in order to prevent opportunistic infections,
to provide nutrition support, to provide routine care such as family planning, and to link
women with other support services. Since many maternal deaths occur in the postpartum
period, good postnatal care can help to ensure the survival of mothers, which is critical to
the survival of their infants 1 . In the initial postpartum period care should centre on the prevention
of postpartum sepsis, provision of multivitamins, provision of information on nutrition, and
ongoing counselling and support for infant feeding. Postnatal infant feeding support is essential
to help mothers overcome difficulties and to ensure that the chosen method is practiced safely.
Regarding postnatal nutrition support, preliminary analysis of data from Kenya suggests that
HIV positive women who breastfeed may be at greater risk of weight loss and postpartum
mortality than HIV infected women who do not breastfeed 2 . While this finding requires further
research, it strongly suggests that programmes to prevent MTCT should also provide nutrition
support to HIV infected women in the postpartum period, particularly those women who are
breastfeeding their infants.
The involvement of community health workers for postpartum support, as is being explored
in KwaZulu-Natal, is encouraging and may serve as a cost effective approach for other
provinces to adopt. WHO 3 places great emphasis on the importance of postpartum support
and recommends that at least 90% of HIV infected women should be referred to a support
network.
Ultimately, the destigmatisation of HIV/AIDS at both the community level and the health service
level may enable individuals with HIV to feel more comfortable disclosing their status to health
workers. That is certainly a long term aim; however, some strategies will need to be developed
in the short term to promote improved follow up of mothers and infants as a means to providing
improved care.
35

RECOMMENDATIONS FOR IMPROVING THE POSTNATAL MANAGEMENT OF
HIV POSITIVE WOMEN AND THEIR INFANTS
• A facility level strategy that integrates follow up care for all HIV positive women and
their infants into routine primary health care services should be developed.
• Peer support programmes to encourage continuing support, education and mentorship
for mothers living with HIV should be encouraged.
• A postnatal visit for mothers and infants after one week should be recommended,
together with a greater focus on maternal care during routine visits for immunizations
and growth monitoring.
• Health workers should be knowledgeable on practical guidelines for the nutritional
management of persons living with HIV/AIDS.
• Faster implementation and training of health workers is needed on the new IMCI
guidelines that address issues of follow up care for infants with HIV.
• Appropriate referrals should be provided to community support structures for homebased
care and support groups.
RECOMMENDATIONS FOR FURTHER RESEARCH
Research should be commissioned to evaluate the current postpartum care received by HIV
positive women and their families who have participated in the PMTCT programme. The
research should focus on evaluating the extent to which the current protocol and other guidelines
such as IMCI are being followed.
REFERENCES
1. Preble EA, Piwoz EG. Prevention of mother to child transmission of HIV in Africa:
practical guidance for programs. Washington: Academy for Educational Development,
2001.
2. Nduati R et al. Effect of breastfeeding on mortality among HIV-1 infected women: a
randomised trial. Lancet 2001; 357: 1651-55.
3. WHO/UNICEF/UNAIDS. Local monitoring and evaluation of the integrated prevention
of mother to child HIV transmission in low-income countries. Geneva: WHO, 2001.
36

6.5 Infant Feeding
Infant feeding remains one of the greatest challenges in the PMTCT programme. The
dilemma is that breastfeeding prevents millions of infant deaths each year throughout the
world, but causes at least one-third of all paediatric HIV infections. The HST’s interim
report on the PMTCT programme highlighted infant feeding as the major policy issue for
government with a caution that the policy of providing free formula may do more harm
than good in many communities. The report also recommended that a national commission
of experts be established to discuss infant feeding policy in the context of HIV. Such a
commission has not been established; however, at the national scientific consultative forum
hosted by the National DoH and HST in August 2002, a group of infant feeding experts
worked together to produce a discussion document with clear policy options for the
government. Members of this team included: Dr Mickey Chopra, Dr Mark Colvin, Professor
Anna Coutsoudis, Ms Tanya Doherty, Dr Nigel Rollins, Dr Haroon Saloojee, Dr Christine
Varga, Professor David Sanders, Dr Glenda Gray, Dr David Woods, Dr David McCoy
and Dr Ameena Goga.
This chapter presents the key findings of the 2 nd evaluation of the pilot sites, and makes
recommendations for an infant feeding policy drawing on this evaluation and policy
recommendations of the August 2002 National Scientific Consultative Forum.
BACKGROUND
The advent of HIV and the knowledge that the virus can be transmitted through breastmilk
has led to the need for the promotion of breastfeeding to be qualified by information
regarding the risks of HIV transmission through breastmilk. These risks however need to
be weighed up against the immunological and nutritional benefits of breastfeeding, and
the potential dangers of replacement feeding, even for infants born to HIV positive women.
In recognition of the trade-off between harm and benefit, a WHO Technical Task Team
has recommended that exclusive replacement feeding should only be encouraged in HIVinfected
women if it is safe, feasible, acceptable, accessible and sustainable, but that if
any of these conditions are not met, exclusive breastfeeding should be promoted 1 .
Currently the PMTCT pilot programme in South Africa offers free formula milk for a period
of six months to HIV positive women who choose not to breastfeed. With the low follow
up rates displayed in this report, and the acknowledgement that routine data cannot be
used to track cohorts of infants, very little is known about the actual infant feeding practices
of HIV positive women nor of the impact of the provision of free formula milk on infant
morbidity or on infant feeding practices in the non-HIV positive population.
37

KEY FINDINGS FROM THE EVALUATION
Infant feeding intentions of HIV positive women in the pilot sites
Public health concerns have been raised about the decision to supply free formula as part of
the package of care for PMTCT. The interim report on the PMTCT pilot programme noted that
the uptake of free formula varied considerably between sites with similar socio-economic
contexts, and that free formula was being taken up by women under conditions that were not
safe or feasible 2 . It was also indicated that some women who were provided with free formula
did not formula feed exclusively, and often mixed fed with breastmilk.
This evaluation found evidence of high rates of intentions to formula feed in both urban and
rural sites. However, intentions to breastfeed have increased during the course of 2002 in
many provinces. Figure 6.5.1 shows the infant feeding intentions that were recorded prior
to discharge for all HIV positive women in the pilot sites during 2002.
Figure 6.5.1: Infant feeding intentions of HIV positive women in the 18 pilot sites,
2002
Average (choices)
Siloam (LP)
Virginia (FS)
Durban (KZN)
Frankfort (FS)
Mankweng (LP)
Pietermaritzburg (KZN)
Rustenburg (NW)
Umzimkulu (EC)
Paarl District (WC)
Kimberley (NC)
Evander (MP)
Kalafong (GT)
Lehurutshe (NW)
De Aar (NC)
East London Complex (EC)
Shongwe (MP)
Guguletu (WC)
Natalspruit (GT)
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Formula Feeding
Breast Feeding
38

An average of 58% of HIV positive women expressed an intention to practice exclusive formula
feeding and an average of 42% of HIV positive women intended to practice exclusive
breastfeeding. These rates differ substantially between provinces and may be related to
institutional or facility policies, different training initiatives or staff biases towards one or other
option.
Figure 6.5.2: Infant feeding intentions of HIV positive women according to urban/rural
location
%
100
90
80
70
60
50
40
30
20
10
0
Formula
Breast feeding
Rural
Urban
Figure 6.5.2 displays infant feeding intentions according to rural or urban location of the sites.
It is clear that the predominant choice of HIV positive women across both locations is formula
milk. Of concern is the slightly higher rate of intention to formula feed in rural areas compared
with urban areas. In the two most rural sites, Shongwe hospital in Mpumalanga and Rietvlei
hospital in the Eastern Cape, the formula feeding intention rates are 90% and 69% respectively.
These are marked increases from the first evaluation where the formula feeding intention rate
in Shongwe was 74% and in Rietvlei, 54%. In the Rietvlei site, there have been reports of
formula supplies running out and generally limited access to formula as only a few of the
feeder clinics maintain supplies.
Despite the increases noted above, the finding in most provinces is that formula feeding
intention rates have decreased since the first evaluation (January to December 2001). The
most marked changes have been seen in the Free State, KwaZulu-Natal and Limpopo where
both pilot sites showed a decrease in intentions to formula feed. In the Free State intentions
to formula feed have decreased from 73% to 36%. In KwaZulu-Natal a similar decrease has
been seen from 53% to 41%, and in Limpopo formula feeding intentions have decreased 73%
to 37%. In the Western Cape and the Northern Cape the rates have decreased but remain
above 70%. The only province showing an increase in formula feeding intention rates across
both sites is the Eastern Cape where the rate increased from 62% to 80%.
The decrease in intentions to formula feed and increase in the intentions to breastfeed are due
to a variety of factors including:
• The introduction of infant feeding training for health workers involved in PMTCT.
• The stigma associated with the free distribution of formula milk from clinics.
• The unreliable supply of formula to facilities, particularly feeder clinics.
The provinces with the highest rates of breastfeeding intentions; Limpopo (64%), Free State
(64%) and KwaZulu-Natal (60%) have all prioritised training on infant feeding counselling.
In addition, the Free State PMTCT programme is managed through the MCWH directorate
and not the HIV directorate and a decision has been made not to supply formula to new
PMTCT sites.
39

There is a need for caution when interpreting these rates as these reflect stated intentions.
There is no data on actual feeding practices nor the outcome of infants in relation to feeding
practices as no prospective follow up was undertaken during this evaluation. A prospective
cohort study commissioned by the National Department of Health is underway in three sites
to monitor infant feeding practices.
Infant feeding counselling and risk assessment
Infant feeding counselling of pregnant women to make appropriate decisions for themselves
is complex. Counselling can influence and bias the choice that mothers make regarding infant
feeding practices. Evidence from this evaluation suggests that there is currently significant
inconsistency and misinformation in infant feeding counselling at South African PMTCT pilot
sites. In particular, we have seen that poor infant feeding counselling seems to lead to high
intentions to exclusively formula feed in places where free formula milk is provided. As indicated
earlier, in provinces where efforts have been made to increase the training of health workers
on infant feeding, such as Limpopo, KwaZulu-Natal and the Free State, fewer HIV positive
women choose to formula feed.
In KwaZulu Natal, although the two PMTCT sites (Durban and Pietermaritzburg) are quite
similar, more women intend to exclusively breastfeed at the Durban site compared with the
Pietermarizburg site (including the rural area which is part of this site). It is possible that
information on the relative risks of HIV transmission through breastfeeding versus the relative
risks of not breastfeeding is presented differently at various PMTCT sites. This could be due
to the fact that the PMTCT programme has embraced the opinions expressed by influential
staff and infant feeding experts in different regions.
The current PMTCT protocol for the pilot sites 3 recommends that counselling on safe infant
feeding should take place both antenatally (during the post test counselling session) and
postnatally before the first feed. Within the antenatal setting, formal counselling is conducted
mostly by lay counsellors. Very little is known about the extent to which nurses or doctors
reinforce infant feeding options during their consultations with clients. The training of lay
counsellors is largely focussed on counselling for an HIV test and training typically consists
of a 2-3 week VCT course run by organisations such as ATICC or Lifeline. The infant feeding
component of counselling is inadequately covered in these training courses largely because
the training was designed to prepare individuals to conduct VCT. Attempts by the DoH to focus
more on infant feeding within PMTCT training have also been directed at professional health
workers and not lay counsellors. This raises serious concerns regarding the ability of lay
counsellors to accurately present infant feeding options to mothers.
Some provinces have made impressive attempts to assist counsellors in the process of assessing
the suitability of infant feeding options. The illustration below was developed in KwaZulu-
Natal and was seen used at the rural Church of Scotland site. It provides a list of determinants
that should be assessed in the counselling session to decide on an infant feeding option. Other
international initiatives are also underway to develop similar counselling tools. The World
Health Organisation has developed a set of counselling cards to guide health workers through
various stages of antenatal and postnatal support for infant feeding. These cards have been
field tested in South Africa and will be incorporated into the PMTCT and infant feeding training
course.
40

Kwazulu-Natal infant feeding assessment guide
Operational problems experienced in the pilot sites
This evaluation found many logistical problems with the supply of free formula milk. There were many
cases of women reporting that they had run out of formula before their next clinic appointment and
were refused additional supplies before the scheduled follow up date. In addition, the same quota of
milk tins is given irrespective of whether the infant is term or premature. Premature infants have higher
energy requirements and need to be fed more frequently in the first few weeks of life to promote
adequate weight gain. Women should therefore be given the appropriate amount of formula for the
infant’s milk requirements to avoid supplies running out before the next scheduled clinic visit.
Some facilities have reduced the amount of formula given to mothers from monthly supplies to fortnightly
supplies out of fears that providing large amounts of stock would promote the sale of formula within
communities. Fortnightly visits to clinics are costly for many women who have to travel long distances
and this system may actually serve to promote mixed feeding in order to make supplies of formula last
longer.
There have been reports in many provinces of health workers being unsure of what to advise mothers
regarding infant feeding after six months when the free formula supply ends. The solution adopted in
many areas is to automatically transfer these infants to the PEM (Protein Energy Malnutrition) Scheme
in order for them to continue to receive free milk. This will have serious financial implications for the
PEM scheme. There is a lack of clarity at the national level as to whether infants born to HIV positive
women should be included in the category of ‘high risk’ children and thereby qualify for free formula
milk through the PEM scheme.
If free formula milk is to continue being included in the package of care for PMTCT, consideration should
be given to extending the period of supply of the free formula to prevent the risk of growth faltering
at the critical time of 6 to 12 months where milk still constitutes a major component of infant nutrition.
There have been instances in the Eastern Cape and Mpumalanga where the formula supplies have run
out for periods of up to two weeks. This has serious implications for the nutritional safety of infants and
reflects poor planning and stock control.
There was evidence in a few sites of HIV positive women choosing to purchase formula from local stores
rather than accessing the free formula from PMTCT facilities because of fear of Pelargon (the formula
brand used for the PMTCT programme) being associated with HIV.
These problems highlight the fact that the provision of free formula milk does not ensure exclusive
formula feeding or optimal nutrition for infants as reliable delivery of supplies is not guaranteed in
many settings and the management of supplies at facilities does not appear to take into consideration
the needs of mothers and infants.
41

Differences in provincial policies
In the absence of a national policy on HIV and infant feeding for the non-pilot sites, provinces
have developed their own policies based on their experiences with the pilot sites. As a result
there are various infant feeding policies being implemented across the country. In the Free
State and Northern Cape the decision was made not to supply free formula outside of the
pilot sites. The Free State made this decision based on findings from the pilot sites that despite
the availability of free formula milk, women still mix feed with breastmilk and formula milk.
It is interesting to note that the MCWH directorates and not the HIV directorates in these two
provinces manage the PMTCT programme. The Free State has the highest rate of breastfeeding
intention amongst HIV positive women in the pilot sites. This is most likely attributable to the
influence of the MCWH management and their commitment to lactation management training
and the Baby Friendly Hospital Initiative. The Free State plans to phase out the free formula
from the pilot sites as soon as they receive notification that the pilot sites have ended their
term.
The other seven provinces are supplying free formula to non-pilot sites, however, there are
reports from many sites of poor stock control and procurement and, in Mpumalanga, of
formula only being available at clinics and not hospitals. On discharge, mothers are informed
that they can collect formula from their nearest clinic.
Provinces will continue to develop their own policies in the absence of national guidance which
may be detrimental to infant nutritional safety and cause confusion amongst health workers.
DISCUSSION
Concerns about spillover
There have been concerns that the promotion of formula feeding in HIV positive women could
‘spill over’ into the general population 4 . ‘Spillover’ is considered to be increased use of formula,
either earlier introduction, increased use of formula feeds or stopping breastfeeding altogether
in HIV uninfected populations, or populations of unknown HIV status.
Data from Botswana 4 suggests that the provision of free formula by facilities could be perceived
by the general population as an official endorsement of formula feeding as being superior
to breastfeeding. Together with the low levels of knowledge about the value and benefits of
exclusive breastfeeding amongst health workers, and with the added confusion related to HIV
transmission, the policy could lead to an undermining of breastfeeding promotion and a
deterioration of child health outcomes. These concerns have been given further justification
by a UNICEF study of four countries in Southern Africa reporting that uncertainty over HIV
and infant feeding was leading to a dangerous demise in support for breastfeeding 5 .
The study in Botswana found that 95% of the women (unknown HIV status) at non-PMTCT sites
were breastfeeding, while only 76% of HIV uninfected women at PMTCT sites were breastfeeding.
The research concluded that the decrease in breastfeeding amongst uninfected women at
PMTCT sites was due to the availability and distribution of free infant formula, which indirectly
promotes infant formula as being a good form of feeding.
There is also evidence that the provision of commercial infant formula increases the potential
for, but does not guarantee, exclusive formula feeding. Data from Nairobi, showed that at
least 30% of HIV-infected women who chose to formula feed and who were provided with
subsidised formula milk, did not exclusively formula feed 6 . It is possible that when infant
formula is offered free of charge, clients might be tempted to choose formula feeding because
this option would increase the food security of the household and not because they are
committed to exclusive formula feeding. Hence the provision of free infant formula might
increase the likelihood of mixed feeding which is thought to be particularly dangerous.
42

There has thus far been no evidence of spillover in South Africa 7 although this will be validated
from a repeat cross sectional survey of infant feeding practices in PMTCT and control sites
in South Africa which is due to be conducted during 2003. This evaluation found no evidence
of advertising of formula milk within the clinics visited nor of inappropriate dispensing of
formula milk to HIV negative women. Breastfeeding is still recommended by health workers
as the optimal feeding option for HIV negative women.
Weaning and rapid cessation of breastfeeding
According to the pilot site PMTCT protocol 3 , women who choose to breastfeed should be
counselled to exclusively breastfeed for 4 months and to abruptly stop breastfeeding at 4
months. Thereafter they are entitled to receive free infant formula for 2 months.
Very little is currently known about the feasibility of abrupt cessation of breastfeeding within
the South African context; however, experience within the pilot sites indicates that this is very
difficult to achieve due to cultural beliefs regarding length of breastfeeding and difficulty in
accessing the free formula supply following early breastfeeding cessation. Abrupt cessation
of breastfeeding at the early age of four months could have serious consequences for the
nutritional status of the infant, especially since access to free formula milk is not guaranteed
in many settings and supplies may be erratic.
With recent consideration given to earlier infant testing algorithms, breastfeeding mothers
could potentially know their babies HIV status at 6-weeks of age. One consideration offered
to promote early testing of infants was that mothers could modify feeding practices. Breastfeeding
mothers with HIV positive babies would be offered an opportunity to continue breastfeeding
their babies thus avoiding the need for early weaning. Formula feeding mothers with HIV
positive babies could be offered an opportunity to re-lactate.
An evaluation of a PMTCT intervention in the Ndola district, Zambia 10 , showed that although
women’s knowledge of early weaning as a possible means to reduce likelihood of HIV
transmission increased during the study period (from a baseline of 52% to 74% at midterm),
almost 100% of mothers of infants between 6 and 12 months old were still breastfeeding at
the midterm evaluation. This evaluation concluded that knowledge of HIV status does not
appear to affect the practice of continued breastmilk beyond 6 months, most likely for economic
and social reasons and to avoid the stigma associated with not breastfeeding.
Community support for infant feeding
HIV-infected women need to receive ongoing counselling and support for whichever infant
feeding choice they make. Research has shown that the likelihood of achieving either exclusive
formula feeding or exclusive breastfeeding are greatly enhanced if proficient support is
available i.e. ongoing counselling and emotional / psychological support, which takes into
account the mother and family’s concerns and difficulties. This has been demonstrated through
numerous studies.
Self-reported exclusive breastfeeding rates of approximately 75% at 3 months have been
achieved in Cato Manor, KwaZulu-Natal (HIV infected population) and in Hlabisa, rural
KwaZulu-Natal (general population) with significant support. In Cato Manor the support
consisted of clinic based breastfeeding counsellors who did occasional home visits, while in
Hlabisa the support consisted of regular home visits by well-trained breastfeeding counsellors.
Similar experience has been described in non-HIV positive populations in Mexico 8 and
Bangladesh 9 , where peer counsellors provided support at regular intervals. In Bangladesh
exclusive breastfeeding rates increased from 9% to 70% at 5 months.
In Zambia exclusive breastfeeding rates after proficient support was provided to women, were:
85%, 87%, 92%, 88% and 85% in children aged 1week, 1week-1month, 1-2 months, 2-3
months and 3-4months respectively 10 .
43

With only moderate support (one home visit two weeks after delivery, with repeat visits on
an as-needed basis or following a failed clinic appointment – i.e. no regular ongoing counselling
and no involvement of community or family members), HIV-infected women in Nairobi provided
with free infant formula reported 70% compliance (i.e. 30% used breastmilk) 6 . 100% compliance
may have been achieved with more intensive support for exclusive formula feeding. In the
breastfeeding arm (defined as any use of breastmilk), in the absence of support and against
a background of low exclusive breastfeeding rates in Nairobi, only 9% of women who chose
to breastfeed were exclusively breastfeeding at 6 months. This data indicates that with no or
moderate support it is difficult to achieve exclusive formula feeding, and even more difficult
to achieve exclusive breastfeeding.
Community support is especially important for women’s feeding choices in contexts where
decisions are not made by the mother alone, and where cultural or family practices are highly
influential in determining ultimate practices. A study of social and community perspectives on
PMTCT conducted in the Limpopo 11 province found that a common cultural belief in the region
is that babies cry because they do not receive adequate food. In relation to exclusive
breastfeeding, women may experience immense pressure from family members to mix breastmilk
with formula milk in order to ‘satisfy’ the infant. This was confirmed by the finding that 27%
of the individuals interviewed believed that breastmilk alone is not enough for an infant. When
asked about the sources of infant feeding information, respondents cited clinics or nurses as
the most common source of information (57%), followed by mothers and grandmothers (36%).
With the kind of social pressure described above, the current system of counselling within the
PMTCT programme is clearly inadequate to provide sufficient support to women in their infant
feeding choices. Initiatives outside of the health centre such as community and peer support
need to be explored to enhance safer infant feeding practices.
Infant feeding research: The South African National PMTCT Cohort Study
In anticipation of possible poor follow up of infants through the routine system, the national
research and evaluation framework developed by the Health Systems Trust and the National
DoH made provision for a prospective cohort study of mother-child pairs with active followup
and case finding to determine the impact of the programme on infant feeding practices
and vertical transmission rates. In order to estimate the proportion of children infected postnatally
through breastmilk, the cohort study is designed to track feeding practices and to
measure HIV status at 3 weeks, six months and nine months postpartum. The study sites are
nearing completion of recruitment and results are due in December 2004.
Designing an Appropriate Policy
Given the fact that all provinces are attempting to scale up PMTCT services, clear national
policies are required on the promotion of appropriate and safe infant feeding in the context
of HIV. Of particular importance is a decision on whether government should extend the pilot
programme protocol of providing free (state subsidised) formula to HIV positive mothers who
choose to exclusively formula feed. As there are still gaps in knowledge, and differences in
expert opinion, decisions need to be based on the best available data and on the basis of
sound public health arguments.
44

RECOMMENDATIONS
1. Infant and Young Child Feeding
a. Promote exclusive breastfeeding in the general population and for children already
infected with HIV
• 76% of pregnant women in South Africa are HIV negative. Exclusive breastfeeding
for the first 6 months of life should be aggressively promoted and supported
amongst (i) HIV negative women, (ii) women of unknown HIV status, and (iii)
HIV infected women who choose to breastfeed.
• The Baby Friendly Hospital Initiative that supports exclusive breastfeeding
amongst the three groups of women mentioned above should be accelerated
– targets for BFHI accreditation of all levels of hospitals in each province should
be promoted and set. This will help minimise any potential “spillover” effect
from HIV positive women who choose to formula feed from affecting the
general population.
• The International Code for the Marketing of Breastmilk Substitutes should be
reviewed in South Africa, adapted, legislated and enforced. The South African
code is currently a position paper, and certain details relating to the distribution
of formula need to be discussed in the South African context.
• Other groups in society e.g. the local community, men, church groups, traditional
leaders etc. need to understand the importance of exclusive breastfeeding for
6 months and continued breastfeeding till 24 months for HIV negative women
and women of unknown HIV status.
b. Promote exclusive formula feeding (no breastmilk at all) amongst HIV infected
women for whom exclusive formula feeding is acceptable, safe, sustainable, feasible
and affordable and who have chosen to formula feed after individualised counselling
and education
• There is a need to define and understand what is meant by “being able to
safely prepare formula”. This will permit more appropriate counselling and
information to HIV positive mothers who have to choose the best infant feeding
choice for their infant.
• The Baby Friendly Hospital Initiative needs to accommodate the support of
formula feeding amongst HIV positive women who are able to safely prepare it.
2. Provide Better Counselling and Information for HIV infected women on infant feeding
options
Under the present social, environmental and economic circumstances in South Africa, there
isn’t one single feeding method for all HIV infected women that can be recommended. Hence
all HIV infected women should received appropriate, high quality counselling and information
on infant feeding options, and support to implement their chosen option.
45
• Accurate and consistent messages regarding infant feeding should be provided
at all health facilities, and through a public IEC campaign. Information on
formula feeding should only be provided to women known to be HIV positive.
• An unequivocal message that mixed breastfeeding is the worst option for all
mothers and children should be delivered in all health facilities and through
public IEC campaigns.
• Review the training courses, the preparation of and the support for counsellors
and health workers who conduct infant feeding counselling.
3. Investment in human resource development
• A greater investment in the effective training and continuing support of PHC
health workers and lay counsellors is required so that high quality infant
feeding counselling and support is provided.
• All facilities implementing PMTCT services should have trained nurses and lay
counsellors who are able to provide infant feeding counselling and support
to women.

4. Ensure on-going Support After Delivery
• HIV-infected mothers who choose replacement feeding, either in the first or
second 6 months of life, should receive proficient continuing support from
health workers to achieve the safest degree of replacement feeding possible.
• HIV-infected mothers who choose to breastfeed should receive proficient
continuing support from health workers to support exclusive breastfeeding.
• Means/models to reduce HIV/AIDS-related stigma, both in general as well
as specifically related to PMTCT (i.e. mother or infant testing, choosing
replacement feeding, etc), need to be found.
5. Accelerate research into the provision of HAART to allow safe breastfeeding
Another long-term goal should be the possible provision of HAART (or a variation of HAART)
to all HIV positive mothers in order to improve their general health status and to make
breastfeeding safe. Alternatively, providing prophylactic anti-retroviral therapy to babies
during breastfeeding should be explored. Studies assessing these options are underway in
South Africa.
RECOMMENDED RESEARCH
Rapid appraisals
Of feasibility and acceptability regarding:
• How formula is used in the households of mothers who accept free formula
feeds.
• To determine how much the provision of free formula influences the choices
around infant feeding practices.
Longer-term studies
• The effect of the provision of free formula on child health.
• To explore the quality of counselling in PMTCT sites to determine whether
quality of counselling biases choice.
• To explore ways to increase community acceptance for infant feeding practices.
• To understand how much women in different settings are free to make infant
feeding choices, and whether they can sustain that decision within the household.
• Research is needed to develop models for effective stigma reduction in
communities and effective community engagement to increase support for
infant feeding.
• As part of stigma reduction, issues of “best practice” surrounding encouragement
of disclosure and ensuring (shared) confidentiality on all levels should receive
priority attention.
• Research is needed to determine what modes of cessation of breastfeeding
are feasible, and what community attitudes towards these modes of cessation
are.
• Further research is needed to determine the impact of antiretrovirals for mothers
or infants on breastmilk transmission.
46

REFERENCES
1. WHO. New data on the prevention of mother to child transmission (MTCT) of HIV and
their policy implications. WHO Technical Consultation on Behalf of the
UNFPA/UNICEF/WHO/UNAIDS InterAgency Task Team on MTCT. Geneva: WHO,
2000.
2. McCoy D, Besser M, Visser R, Doherty T. Interim findings on the National PMTCT pilot
sites. Durban: Health Systems Trust, 2002.
3. South African National Department of Health. Protocol for the eighteen PMTCT pilot
sites in South Africa. Pretoria: Department of Health, 2001.
4. Willumsen J, Rollins N. Evaluation of infant feeding practices by mothers at PMTCT
and non-PMTCT sites in Botswana. Gabarone: UNICEF, 2001.
5. Latham MC, Kisanga O. Breastfeeding and HIV: a four country study. Paper presented
at 17th International Congress of Nutrition. Vienna: August 2001, abstract no:
3.03.012.
6. Nduati R, John G, Mbori-Ngacha D, et al. Effect of Breastfeeding and Formula Feeding
on Transmission of HIV-1. JAMA 2000; 283: 1167-1175.
7. McCoy D, Goga A, Levin J, Doherty T, Makakole-Nene S, Chopra M, Rollins N. A
baseline survey of young infant feeding practices in the context of HIV in South Africa.
Durban: Health Systems Trust, 2003.
8. Morrow AL, Lourdes Guerrero M, Shults J, Calva JJ, Lutter C, Bravo J, Ruiz-Palacios
G, Morrow R, Butterfoss FD. Efficacy of home-based peer counselling to promote
exclusive breastfeeding: a randomised controlled trial. Lancet 1999; 353:1226-1231.
9. Haider R, Ashworth a, Kabir I, Huttly SRA. Effect of community-based peer counsellors
on exclusive breastfeeding practices in Dhaka, Bangladesh: a randomised controlled
trial. Lancet 2000: 356:1643-1647.
10. Kuhn L et.al. Uptake of interventions to reduce mother to child transmission of HIV:
Nevirapine and exclusive breastfeeding in the Zambia Exclusive breastfeeding study.
International AIDS Conference: Barcelona 2002, TuOrB1177.
11. Varga C. The social context of PMTCT. Report from the scientific consultative forum
on HIV/AIDS. South Africa, August 2002.
47

6.6 Health Care Infrastructure
This section discusses key areas of health care infrastructure namely human resources,
management, information systems and management of consumables and supplies. The pilot
sites have highlighted the importance of leadership and effective management as key components
of a successful PMTCT programme. This is not surprising given the fact that this programme
has required extensive planning and management of additional budgetary allocations,
recruitment of new staff (lay counsellors), training of health workers, additional health
information, the supply of test kits, formula and nevirapine, referral networks between delivery
centres and clinics, and the involvement of NGOs and communities.
6.6.1 Human Resources
A. COUNSELLING
Counselling and testing for HIV, the entry point to PMTCT services is a difficult and timeconsuming
procedure. As a consequence the availability of lay counsellors to support health
workers is a cornerstone of the PMTCT programme. This section will outline the key findings
relating to the human resource requirements for counselling as well as providing recommendations.
Key Findings from the Evaluation
Management of lay counsellors
All provinces have made attempts to hire lay counsellors to support PMTCT counselling. The
approaches used to employ and manage lay counsellors have differed greatly between
provinces. There are large differences in remuneration between and within provinces as can
be seen from the table below.
Table 6.6.1: Employment and Management of lay counsellors
Province
Monthly salary of lay
Who pays the
Management by
counsellors
counsellors, NGO or
NGO or
province/local
province/district
authority
Eastern Cape
R500 paid to counsellors
District Councils
District Councils
in East London, not paid at
other sites yet.
Free State
R500
NGO (NPPHCN)
NGO (NPPHCN)
Gauteng
R 800
Regions
Regions
KwaZulu-Natal
R 2900
Province
Province
Limpopo
R1500 (only paid from
NGO
NGO
November 2002)
Mpumalanga
R 500- planned salary for
NGO
NGO
lay counsellors, not
currently paid except in
Evader where they are
paid R1300.
North West
No salary
No salary
Province
Northern Cape
R500
Province
Province
Western Cape
R2000
NGO
NGO
48

The monthly salaries for lay counsellors range from R2900 in KwaZulu-Natal to R500 in
the Free State, Northern Cape and Eastern Cape. In addition to differences between
provinces, differences within provinces also exist. In Mpumalanga, the lay counsellors at
the Evander site are paid R1300 per month yet the provincial plan is for the rest of the
lay counsellors who have not yet been employed to receive R500 per month. Improved
co-ordination is needed to prevent a negative impact on the morale and motivation of the
counsellors, and high turnover rates.
Provinces such as Gauteng, Northern Cape and Evander, where lay counsellors are paid
between R500-R800 per month are experiencing many problems in retaining trained
counsellors. The counsellors are supposed to work a 20-hour week yet due to large client
loads they are frequently expected to work longer hours without over-time remuneration.
Due to the unco-ordinated nature in which lay counsellors have become part of PMTCT
services, their supervision has been haphazard and unsatisfactory. Some provinces chose
to contract NGOs for the recruitment and management of lay counsellors whilst others
allocated the funds to local authorities. There are positive and negative aspects to both
of these systems and the choice is often dictated by provincial financial management
procedures. However, the situation has resulted in confusion over who is responsible for
the supervision of lay counsellors, the NGO or the health workers in the facilities where
the counsellors work. The identification of specific individuals who would be responsible
for the supervision and mentoring of lay counsellors together with clear performance
indicators would improve this situation. In some of the pilot sites the contractual relationship
and accountability of NGOs was to the Provincial managers. Local facility managers were
not empowered to address poor performance issues directly with the NGOs or lay
counsellors.
This report shows that many provinces have not yet established a system for the recruitment,
management and remuneration of lay counsellors. In Mpumalanga and the Eastern Cape,
almost two years since the initiation of the programme, some of the pilot sites still do not
have lay counsellors. Some provinces, particularly the Eastern Cape, North West and the
Northern Cape, have cited bureaucratic, administrative and labour relations problems
with the recruitment of lay counsellors. The lack of lay counsellors in these provinces has
significantly limited the uptake of HIV testing by pregnant women.
During interviews with provincial managers there were many calls for guidance from the
National Department of Health in the employment and management of lay counsellors.
No national policy currently exists on the employment of middle level health workers and
a guiding document laying out minimal criteria for the selection, training, payment and
performance management of lay counsellors is necessary.
49

Two options exist for the contracting of lay counsellors: direct contracting of individual
lay counsellors to the provincial health department or provincial contracting of NGOs to
supply and manage lay counsellors. There are advantages and disadvantages with both
of these options. The addition of a new group of civil servants would pose an enormous
challenge in terms of additional administrative work, however this may ultimately be a
more sustainable approach. Contracting lay counsellors through NGOs may result in more
complex management arrangements between district and facility managers and the NGOs,
however utilising local NGOs may service to improve the site support and mentoring of
lay counsellors and would facilitate the transfer of funds to local community-based
organisations.
Integration of lay counsellors
Co-operation with and acceptance of lay counsellors by other health workers involved in
PMTCT has been poor in many sites as lay counsellors have not been integrated into
facilities as members of the health team. The lack of standardised job descriptions, regular
and reasonable compensation, adequate employment conditions and a human resource
plan for lay counsellors has contributed to this situation. There have also been reports of
conflict between nurses and lay counsellors at some facilities. This is often due to lack of
clarity regarding the role and functions of lay counsellors. In some facilities lay counsellors
have been used as general workers to clean clinics. This exploitation of lay counsellors
is no different from the experiences of other lay workers such as community health workers
and home based carers. It will only be curtailed with a national human resource plan for
the entire cadre of lay workers. Regular forums where health workers and lay counsellors
can share problems and concerns should be encouraged.
When the pilot PMTCT programme was introduced, it was decided that a specific cadre
of counsellor was necessary to undertake counselling in this context. Many of the PMTCT
sites were already VCT sites with existing VCT counsellors. In many provinces the recruitment,
employment and management of PMTCT counsellors differs from that of VCT counsellors
operating within the same facilities. These include differences in salary, working hours
and training. This approach only serves to isolate the PMTCT programme from other
HIV/AIDS services. There is certainly justification for having specific training requirements
for PMTCT counsellors beyond basic VCT counselling, particularly with regard to infant
feeding, however given the general shortages of counsellors within facilities it would be
wise to develop a cadre of counsellors who have the skills to move interchangeably between
VCT, PMTCT, STI, or TB services as needed. Certainly greater attention should be paid to
ensuring standardisation of remuneration and salary conditions amongst these lay workers
so that greater integration can be facilitated.
50

Training
Currently, lay counsellor training focuses on counselling skills needed for HIV testing and does
not include counselling on infant feeding options. According to the national PMTCT protocol
for the pilot sites, infant feeding options should be discussed at the post-test counselling session,
which, is generally undertaken by lay counsellors. There is no specific time in which nurses
are supposed to discuss infant feeding options and it is most likely mentioned during routine
antenatal assessments; therefore, if this training is not extended to lay counsellors, we should
be concerned about the accuracy and quality of the infant feeding information being given
to clients. The manual currently being developed for health workers should therefore be
adapted to create a version for lay counsellor training.
The involvement of lay counsellors in PMTCT should not be seen as abdication of the counselling
role of nurses. Counselling is an integral part of a nurse’s interaction with clients and it is
needed far beyond the limited context of HIV/AIDS. Nurses and doctors need to be able to
assist with counselling as required, to reinforce infant feeding options during routine antenatal
care and to provide supervision and mentoring for lay counsellors. However, when the PMTCT
programme was introduced, the impression was given that nurses require additional training
in counselling in order to provide counselling in the context of PMTCT. Training courses for
counsellors range from 10 days to three weeks and require staff to be released from services
and often to travel long distances to reach training venues. As a result the backlog of nursing
staff who still require counselling training, particularly from rural facilities, is huge. There is
certainly a place for some refresher training in counselling skills for nurses but it seems
unrealistic to expect all nurses involved in antenatal care to attend a course of a few weeks
that would result in a large disruption to services.
There are clinics in the Eastern Cape and Mpumalanga that are run by one professional nurse.
These nurses have been unable to attend any counselling training because it would require
the entire clinic to close. Therefore alternative approaches are necessary that could consist
of on-site training over a few days with a focus on counselling skills as well as infant feeding
counselling. In addition, the completion of these courses should not be a pre-requisite for the
establishment of a PMTCT programme at a facility, nor should it be a reason to delay expansion
of the programme.
Recommendations
• The supervision, support and mentoring of lay counsellors as well as their motivation
in terms of remuneration requires urgent attention.
• Greater involvement of provincial treasury departments may prevent the difficulties
associated with the transfer of funding for the payment of lay counsellors.
• Development of lay counsellor-client ratios is needed to prevent burnout of counsellors
and to maintain quality control standards.
• Lay counsellors require regular on site refresher courses to improve their performance.
Re-training should emphasise the importance of confidentiality.
• Lay counsellors should be given infant feeding training in addition to the training on
pre and post HIV test counselling.
• A national guiding document on the employment and management of lay counsellors
should be developed to prevent the large disparities between provinces. Salaries should
be commensurate with the level of service provided by the counsellors.
51

B. TRAINING OF HEALTH CARE WORKERS
As with any new health service, introduction of PMTCT activities requires training of health
workers to acquire specific knowledge, skills, and attitudes. At the same time, facilities must
create an enabling and supportive environment that motivates health workers to effectively
apply their learning. These new skills need to be integrated into broader maternal and child
health care.
Training in the context of a newly introduced programme requires both a long-term and shortterm
approach. The aim of a short-term approach is to prepare front line health workers to
implement and manage the new programme, and the aim of a long-term approach is to
integrate PMTCT training into graduate, postgraduate and in-service training courses.
One of the key recommendations from the first evaluation in terms of training was that the
focus of training should shift from HIV counselling and testing to greater emphasis on information
relating to infant feeding. The Department of Health together with UNICEF have acted on this
recommendation and have put a great deal of effort into developing a training course that
focuses on infant feeding counselling.
When the programme was initiated there was no strategic plan to train health care workers,
instead Provinces either tapped into local academic resources or local NGOs to assist with
the training. Some provinces decided to develop their own training guide. As a consequence,
the mode and duration of the training undertaken by the provinces varied widely. Limpopo
province together with the National DoH and UNICEF designed a 5-day training course that
included more information on infant feeding and HIV. The training was done on five consecutive
days following two weeks of VCT training. There was also an attempt to integrate this training
into the IMCI training to prevent duplication of efforts.
The Free State took the national protocol as the basis for in-service training that the MCWH
co-ordinator - tasked with PMTCT at the time - and her team conducted at each facility
individually with the assistance of academic institutions. The Eastern Cape, Western Cape and
KwaZulu-Natal relied on NGOs and academic institutions to assist with training. The Northern
Cape, North West Province, and Gauteng requested assistance from the Peri-natal Research
Unit (PHRU) at the Chris Hani Baragwanath Hospital. Mpumalanga used existing trainers who
were seconded from facilities to facilitate initial training efforts.
In an attempt to co-ordinate PMTCT training efforts within the country, the nutrition, HIV/AIDS
and child health directorates at the National DoH, convened a meeting in September 2001
to discuss capacity development for PMTCT and infant feeding. The outcome of this meeting
was the development of a training working group (TWG). The TWG recommended that a two
pronged approach to training be developed: 1) A short-term approach where a consultant
would be seconded from UNICEF to facilitate training in the provinces; 2) a longer term
approach where a tender would be issued to co-ordinate and sustain the demand for training
in the provinces.
The training conducted by the UNICEF consultant utilised the WHO/UNICEF Breastfeeding
counselling manual and the WHO/UNICEF HIV and Infant feeding manual. The training
programme was designed to take place over a period of 5 days with 3.5 days devoted to
effective breastfeeding. All logistical arrangements and funding for the training were arranged
by the training co-ordinator at the national DoH.
As the demand for training increased and the infrastructure to support training within provinces
was not sufficient, it was decided that a tender would be issued to provide support to provinces
in their efforts to plan and co-ordinate PMTCT training as per the longer term approach of
the DoH. The Centers for Disease Control and Prevention (CDC) agreed to fund this tender
and it was issued by the National DoH in May 2002. The tender was awarded to a consortium
consisting of Health Systems Trust, Women’s Health Project and the University of the Western
Cape.
This section will highlight progress that has been made with PMTCT training as well as ongoing
challenges to be addressed.
52

Key Findings from the Evaluation
Training models
The training model adopted for the PMTCT and infant feeding training supported by the
National DoH and UNICEF, was a modified training of trainers approach in which participants
went through a series of attachments to experienced trainers in order to become trainers and
subsequently course directors. The aim of this model is to develop infant feeding counsellors,
trainers and course directors. Ultimately, it was hoped that each province would have a few
qualified course directors and a pool of trainers so that they could take control of their own
training plans and not be reliant on the national training facilitator.
The main problem with this model is that it takes several weeks before someone is accredited
as a trainer and even longer for accreditation as a course director. During 2002, the UNICEFfunded
trainer facilitated at least one training course in every province; by the end of 2002,
4 course directors and approximately 70 trainers had been accredited. This is less than optimal
to sustain training in the provinces. However, difficulties were experienced in facilitating the
release of trainers from their clinical duties in order to attend several attachments and to travel,
often to another province to attend training. Despite the difficulties developing trainers, a total
of 700 health workers attended the course and were accredited as infant feeding counsellors.
These courses take place at an off-site venue, usually a hotel, where several staff from different
facilities gather. There are generally 40 health workers attending each course and they need
to travel to the venue and be accommodated for a period ranging from one week to two
weeks. This is a very costly approach, one course can cost between R50 000 to R70 000,
and results in large disruptions to services.
The use of this model, although effective for developing infant feeding counsellors, is not ideal
for developing trainers due to the lengthy period of attachment to more qualified trainers.
Provinces should consider the option of a dedicated course for training trainers that is separate
from the course to develop infant feeding counsellors.
The Western Cape adopted a different approach to PMTCT training that was more focused
on the protocol and operational challenges of implementing the programme. This course had
limited detail on infant feeding.
This province has successfully trained all staff working in facilities offering PMTCT services
through a two-day on-site training course taught by local experts from the health services and
academic institutions. The training focuses on understanding of the PMTCT protocol and
operational issues such as information management.
The two training courses should be seen as complimentary to each other as one is focused
specifically on infant feeding and the other on the protocol and operational issues. All provinces
should train staff on the PMTCT protocol prior to implementing a more focused course on
infant feeding counselling.
During 2003, the Western Cape requested that the national DoH/UNICEF infant feeding
training be held in the province. Two courses have since been held and the province plans
to extend this training to include more health workers.
Content of training courses
The main focus of PMTCT training in all provinces except the Western Cape has been HIV
and infant feeding. There is very little time in the HIV and infant feeding course for operational
issues and orientation to the PMTCT protocol. By contrast, the training in the Western Cape
focuses mostly on operational and management issues and little time is spent on infant feeding.
There are problems with both approaches and a balance is needed between the two focus
areas. Efforts are currently underway to develop a standardized national PMTCT training
manual. This is being written by the training consortium together with the national DoH. The
curriculum will cover 5 days of training with a focus on both the PMTCT protocol and infant
feeding counselling. It is hoped that the manual will be complete during 2003.
53

Logistical and administrative support for training
Interviews with participants and key personnel at provincial levels highlighted problems with
communication. This is largely due to the lack of administrative support for the planning
necessary for training.
In Mpumalanga training has been severely delayed due to the lack of administrative and
management support at the provincial level. Courses have had to be cancelled at late notice
due to lack of authorization for the expenditure. In other provinces the lines of communication
between the provincial, district and facility levels are weak resulting in late notification of
training and difficulties in getting staff released from their duties.
Many provinces require ongoing support in planning and communication to ensure the success
of training efforts.
Accreditation for training courses
There are two issues relating to accreditation: firstly accreditation of the training curriculum
and materials and secondly accreditation of trainers.
With regard to the curriculum and materials, the 5-day HIV and infant feeding course designed
by the National DoH and UNICEF is currently not accredited by an educational authority.
There have been requests at the national PMTCT steering committee meeting for more formal
accreditation from a Technikon or University. This would provide greater motivation for health
workers to attend the training as completion of the course could contribute to higher education
qualifications. This process is likely to take a long time and it should not hamper ongoing
training initiatives. An alternative would be to award continuing education points.
Currently, accreditation of trainers is the responsibility of the training co-ordinator at the
national DoH. The approach that has been adopted is to provide certificates signed by the
national DoH to confirm completion of the 5-day course. This is not an ideal system, as
provinces need to take ownership of their capacity development initiatives and to have control
over the quality of their trainers. Accreditation of trainers should therefore be a provincial
responsibility and based on certain key competencies.
Sustaining training initiatives
The national PMTCT and infant feeding training is a short-term approach as it targets frontline
health workers in order to prepare them for implementation of the PMTCT programme. In
order to sustain training initiatives the focus should be both on training current providers as
well as pre-service individuals.
PMTCT training should be included in the core curriculum of all training programs for health
professionals (nurses, doctors and allied health professionals). All graduates of training
programs should be informed about PMTCT and should not require additional in service
training.
A curriculum for PMTCT training suitable for introducing PMTCT to practicing health care
providers should be developed. The curriculum should be specific to the skills and function
of the health care provider.
Recently attention has been paid to a longer-term approach to training. An initiative by the
MCWH and Nutrition section of the National DoH resulted in a National Workshop of nursing
institutions in June 2003. The workshop, attended by 52 institutions, focussed on the integration
of various aspects of child health care into curricula. The integration of PMTCT and IMCI into
curricula was discussed, and the MCWH and nutrition sections are pursuing this to ensure
sustainability and increased skills of health workers.
In order to sustain training efforts, there is also a need to establish a system for monitoring
the quality of training. This would involve setting targets for trainers with regard to how many
sessions they should facilitate over a particular period of time. A system of reporting should
be established in order for a database of participants and trainers to be maintained.
54

One of the major problems highlighted by trainers during this evaluation was the fact that
they are not employed as dedicated trainers. They are usually health workers with a full quota
of clinical duties. The only provinces that have hired dedicated trainers are KwaZulu-Natal
and the Western Cape; the rest of the provinces rely on health workers who have to accommodate
their training duties within their existing workload. This system relies heavily on the support
of management to allow trainers to be released from clinical duties to facilitate training.
Provinces should explore the possibility of employing dedicated PMTCT trainers, especially
at this critical time when the programme is expanding rapidly. Trainers may need to be
deployed in regions or districts for initial training and on-going support during programme
implementation. This may be particularly important as PMTCT services are integrated into
MCWH programmes. Once the expansion has occurred, it may not be necessary to have
dedicated trainers but rather fulltime training administrators to undertake the planning and
co-ordination for training initiatives and to provide support to trainers.
Some provinces such as Limpopo, Eastern Cape and Mpumalanga are exploring the option
of outsourcing PMTCT training. This is due to the problems in sustaining training without
dedicated trainers and inadequate administrative support at the provincial level to plan and
co-ordinate training. It will be important to evaluate these strategies to determine whether they
achieve better outcomes than provincially led training.
Summary
Except for initiatives in KwaZulu-Natal, Limpopo and the Western Cape Province, much of
the training on PMTCT to date has been driven by the National Department of Health together
with UNICEF. The infant feeding and PMTCT training course has been supported by a UNICEF
consultant and planning and co-ordination was done by the National DoH. As a result of
these training efforts many provinces have developed skilled and experienced trainers. Some
of these trainers have succeeded in initiating training courses in their provinces under difficult
circumstances and often with little administrative support. Provincial managers now need to
start taking ownership of this training by supporting their trainers, developing comprehensive
training plans and co-ordinating them with other initiatives such as IMCI and VCT training.
Provinces should also explore involving local experts and institutions in their training as these
could serve as valuable sources of support.
Recommendations
• On-site training should be encouraged rather than residential training, as it
is less expensive and less disruptive to services.
• The option of dedicated trainers deployed to regions or districts should be
explored. Alternatively, a dedicated administrative assistant should be engaged
by each province to plan and co-ordinate training.
• PMTCT training should be included in the core curriculum of all training
programmes for health professionals.
• All registered health professionals should be required to complete a training
programme in PMTCT as a condition of professional re-registration.
• The accreditation of trainers and training materials requires attention to ensure
adequate competency levels.
• A system for the monitoring of training should be established in each province.
55

6.6.2 Management
A. NATIONAL MANAGEMENT
The National Department of Health’s HIV directorate has continued to operate in a difficult
and constraining political and administrative environment. National leadership and management
successfully addressed many requirements to establish the pilot sites, but ongoing management
and support to these has not always been adequate, largely because of staffing disruptions
and a lack of technical capacity in some areas. The additional requirements of having to
provide guidance and support to Provincial expansion of PMTCT has been difficult to address.
During the rapid establishment of the 18 national pilot sites in 2001, the National Department
developed a protocol outlining the clinical and management aspects of PMTCT implementation,
including site preparation, training, counselling, testing, antiretroviral regimen, follow up,
monitoring and evaluation and project management. This protocol served as a useful tool for
the pilot sites. However, at this point a new National PMTCT protocol for expansion beyond
the pilot sites has not yet been developed. The current protocol was designed specifically for
the pilot sites and is now outdated as certain policies, such as issuing repeat doses of nevirapine,
have changed. There is therefore a critical need to update all protocols, to develop protocols
where no official ones exist (infant feeding), and to make these widely available within the
shortest possible time to support provincial expansion of this programme.
Financial resources for this programme were provided by National through conditional grants.
These grants provided for the appointment of a PMTCT co-ordinator in each Province at the
level of a CCLO; the appointment of a data entry clerk, and provision for the costs of drugs,
tests and formula in each of the pilot sites. The criteria used to determine the conditional grant
allocations to the provinces include adult infection rates (by province), and selected annual
antenatal clinic attendance at the two provincial pilot sites. These conditional grants enabled
the establishment of the pilot sites in the absence of provincial resources. Some provinces,
however, experienced difficulties in accessing the funding supplied through these conditional
grants. Problems spending this grant were seen particularly in the Eastern Cape and Mpumalanga
who have not succeeded in spending the conditional grant provided for the 2002/3 financial
year. Factors which contributed to these difficulties include management capacity at the
provincial level and poor co-ordination between provincial treasuries and programme units.
At this stage, provinces need to take greater responsibility for the budgeting and financing
of expansion of PMTCT, and National’s role should shift to one of providing guidance and
support, and integrating financing for PMTCT within the existing budgetary channels from
National to provinces.
Procurement of supplies for the pilot sites was facilitated through national tenders with
pharmaceutical and medical supply companies. Provinces were instructed to indicate their
specific requirements to the national HIV directorate for the first order of quantities covering
the first two months of the pilot sites. Supplies were delivered either to medical depots or
directly to the pilot sites. Following this initial order, provinces were instructed to take responsibility
for their own procurement although many of the tenders were still held at the national level.
National procurement allows the best prices to be obtained, but has resulted in disruptions
to supply on occasions, and backup systems in provinces should be developed to prevent such
supply problems. Additional training and support should be focussed on issues of procurement
and management of supplies for PMTCT co-ordinators and provincial managers.
56

Dedicated data collection systems for the pilot sites were developed in 2001, and key indicators
were used to monitor progress by National DoH. The completeness and quality of this data
however was often problematic, as provinces did not fully own and use this data. Some
provinces also indicated that despite submitting regular reports, they did not receive adequate
feedback from national managers. This is discussed in further detail under information systems,
but there is a need for the PMTCT information system to collect a minimum data set incorporated
within the District Health Information System, and for feedback mechanisms for information
and reporting between National and provinces to be strengthened.
Although National provided adequate guidance and support to the pilot sites, provincial coordinators
expressed frustration at the limited national support and guidance around strategies
to expand the programme, information requirements for an expanded programme and infant
feeding policy. Expansion strategies and a planning framework to assist Provinces would be
useful tools for National to develop with provinces.
Lastly, a national PMTCT steering committee was established to provide a forum where all
provinces could meet with the national PMTCT managers to provide feedback on implementation
and to discuss key operational and policy issues. This meeting has been held on a quarterly
basis since 2001, but during 2002 the meetings have not been well attended by provinces
and national staff on several occasions. The absence of senior decision makers at these
meetings, has meant that key decisions could often not be made by the committee. As a result,
provinces with active provincial managers have developed their own policies and guidelines
whilst others with little capacity struggle to manage even the pilot programme. The meeting
has also attempted to combine national co-ordination and technical support in one forum.
This has not always worked effectively, and consideration should be given to establishing a
Technical Advisory Forum where technical experts can advise on clinical/technical policy and
practice, and a Co-ordinating Committee which makes decisions and implements the programme.
As a rapid scaling up of PMTCT services is underway it is critical that clear national policies
are developed on key issues to prevent fragmentation of practices between provinces. The
National DoH could make use of the extensive clinical and research expertise in South Africa
to develop comprehensive policies and guidelines.
B. PROVINCIAL MANAGEMENT
Sites with the involvement of the highest levels of provincial government and health managers
have been the most successful in implementing the PMTCT programme. This evaluation found
that the level and standard of leadership and management in the PMTCT programme varies
greatly between provinces.
Each province, except the Western Cape, employed a provincial PMTCT co-ordinator (CCLO)
and in most cases a data entry clerk. These were national appointments and the contracts ran
from July/August 2001 for one year. There were delays in the renewal of some of these
contracts due to confusion around the devolution of these positions to provincial level. In
addition to the CCLOs, some provinces hired other staff to manage the programme (such as
KwaZulu-Natal and the Western Cape), whilst others re-allocated existing staff. The PMTCT
programme is situated in the provincial HIV directorates in all provinces except for the Northern
Cape and Free State where it is situated in the Maternal and Child Health directorate.
The active interest and support of senior managers in the PMTCT programme has led to faster
and more effective implementation in some provinces such as KwaZulu-Natal, the Western
Cape and Gauteng. These provinces have utilised resources to hire dedicated PMTCT staff
at provincial level and by local government to provide technical support for the expansion
process.
National financing for the programme is in the form of conditional grants. Many provinces
found these difficult to utilise due to problems accessing finances through provincial treasuries
and a lack of capacity at provincial level to manage conditional grants. In a few provinces
there was under-spending and inappropriate budgeting.
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C. MANAGEMENT OF CONSUMABLES AND SUPPLIES
The evaluation found evidence of poor management of the procurement and supply of test
kits and formula milk in several provinces resulting in large disruptions to services. Stock outs
of rapid test kits, formula and nevirapine were found in Mpumalanga, Free State and the
Eastern Cape. Periods of stock outs ranged from a few days to 2 weeks. The reasons for the
disruptions to these supplies included:
• Short expiry limits on nevirapine tablets and syrup resulting in delays while waiting
for new stock
• Poor management of stock procurement at the district and provincial levels
• The system used for procurement of drugs and supplies for PMTCT being separate
from the procurement process for primary level essential medicines
• National level tenders for rapid test kits with inadequate quality control.
In the absence of rapid test kits, blood samples were sent to laboratories for ELISA tests and
results were only available after several days. This influenced the number of women who
participated in the programme as many did not receive their test results. The poor performance
of the Efoora test kit led to several batches being returned to pharmacy stores and lengthy
delays in the receipt of replacement stock. Greater involvement of the National Health Laboratory
Service is needed to ensure regular quality control of rapid test kits.
The disruptions in formula supplies have serious consequences for the nutritional safety of
infants as mothers may be forced to mix feed or use limited resources to purchase formula.
The packaging and expiry limits of nevirapine tablets and syrup also led to some disruptions
in supplies as stocks were frequently labelled to expire a few months after their delivery. With
some sites having very low client loads, much stock wastage occurred as bottles expired before
they could be used and had to be returned to the pharmacy while new orders were still
awaited.
The nevirapine syrup is bottled in 20ml bottles, sufficient to treat approximately 33 infants.
In small facilities with a low client load, these bottles usually expire before they can be finished.
The manufacturer should consider packaging the syrup in smaller bottle sizes to prevent this
wastage.
Nevirapine is handled as a schedule 5 medicine in facilities offering PMTCT services. This is
most likely done to ensure adequate monitoring of the drug and to prevent its misuse. Under
this management system all doses of nevirapine that are dispensed have to be recorded in a
drug register and the tablets and syrup are kept in a locked drug cupboard at all times. This
system may be preventing access of this essential drug to women who may be eligible for it.
The need to control this medicine should be balanced against the need to provide easy access
to women who need it. Consideration should also be given to including nevirapine on the
national essential drugs list (EDL) and standard treatment guidelines (STGs) as a means to
ease the procurement, use and monitoring requirements for this drug.
Improved management capacity at district and provincial levels is needed to improve the
supply of consumables to PMTCT sites. Decentralised management of tenders with companies
may assist this process as many tenders for consumables such as rapid test kits are still
managed by the National DoH leaving provinces with little control over these procurements.
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D. MANAGEMENT OF INFORMATION FOR PMTCT
The data management system for the pilot sites was specifically created for the purpose of
monitoring and evaluating the pilot programme in order to determine the feasibility of
implementing a broader programme. There were many data items, a more regular reporting
period and reporting was directly to the national HIV directorate. The data collected at the
PMTCT pilot sites was aggregated data collected through tick sheets and registers. It thus did
not allow for longitudinal analysis of programme outcomes for individual mother-child pairs.
The need to support the development of the information management component of the PMTCT
project was only identified after implementation of the project in mid 2001. The Health
Information Systems Programme (HISP) was contracted to support provinces in developing
and strengthening data handling processes that would facilitate the analysis, interpretation
and use of information to improve management of the project at the local level, and monitoring
and evaluation at the national level. Training and support was provided on data handling
and information management issues. Support was given to information officers, provincial
and site co-ordinators, and clinical staff involved in the pilot sites. This support achieved
different results in different provinces and was influenced by the status of routine data handling
systems and human resource capacity.
This section will highlight the key challenges relating to PMTCT information management and
the implications for programme expansion.
Key Findings from the Evaluation
The evaluation found that the following challenges impacted most profoundly on PMTCT
information management:
1. Absence of clearly defined and standardised data elements and indicators – a PMTCT
essential dataset.
2. Poor technical infrastructure: lack of access to computers with appropriate software
and email connectivity.
3. Limited human resource capacity to enter and analyse data.
4. Duplication of recording efforts with numerous data collection tools.
5. Different data handling and flow processes for pilot and expansion facilities.
6. Poor data quality.
7. Limited capacity for interpretation and use of data for provincial and national level
programme monitoring.
Data Elements and Indicators
Pilot Sites
The PMTCT pilot programme was implemented as a vertical programme with its own data
handling and management structures. At the onset of the PMTCT programme, there was an
absence of clearly defined standardised data elements and indicators. Some provinces initially
developed their own registers with additional data items.
The purpose of the pilot sites was to assess the feasibility of implementing a national programme
therefore far more data items were required for these ‘research sites’ than is required for new
sites. During 2001, the national PMTCT dataset for the pilot sites was finalised. It consists of
20 data elements from which 13 indicators are calculated.
Substantial problems were encountered with this dataset. Many provinces had already defined
their data elements as they understood them and had developed or refined the nationally
suggested data collection tools. These ‘new’ national data elements caused confusion and
uncertainty, impacting negatively on data quality.
Practical Example 1
Much confusion was created by the data element First Antenatal Visit. Some sites tended to
call these Attendees. It became very difficult to determine what this data element really meant:
was it only those coming for a first ANC visit, or only the first time women were counselled
or did it include everyone who was there that day i.e. ALL ANC visits which then included
the follow up visits.
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The changes made in data elements and their appropriate use demanded re-training on the
understanding and use of data elements and indicators. Extensive ongoing training and
support on understanding and use of the data elements was done by HISP. Provincial and site
steering committee meetings were a valuable forum to review data and clarify the meaning
of terms.
Non-Pilot Sites
The plan to expand PMTCT activities beyond the pilot sites required the institutionalisation of
data handling processes. This has resulted in a reduction in the number of data elements and
indicators used to monitor PMTCT services in the non-pilot sites.
Many of the data items chosen for the pilot sites were not collected consistently or accurately.
Experience gained in the pilot phase of the programme has resulted in the adoption of 6
indicators and 7 data elements in the integration and rollout of PMTCT services. These have
been incorporated into the revised National Essential Data Set and have been approved by
NHISSA although approval is still pending from the PHRC:
Revised National Essential Data Set for Primary Health Care
PMTCT
Indicator
Numerator
Denominator
Routine Data elements
HIV testing rate
amongst antenatal
women
HIV test done on
antenatal client
First antenatal visits
HIV test done on
antenatal client
HIV positive rate
amongst pregnant
women tested
Antenatal client HIV
positive – new
HIV test done on
antenatal client
Antenatal client HIV
positive – new
Nevirapine uptake
amongst pregnant
women with HIV
Nevirapine dose to
antenatal woman
Antenatal client HIV
positive
Nevirapine dose to
antenatal woman
Nevirapine uptake
amongst babies born
to women with HIV
Nevirapine dose to
baby born to woman
with HIV
Live birth to woman
with HIV
Live birth to women
with HIV
Nevirapine dose to
baby born to woman
with HIV
HIV testing rate of
baby
First HIV test of baby
at 1 year
Live birth to woman
with HIV
First HIV test of baby
(1 yr)
HIV transmission rate
at 1 year
First HIV test of baby
at 1 year positive
First HIV test of baby
at 1 year
First HIV test of baby
at 1 year positive
Technical Infrastructure
The shift from a data collection system to an information management system that would assist
in achieving and measuring the objectives of the PMTCT programme was facilitated by the
decision to use the District Health Information Software (known as the DHIS) as the mechanism
for capturing and processing data. The DHIS is accepted as the national standard for districtlevel
anonymised information systems.
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Many provinces had captured initial data on excel spreadsheets. This data needed to be
aligned with the new data elements and entered into the DHIS. Eighteen months into the
programme, a number of provinces are still using alternative software programmes to capture
PMTCT data. Integration of data sets at national level has not occurred.
Staff needed technical training on use of the DHIS. Problems were mainly experienced with
logistical issues such as having no dedicated computer for the PMTCT co-ordinator, inappropriate
computer specifications, no access to email, and limited support from the provincial HIS
directorates and IT sections. Many of these issues, identified early in the programme, have
not yet been satisfactorily addressed. Extensive ongoing training and support are still required.
Data is captured by a variety of cadres ranging from clinicians, data entry clerks, district
information officers, provincial PMTCT co-ordinators and HISP facilitators. The varied skill
levels and knowledge impacts on data quality.
Human resource capacity
Although the conditional grants to provinces made provision for the appointment of a dedicated
data entry clerk, not all provinces made this appointment. In the absence of a dedicated
person to handle data for the programme, existing staff at district and provincial levels took
responsibility for PMTCT data. Many of these individuals did not have the skills to enter data
into the chosen software. Capacity to interpret data and provide feedback to site managers
was also limited.
Data collection tools
The primary purpose of the range of registers and forms provided by the National DoH was
to facilitate data collection and submission to provincial and national levels. Maternal health
and VCT services, as vertical programmes, have their own data handling systems, with most
provinces keeping separate VCT, antenatal, delivery (maternity) and child health registers.
The large number of data collection tools developed for the pilot sites resulted in substantial
duplication of recording efforts. This impacted negatively on data quality. Additional problems
identified included:
• General access to records
• Maintenance of confidentiality
• Ability of facilities to track clients across services.
It was imperative that the number of data collection tools be reduced and streamlined for nonpilot
sites in order to facilitate staff buy-in and commitment to recording of good quality
relevant data for use in local monitoring. This was particularly relevant in light of the need
to expand and scale up PMTCT services across all health facilities.
In light of the plan to expand PMTCT activities, mechanisms are being explored to integrate
PMTCT information into existing records, specifically VCT, maternal health and child health
records. A number of provinces are piloting a range of individualised patient registers that
will enable monitoring of client care while ensuring patient confidentiality. These tools also
facilitate continuity of care across services, districts and provinces. An example of the
consolidated PMTCT register can be found in Appendix 6.6.
Practical Example 2
In the Free State and Mpumalanga provinces the number of data collection tools was reduced
by consolidating recording efforts into a single register for antenatal and child health services.
The delivery register was adapted to record HIV test done (not status) and NVP dispensed for
both mother and baby. Existing tally sheets used in PHC facilities were adapted to collect
aggregated PMTCT data.
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Data flow
The PMTCT pilot programme, as a vertical programme, established a separate data flow
process that ran parallel with the existing routine PHC information system. Generally, data
was submitted by facilities to the pilot site co-ordinator for correlation and validation. This
data was then submitted by the site co-ordinator to either the district or provincial level for
capture on the DHIS. Once captured the data was submitted by the provincial co-ordinator
to the national HIV directorate. The absence of a dedicated officer at the national level to
receive, process and disseminate data has impacted negatively on their ability to respond
proactively to identified systemic and infrastructural problems. Mechanisms are currently being
established to integrate and formalise PMTCT data handling processes for the expanded
PMTCT programme within established routine PHC data collection systems.
Data quality
This report has required an in-depth scrutiny of the PMTCT data. The analysis of both raw
and indicator data has highlighted substantial data quality problems. Despite ongoing training
and support, poor data quality with regard to data completeness, correctness and consistency
demonstrates the gap between collection of data and its use in local level monitoring of service
delivery.
Ongoing problems are experienced with correlation of datasets submitted at various time
periods to the site, district and provincial levels. Review of data in order to improve data
quality has meant that data corrections are often made some months after submission. Various
levels have different datasets with no one being sure which dataset is the most recently
validated. Identified data errors are followed up at site level. The corrected data submitted
is often completely different from the original dataset. Determining the correct dataset is a
challenge.
Practical Example 3
Where data quality was suspect, other routine data collected by the site was examined. For
example, the number of 1st ANC visits recorded in the PMTCT data set should be the same
as the number of 1st ANC visits reported by the facility for the PHC dataset. In a number of
instances this was found to be different. Part of the problem was that the PHC and PMTCT
reporting cycle dates were different. The staff were required to use different time periods for
the same data elements collected. This made assessment and correction of the data problematic.
Interpretation and Use of Information for Local Management
Data and indicators were extracted at provincial level for reporting to the provincial and
National PMTCT Steering Committee meetings in the form of tables and graphs. There was
a focus on the development of reports, which facilitated data quality review and cross-site
trend comparisons. Although this led to an improved understanding of data element and
indicator definitions, there was limited discussion on understanding the potential use of the
data to improve management of the programme at site level. Extensive training and support
is still required. Regular feedback to sites on their performance is generally poor. Formalisation
of feedback mechanisms is needed.
There was a feeling amongst site co-ordinators that data was collected because ‘national’
required it for research purposes and not for monitoring progress in the sites. Discussion on
cross-site comparisons focussed on addressing data handling problems. Data was used in site
meetings for discussions on logistical service issues; however, monitoring and evaluation of
coverage, quality and effectiveness of service delivery was limited.
Practical Example 4
The NVP dispensing rate to HIV positive pregnant women is a key indicator of service coverage.
Staff recorded nevirapine dispensed to HIV positive pregnant women either at ANC clinics
or at the point of delivery. In many cases the data was collected and recorded at both sites.
This indicator demonstrated both gaps and double counting. As staff were not involved in
data analysis and decision making, they failed to realise that the nevirapine dispensing rate
was not an accurate way to monitor actual nevirapine uptake by women.
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A number of factors impacted negatively on the ability of sites to monitor their own performance
for key indicators:
• The lack of clearly defined objectives and targets
• Lack of an operational plan specifying exactly what facilities were expected to achieve
• Poorly established management infrastructure for local responsibility and decision making.
At provincial level, co-ordinators have demonstrated the application of data in management
of the PMTCT programme. A number of provinces have developed targets for some key
indicators and have presented this information at provincial and national steering committee
meetings. Mechanisms are being established to enable provinces to assess their performance
and take management decisions. This process must be expanded to facilitate local level
monitoring. Staff must be trained to understand the role of data in facilitating local level
monitoring and evaluation of service delivery.
Conclusion
Inherent problems associated with routine information systems have been brought sharply into
focus with the implementation of an information management system for PMTCT.
There is an urgent need for guidelines on the integration of the essential PMTCT dataset into
routine district health information systems to prevent the capturing of excessive amounts of
data and continued reporting directly to provincial and national levels.
Substantial progress has been made on standardisation of PMTCT data handling processes.
The next step is to strengthen the organisational capacity of the health service to manage an
integrated PMTCT data handling process in primary health care services. The focus of training
and support should be on facilitating local level monitoring of service delivery. Implementation
of a reduced dataset, that is integrated into the national essential data set for PHC, with clearly
defined objectives and targets, will facilitate improved PMTCT management.
Recommendations
• It is recommended that the original pilot sites discontinue collecting the research data
elements. These pilot sites have been operational for two years and many lessons have
been learnt. The continued collection of research data at these sites is no longer necessary
and may serve to confuse provinces regarding data requirements for this programme as
the service becomes more widely available.
• Improved capacity at national and provincial levels to interpret data and provide feedback
to programme managers is urgently required.
• Data items and indicators should be based on the targets and objectives of district, provincial
and national plans for PMTCT.
• Data flow mechanisms should be streamlined and integrated into the routine district health
information system
• The number of data collection tools should be reduced and, as far as possible, combined
with existing tools such as maternity registers.
• The design of data collection tools should allow for the specific needs of individual provinces.
• A national unique identifier is required for tracking of clients across facilities and provinces.
• Extensive ongoing training and support is required to improve data quality and interpretation.
• Ongoing training is also recommended on the use of information for local level monitoring
of service delivery
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Appendix 6.6
MTCT REGISTER (to be kept in the antenatal unit)
SITE: FACILITY: PAGE NUMBER:
Register
Number
Date of Entry
month & year
Name
full name & surname
Facility ID
folder number
MTCT ID
tracking number
CCVT
NVP
administered Comment
Pre Post 1 Post 2
result
home labour
MODIFICATIONS: * sites may choose not to write in name of mother – use just folder & tracking numbers
for follow up
INFANT REGISTER (to be kept in all PHC facilities where babies are monitored)
SITE: FACILITY: PAGE NUMBER:
b1 st HIV test
@ 1 year
2 nd HIV test
confirmatory
Register
Number
Date of Entry
month & year
Name
full name & surname
Facility ID
folder number
MTCT ID
tracking number
NVP
given
Bactrim
started
Month &
year
Mode of Feeding
B=Breast
F=Formula
M=Mixed
123456789
MODIFICATIONS: * sites may monitor mode of feeding for 12 months & /or add a comment field
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6.7 Scaling up and Integrating PMTCT Initiatives
A PUBLIC HEALTH OVERVIEW OF PMTCT
Efforts to prevent MTCT should relate to, and be considered within, the entire spectrum of
HIV/AIDS primary prevention, care, and support activities, as shown in Table 6.7.1.
Table 6.7.1: MTCT and the prevention to care continuum 1
PRIMARY PREVENTION OF
HIV/AIDS IN ADULTS:
• Promotion and provision of
condoms
• Behavior change
communication (including
education and involvement of
partners, families, and
communities; life-skills and
other programs targeted to
youth)
• Prevention and treatment of
sexually transmitted diseases
• VCT
CORE INTERVENTIONS FOR
THE PREVENTION OF MTCT:
• Comprehensive MCH
services (antenatal, postnatal,
and child health)
• VCT
• Improved breastfeeding
and
alternative infant feeding
counselling & practices
• Optimal obstetric care
• Short-course ARV
prophylaxis
• Family planning
CARE AND SUPPORT:
• Postpartum care for mothers
(including family planning)
• Postpartum care for infants
(including identification,
treatment of, and palliative
care for AIDS-related
conditions)
• Social support for families
and communities affected by
HIV/AIDS, especially orphans
and vulnerable children
• Support to carry out infant
feeding decisions
Core PMTCT interventions are those that directly prevent MTCT during pregnancy, labour and
delivery, and during the postpartum period for women who are already HIV-infected. The
core interventions listed in Table 6.7.1 are those that are known today to be the most effective
for identifying HIV infected women and for reducing the risk of HIV transmission during each
of these periods. The core interventions listed above are either general (applied to all pregnant
women) or specific (require information on HIV status of mothers).
The main objectives of the core PMTCT interventions are to:
1. Reduce HIV transmission from mother to child
2. Reduce infant and child morbidity and mortality (AIDS specific and overall)
3. Identify and care for HIV positive mothers
4. Strengthen HIV/AIDS awareness and response in health services and the community.
These core interventions for PMTCT cannot and should not all be achieved at once. What
matters most for any preventive intervention is high coverage of the target population with
the basic steps, as soon as possible. Simple measures applied to a whole population will save
more lives than complex interventions applied to a limited population. If a step-wise plan is
followed, that includes the provision of free formula, the first step in ensuring coverage of the
population is to expand access to nevirapine to women already known to be HIV positive,
followed by an expansion of existing counselling and testing services, including counselling
on infant feeding, and then the provision of free formula, if this is suitable for the programme.
The stage at which facilities move from one level of the programme to the next is dependent
on human, physical and management infrastructure. However, the ability of a facility to offer
a comprehensive service should not hamper it from offering nevirapine alone to women of
known HIV positive status.
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The key to high coverage of the interventions is to integrate them progressively into the standard,
ordinary package of maternal and child care. In the South African setting, attempts are being
made to integrate PMTCT into routine maternal and child health care. The programme has
however been introduced in pilot sites initially, to identify operational constraints to implementation.
Progress with expansion was therefore initially slow, but a Constitutional Court ruling and
National decision in April 2002 to expand the programme beyond the pilot sites, has facilitated
a fairly rapid expansion in some provinces.
REVIEW OF THE PILOT STRATEGY
The approach adopted in South Africa was to initiate the national PMTCT programme through
pilot sites in order to assess the feasibility of implementing the programme under routine health
service conditions, and to learn lessons from these sites.
• As a national pilot programme, national co-ordination was a necessity to fast track
the process, with dedicated budgets, nationally financed provincial co-ordinators, and
nationally defined information systems to monitor progress in the pilots. Ownership
of the programme at provincial level in several provinces was therefore poor. This was
evidenced in the reliance of provinces on nationally appointed provincial CCLOs to
manage most aspects of the programme. Although the pilots provided an opportunity
to develop provincial capacity, this did not happen sufficiently. This was reflected in
the limited or lack of training plans, inadequate expansion plans, limited local use of
date collected and limited participation by local clinicians and academics except in
the Western Cape and KwaZulu-Natal. In order to facilitate expansion, the national
focus on the pilots should now be shifted to providing support for provincial capacity
development, planning and ‘ownership’ of expanded PMTCT programmes.
• A national protocol was developed to guide implementation in the pilot sites. Sections
of this protocol, although relevant in the past, are no longer relevant, and should
be updated using new scientific evidence and lessons learnt from the pilot sites. As a
national protocol or guideline has not yet been developed for expansion of PMTCT,
this is an urgent requirement to support expansion beyond pilot sites.
• ‘Expansion’ or ‘rollout’ should not simply be interpreted as a process of reproducing
pilot sites. Many lessons of how to and how not to implement have been learnt in these
sites. These experiences should be used to inform national and provincial planning
and support for expansion. Alternative models of expanding PMTCT also need to be
explored whereby other ‘best practice’ models, developed in provinces that have
already expanded, can be used to inform expansion.
• Pilot sites run the risk of becoming victim to the ‘pilot syndrome’: the phenomenon of
a micro-managed, over-resourced ’demonstration model’ that cannot be replicated
under routine service conditions. Some provinces are finding the attempt to reproduce
all-or-nothing pilot sites to be beyond their capacity and budgets, leading to delays
and frustration among staff. Under such circumstances, alternative strategies such as
a phased expansion, either on a geographical basis (areas of highest HIV prevalence
first), levels of care (hospitals rather than primary care facilities in their drainage area),
or by level of intervention (ensuring that VCT or nevirapine is provided uniformly first),
should be considered as alternatives to the ‘all or nothing’ approach to expansion.
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• ‘Readiness criteria’ applied to non-pilot facilities, before they are allowed to use nevirapine,
may prevent women from accessing this treatment as facilities feel compelled to meet
numerous criteria before providing care. A limited approach of providing women with
nevirapine only should be allowed in cases where facilities are not able to provide a
comprehensive service.
• The practice of providing free infant formula is not working in many sites. There is lack
of clarity over the policy to be followed for programme expansion, inadequate counselling
of mothers, and irregular supplies to many facilities. The impact of this may be detrimental
to breastfeeding practises and infant well-being. In the expansion this is a critical policy
issue that must be clarified using scientific evidence applied to the South African context.
A new policy should take into consideration the Code of Marketing of Breastmilk Substitutes
and sustainable procurement of supplies.
KEY LESSONS TO FACILITATE EXPANSION OF PMTCT
South Africa needs to ensure rapid coverage of the target population with the important
elements of PMTCT. The end result, as for an immunisation programme, must be implementation
at all health facilities. There are numerous ways of achieving this in a cost-effective manner:
Policy, Planning and Financing
• The national commitment to expand PMTCT within the framework of a national Strategy
for Comprehensive HIV/AIDS prevention and care needs to be communicated unequivocally.
• Update broad national protocols and guidelines relating to VCT, PMTCT, Obstetric
Practices, and Infant Feeding, and make these widely available.
• Provinces, assisted by National, should develop expansion plans in keeping with available
resources and capacity.
• Provinces, with support from National, should address health systems infrastructure and
human resource capacity, to enable them to fully expand PMTCT within the shortest
time frames possible.
• The pilot sites were provided with centrally controlled conditional funding for PMTCT.
Conditional grants have been difficult to manage at a Provincial level, and potentially
inhibit horizontal and integrated service development. Future national financing for
PMTCT should be integrated into provincial budgets, and managed by Provincial
managers within broad budgetary guidelines for PMTCT.
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Health Care Infrastructure
• Strengthen training of health workers nationwide to implement PMTCT and to use
updated protocols. Involve and consult local health managers, clinical experts and
academics in providing these training programmes and for ongoing support.
• Lay counsellors are a valuable and essential resource for PMTCT services. National
policies should be developed for their employment (through NGOs or public services),
training, and support. They should be deployed first to places already attempting to
counsel and test pregnant women.
• Place nevirapine on the EDL (Schedule 4) and make it available to all health facilities.
Nurses must be able to prescribe it (with simple controls). This is essential for passive
case finding.
• Ensure optimal procurement at every level, and a reliable supply and management
of drugs (nevirapine, multivitamins, co-trimoxazole) and test kits. Address problems
of short expiry windows.
• Health facilities must be planned or upgraded to provide for private counselling space
(and other urgent capital works).
• Integrate a minimum PMTCT data set into the routinely collected District Health
Information System, and facilitate monitoring and feedback on indicators at every
level.
Coverage and Uptake of Testing and Nevirapine
• Make VCT universally available at health facilities. A reliable supply of quality test
kits should be guaranteed; quality control and training should be supported by the
National Health Laboratory Service; follow up technical problems (short expiry windows
on different test components, high false negative rates with a particular kit); set up a
recording system to minimise administrative errors.
• Activate whole catchment areas rather than isolated facilities. The conditions for high
acceptance rates are known: country-wide (not site-bound) promotion, engagement
and community mobilisation; ‘good enough’ health infrastructure and staffing; innovative
staff training and support (in-service, locally adapted, integrated); and provision and
support of trained generic lay counsellors.
• Improve uptake further with VCT in maternity and post-natal wards, and for mothers
of unbooked or home deliveries
• Increase successful treatment rates by building clients’ confidence in privacy and
confidentiality, using securely coded records and communication, improving ascertainment
of status at maternity units, and implementing administrative controls to reduce missed
opportunities for treatment.
• Aim to universally provide nevirapine initially through passive case finding: treat all
women who admit (or claim to be) HIV positive, from whatever testing source. Although
this may seem incomplete, it saves lives and has important developmental effects such
as improving the morale of health workers because they can ‘do something’ to help
women with HIV.
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• Explore offering presumptive nevirapine treatment to infants of untested women in
high prevalence areas. This is accepted public health practice when treatment is
important, safe and cheap (de-worming, immunisation, food fortification, syphilis
treatment after screening, syndromic treatment for STIs). Contrary to popular assumptions,
presumptive and targeted treatment strategies are not mutually exclusive: where
targeting via antenatal VCT is already in place, ‘blind’ treatment could be offered post
delivery to infants of mothers who had missed testing for any reason, to catch potential
missed opportunities.
Follow up
• The follow-up of HIV infected mothers has direct benefit to the mother and infant, as
well as great strategic importance. For the first time, large numbers of HIV positive
women will be identified; support groups can be set up; discussion, disclosure, and
stigma reduction will accelerate in the community. They are also the logical group in
which to commence ARV treatment in the public sector, because they are already
identified and improving their health status will impact on infant health.
• Follow up of infants needs greater attention to ensure that proper infant feeding support
is provided, prophylactic treatment is given where indicated, infections are detected
early and appropriately managed, and that the infants are accessing other essential
routinely provided child health services.
General Health Systems Improvements
PMTCT interventions expose the deficiencies in the health system at several levels. This is not
a reason to delay implementation, as shortcomings identified in the health system should be
addressed in a global fashion. Critical health system issues are:
• Strengthened national, provincial and district capacity to plan and manage PMTCT.
• Adequate staffing and facilities for basic PHC services.
• A sustainable solution for the employment of lay counsellors, including legal and
ethical labour practices, adequate recruiting, training, payments, and support, policies
harmonised with those for other community-based health workers, and consistent
NGO involvement if this route is to be used.
• Improve drug and supplies procurement and management systems, including additional
training of management staff at every level.
• A simple information system built primarily for improved patient care and local service
evaluation (including information flow between ante-natal, maternity and child health
services) to reduce missed opportunities.
• Address covert barriers to access such as official booking days, afternoon closures,
and fragmentation of services.
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Strategies to integrate PMTCT into the health system
Integrating PMTCT into antenatal care
• Encourage all facilities to incorporate counselling and voluntary testing into routine
ANC (active case-finding for nevirapine treatment).
• Upgrade antenatal care, including greater accessibility (abolish unofficial ‘days’ for
booking or ANC) and aggressive treatment of infections (STIs and opportunistic
infections).
• Pregnant women with HIV need to be screened by history and clinical examination
for evidence of AIDS-related illnesses. Patients with complications of HIV infection
should be referred from primary care facilities to facilities able to provide appropriate
medical and obstetric services (An example of a screening tool for HIV infection can
be found in Appendix 6.7).
• Mothers living with HIV infection must have access to competent adult health care in
the primary health care facilities. Providers in these facilities should receive continuing
education to ensure that they are trained to recognize signs and symptoms of advanced
retroviral disease in mothers and babies, provide therapy and make appropriate
referrals.
• Counselling and Testing services need to be provided at all delivery sites and before
discharge offered to all women delivering with unknown HIV status. Dedicated
counsellors and/or nursing staff should provide counselling.
• Decisions about infant feeding must be made during antenatal care but preferably not
during initial post-test counselling. Ongoing counselling is needed and infant feeding
should be discussed during these ongoing sessions. Staff providing antenatal care
should be trained to assist and guide mothers in making appropriate decisions about
infant feeding, using standard criteria.
• All pregnant, HIV-infected women should receive anti-retroviral therapy to prevent
transmission of virus to the baby. The choice of anti-retroviral drugs should be based
on the basic therapy provided by the public health care system (usually nevirapine).
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Integrating PMTCT into a comprehensive package of PHC services
• Family planning should be an integral part of PMTCT care. All pregnant women should
make a decision about family planning before delivery. Family planning services must
be available to women after delivery.
• Sterilization procedures should only be offered after adequate counselling of mothers.
Mothers must be aware that the baby could be born HIV-infected and die in the first
years of life.
• Linkages must be established between the antenatal care and primary care services.
This is particularly important when antenatal care is provided in a facility separate
from other health services.
• All HIV infected pregnant women must be screened for STIs and treated syndromically.
• All HIV infected pregnant women must be screened for cervical cancer and its precursors.
• Nutrition education and counselling should be integrated into antenatal and postpartum
care.
• Mothers must be educated about infant care and trained to recognize signs of HIV
infection.
• Medications, like co-trimoxazole, commonly used to treat patients with HIV-related
conditions should be available in all health care facilities.
Appropriate vertical support for expansion
The national and provincial departments need to review the way they support PMTCT to
accelerate expansion, both in breadth (coverage) and depth (quality):
• The management, and staffing to launch a pilot project is not the same as that needed
to expand and maintain an essential part of the PHC package. Move PMTCT into
Maternal and Child Health Directorates at National and provincial levels. HIV/AIDS
directorates should concentrate on universal availability of VCT, and care and support
for people with HIV.
• Formally end the pilot projects (but continue the service) and use the experience gained
to support expansion in all provinces.
• The National Steering Committee should be restructured into two key components, a
Technical Advisory Committee consisting largely of technical experts, and a Coordinating
Committee, consisting of national and provincial managers, which takes
and implements decisions. Mixing the two functions has not been an optimal utilisation
of either group’s skills. There should be senior level representation from the national
department of health at both these meetings in order for decisions to be made on key
issues.
• Provinces should establish similar technical and co-ordinating structures to support
expansion. These structures should harness available expertise within the provinces,
and be supported and supplemented with national (including other provinces) expertise
on planning and management of PMTCT, and clinical and other technical aspects.
• Issue clear national guidelines on PMTCT services within broader standards for maternal
and child care. Allow provinces and facilities to work out the details.
• Support training of health professionals at pre-service, short course and in-service
levels. Develop a local training infrastructure modelled on IMCI. Encourage a range
of training materials and alternative methods. Integrate PMTCT and infant feeding
training with existing training packages in maternal and child health to eliminate
overlaps, gaps and inconsistencies.
• Encourage cross-province learning and local innovation.
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SUMMARY
We need a fundamental rethink of PMTCT implementation if we are to reach the objectives
of reduced child morbidity and mortality, care for HIV positive mothers, and a better
understanding and response to HIV in general. Universal coverage is essential, but it is
unrealistic to do this with a whole basket of interventions simultaneously.
The pilot projects have shown that it is feasible to implement PMTCT in all provinces, in rural
and urban settings, and at hospital and primary care levels with some outstanding success
stories as well as several less successful initiatives. Very real constraints exist in many settings,
and difficulties have been experienced at every level in the planning and implementation of
the programme.
The challenge is to learn from these, and for South Africa to strengthen its implementation of
PMTCT based on these experiences. Increased provincial ownership and leadership for PMTCT
is needed, and a bottom-up, developmental approach as part of the District Health System
should be encouraged. All facilities and districts must be enabled to progressively implement
PMTCT interventions, and PMTCT must become a normal part of the routine maternal and
child health care package.
REFERENCES
1. Preble EA, Piwoz EG. Prevention of mother to child transmission of HIV in Africa: practical
guidance for programs. Washington: Academy for Educational Development, 2001.
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Appendix 6.7
Patient Name: ________________________
Folder Number: _______________________
Date: ________________________________
Screening questions:
SCREENING FOR COMPLICATIONS OF RVD INFECTION
HISTORY
Significant weight loss Yes No
Fever/Chills/Sweats > 4 weeks Yes No
Tongue coating Yes No
Oral ulcers Yes No
Enlarged lymph nodes Yes No
Painful swallowing Yes No
Cough > 2 weeks Yes No
Diarrhoea > 4 weeks Yes No
Genital ulcers Yes No
Rash/Skin Lesions Yes No
Treatment for TB in last year Yes No
Severe Headache Yes No
Confusion, Change in Mental Status Yes No
EXAM
Abnormally Thin Yes No
Unusual skin lesions (not itchy) Yes No
Lymph Nodes > 2cm Yes No
Oral Thrush Yes No
Mouth ulcers or dark spots Yes No
LABORATORY
Hgb < 8.0gm/dl Yes No
Nursing/Midwife Assessment
Routine Care in MOU Referral for Consultation with Doctor
Report by Doctor
Antenatal Care
MOU
Mowbray Maternity/Somerset Hospital
Groote Schuur Hospital
Delivery Care
MOU
Mowbray Maternity/Somerset Hospital
Groote Schuur Hospital
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