PMTCT, and National's - Health Systems Trust

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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
Page 3 and 4: An Evaluation of the Prevention of
Page 5: CONTENTS 1. Executive summary 2. In
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 and 40: 6.4 Maternal and Infant Follow Up I
Page 41 and 42: RECOMMENDATIONS FOR IMPROVING THE P
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
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Logistical and administrative suppo
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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
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SUMMARY We need a fundamental rethi
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