PMTCT, and National's - Health Systems Trust

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.
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