PMTCT, and National's - Health Systems Trust

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
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