PMTCT, and National's - Health Systems Trust

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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
Page 3 and 4: An Evaluation of the Prevention of
Page 5 and 6: CONTENTS 1. Executive summary 2. In
Page 7 and 8: Dispensing of Nevirapine Nevirapine
Page 9 and 10: SCALING UP THE PMTCT PROGRAMME Ther
Page 11 and 12: AIM OF THE EVALUATION METHODOLOGY A
Page 13 and 14: OVERVIEW OF THE PMTCT PILOT SITES *
Page 15 and 16: DESCRIPTION OF ROUTINE PMTCT INDICA
Page 17 and 18: Nevirapine (NVP) dispensing rate to
Page 19 and 20: 6.1 Antenatal Counselling and Testi
Page 21 and 22: This rate has increased slightly si
Page 23 and 24: Group education followed by individ
Page 25 and 26: WHO 2 recommends that at least 50%
Page 27 and 28: APPENDIX 6.1: EXAMPLE OF A PEER COU
Page 29 and 30: Figure 6.2.1: Nevirapine dispensing
Page 31 and 32: 6.3 Infant Testing and Outcomes BAC
Page 33 and 34: DISCUSSION HIV Diagnosis in Infants
Page 35 and 36: Current Status of Infant Testing Cu
Page 37 and 38: Proposed Infant HIV Test Timelines
Page 39: 6.4 Maternal and Infant Follow Up I
Page 43 and 44: KEY FINDINGS FROM THE EVALUATION In
Page 45 and 46: There is a need for caution when in
Page 47 and 48: Differences in provincial policies
Page 49 and 50: With only moderate support (one hom
Page 51 and 52: 4. Ensure on-going Support After De
Page 53 and 54: 6.6 Health Care Infrastructure This
Page 55 and 56: Two options exist for the contracti
Page 57 and 58: B. TRAINING OF HEALTH CARE WORKERS
Page 59 and 60: Logistical and administrative suppo
Page 61 and 62: 6.6.2 Management A. NATIONAL MANAGE
Page 63 and 64: C. MANAGEMENT OF CONSUMABLES AND SU
Page 65 and 66: The changes made in data elements a
Page 67 and 68: Data flow The PMTCT pilot programme
Page 69 and 70: Appendix 6.6 MTCT REGISTER (to be k
Page 71 and 72: The key to high coverage of the int
Page 73 and 74: Health Care Infrastructure • Stre
Page 75 and 76: Strategies to integrate PMTCT into
Page 77 and 78: SUMMARY We need a fundamental rethi

PMTCT, and National's - Health Systems Trust

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