Eliminating mother-to-child HIV transmission in South Africa
Peter Barron a, Yogan Pillay b, Tanya Doherty c, Gayle Sherman d, Debra Jackson e, Sanjana Bhardwaj f, Precious Robinson b & Ameena Goga c
a. School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, York Road, Johannesburg, Gauteng, 2193, South Africa.
b. Department of Health, Pretoria, South Africa.
c. Health Systems Research Unit, Medical Research Council, Cape Town, South Africa.
d. Department of Molecular Medicine and Haematology, University of the Witwatersrand, Johannesburg, South Africa.
e. School of Public Health, University of the Western Cape, Cape Town, South Africa.
f. United Nations Children’s Fund, Pretoria, South Africa.
Correspondence to Peter Barron (e-mail: email@example.com).
(Submitted: 29 April 2012 – Revised version received: 20 August 2012 – Accepted: 13 October 2012 – Published online: 19 November 2012.)
Bulletin of the World Health Organization 2013;91:70-74. doi: 10.2471/BLT.12.106807
The magnitude of the problem of human immunodeficiency virus (HIV) infection in South Africa is illustrated in Fig. 1, which shows the rise of the HIV pandemic since 1990 and its stabilization after 2004. In 2010, 30.2% of all pregnant women who attended public sector health-care facilities were infected.1 The prevalence of HIV infection among pregnant women is likely to remain high for at least the next two decades because the number of people receiving life-long antiretroviral therapy (ART) in South Africa is still increasing and is predicted to plateau at around 3 million in 2016.2
Fig. 1. Prevalence of HIV infection in pregnant women, South Africa, 1990-2010
In 2011, an estimated 70.4% of maternal deaths in South Africa were associated with HIV infection,3 as were half of all deaths of children younger than 5 years.4 Consequently, the success of programmes for the prevention of mother-to-child transmission (PMTCT) of HIV is critical for reducing maternal and child mortality and morbidity.
Evolution of the PMTCT programme
Although the burden of HIV infection in South Africa had been large for many years, the country did not implement a PMTCT programme until 2002. The main steps in the evolution of South Africa’s PMTCT policy are listed in Box 1.
Box 1. Main steps in the evolution of South Africa’s policy on the prevention of mother-to-child transmission of HIV, 1998–2011
- 1998–1999: a PMTCT programme was started at two midwife obstetric units in Khayelitsha, Cape Town by the Western Cape Department of Health, despite the lack of a national policy.
- 2000: thirteenth international HIV conference, Durban. Data presented indicated that antiretroviral drug regimens were effective in reducing mother-to-child transmission.
- 2001: the South African Ministry of Health endorsed the establishment of two research sites in each of the nine provinces for a period of 2 years to understand better the operational challenges of introducing antiretrovirals during pregnancy to reduce mother-to-child transmission.15
- 2001: this policy was challenged in the courts. In December 2001, the government was ordered by the court to develop a fully capable and effective national programme to reduce mother-to-child transmission by the following year.
- 2002: the government challenged the court order, but was unsuccessful. The PMTCT programme commenced.
- 2003: the government published a new operational plan for treating and caring for those infected with HIV. The plan included increased provision of nevirapine, the extension of treatment to all HIV-infected pregnant mothers and their children and the expansion of related health-care services, such as voluntary counselling and testing.
- 2004: introduction of comprehensive care management and treatment of HIV-infected individuals. Pregnant women with a CD4+ T-cell count < 200 cells/mm3 became eligible for HAART.16
- 2008: the Department of Health updated the PMTCT policy to include: (i) dual prophylaxis with azidothymidine and nevirapine from 28 weeks’ gestation; (ii) nevirapine treatment for pregnant women during labour and for their babies within 72 hours of delivery; and (iii) HAART for pregnant women with a CD4+ T-cell count < 200 cells/mm3.
- 2008: the Minister of Health launched the national PMTCT accelerated plan (A-plan) which aimed to reduce mother-to-child transmission of HIV from 12% in 2008 to less than 5% by 2011, in accordance with the National Strategic Plan 2007–2011.
- 2009: President Zuma’s speech on World AIDS Day outlined changes to be implemented in 2010. This gave a clear indication that the political leadership required to address the scale of the problem was available.
- 2010: the Department of Health revised the PMTCT policy again to include lifelong HAART for HIV-positive women with a CD4+ T-cell count ≤ 350 cells/mm3 and dual ART from 14 weeks onwards in the pregnancy for HIV-positive women with a CD4+ T-cell count > 350 cells/mm3, in line with option A of World Health Organization guidelines.17 Infant prophylaxis was daily nevirapine for 6 weeks for all infants. Daily nevirapine was continued for all breastfeeding infants whose mothers were not on HAART, to reduce postnatal transmission.18
- 2011: following a national conference on breastfeeding, the Minister of Health endorsed a policy that breastfeeding should be exclusively used at public health facilities, with formula milk being reserved for when there are medical indications, and that the provision of free formula milk should be phased out.
- 2011: in line with a call from global agencies, the Department of Health developed a national action framework for eliminating mother-to-child transmission of HIV.
In tandem with changes in policy, continuous efforts were also being made to improve the quality of the programme using operational research. A review of the initial 18 pilot sites for the PMTCT programme led to several recommendations for improving health-care systems, including that the programme be scaled up to all facilities.5 It was also recommended that: training of front-line workers be improved; all health-care workers be given more support and supervision; managers’ commitment to the programme be increased; the PMTCT programme be integrated into existing primary health-care services, especially maternal services and services for women and children.
An evaluation of a quality improvement programme in one district in KwaZulu-Natal province showed that, although HIV testing during pregnancy had become routine and universal, coverage was less extensive for other elements of the PMTCT cascade,6 such as ensuring that HIV-positive mothers are treated and continue on treatment; testing infants exposed to HIV; and identifying and treating HIV-positive infants. It was recommended that these elements be given more attention and that programme data related to them be simplified and monitored regularly.7
Paying attention to data and indicators, such as the proportion of HIV-positive mothers receiving ART or prophylaxis, is critical for improving the quality, coverage and impact of the PMTCT programme. This was demonstrated further in a study in 2008 in three districts in KwaZulu-Natal where “a data quality improvement intervention that involved specific training for health-care workers on the importance of public health information, monthly data reviews and feedback, and regular data audits was effective in significantly increasing the completeness and accuracy of the data used to monitor PMTCT services in South Africa”.8 In addition, a 2008 initiative in which data were used to improve quality of care in the programme focused attention on the health districts with the worst performance and strengthened implementation of the PMTCT cascade by sharing good practices.9
Between 2008 and 2011, major changes in professional practice occurred, including a shift towards nurses initiating and managing the use of ART. Nurses and midwives at primary care antenatal facilities were trained to provide ART for eligible pregnant women.
In 2005, slightly fewer than 50% of all pregnant women were routinely tested for HIV infection. By 2009, testing was virtually universal. The maternal treatment regimen used for PMTCT has also changed over the past 10 years, from single-dose nevirapine to either dual therapy with nevirapine and azidothymidine from the 14th week of pregnancy onward or highly active antiretroviral therapy (HAART; Box 1) for women with a CD4+ T-cell count below 350 cells/mm3.
The testing of infants to identify HIV infection early has also increased. The results of routine tests in public health-care facilities are shown in Table 1. Between 2008 and 2011, the proportion of the estimated number of infants exposed to HIV who were tested before reaching the age of 2 months increased from 36.6% to 70.4%. Over the same period, the proportion of infants tested who were HIV-positive decreased from 9.6% to 2.8%.10
Table 1. Polymerase chain reaction testing for HIV in infants younger than 2 months born in public health-care facilities, South Africa, 2008–201110
In 2010, the first national population-based survey of the effect of the South African PMTCT programme on early HIV transmission from mother to child reported an overall transmission rate of 3.5%. When the survey was repeated in 2011, the transmission rate was found to be 2.7%.11,12
The main lessons learnt during improvement of the PMTCT programme were: changes in national PMTCT policy should be implemented rapidly at all facilities; the efforts of partner organizations should be coordinated with those of the formal health-care sector; and data and indicators should be used to provide motivation (Box 2).
Box 2. Summary of the main lessons learnt
- Changes in PMTCT policy should be implemented rapidly at the field level: for example, changes in treatment regimes and in criteria for starting ART should be translated into action on the ground through training and guideline dissemination.
- There should be good coordination at the field level between the formal health-care sector and partner organizations, such as international health agencies and international and local nongovernmental organizations, to support PMTCT policies.
- Greater attention should be paid to data and indicators relating to all aspects of the PMTCT programme as this information can provide motivation.
Despite the remarkably successful implementation of the PMTCT programme in South Africa, many challenges remain. Some health districts have done better than others in ensuring that good quality data are collected routinely and that data are used by health workers and managers to continuously monitor and improve the programme. Moreover, there is also a need for mentoring and supportive supervisory systems that can help facilities use data effectively on a regular basis.7,13
In South Africa, pregnant women visit antenatal clinics at a relatively advanced stage of pregnancy; fewer than 40% of them attend for the first time before 20 weeks’ gestation. Some pregnant women even go into labour without having attended an antenatal clinic once. The PMTCT policy introduced in 2010 (Box 1) requires HIV-positive pregnant women to attend an antenatal clinic early, at 14 weeks’ gestation, so that interventions can be started as soon as possible. Increasing early attendance will require interventions at both the individual and community levels to raise demand for services. In addition, changes in attitudes towards health-care services and in their organization will be needed to boost supply.
Ensuring that all infants undergo early HIV testing is another important challenge, as is making sure that all those who test positive are referred for treatment. In addition, more attention should be given to testing infants exposed to HIV when they are older than 2 months, particularly since breast-feeding may result in on-going postnatal exposure to the virus.
Despite the substantial increase in the number of facilities that can administer ART, 15% of public health-care facilities in South Africa are still not able to initiate treatment (Department of Health, South Africa, unpublished data, 2012). This inconveniences pregnant women, who may have to be referred to another facility for treatment initiation, and increases the possibility that they will be lost to follow-up.
South Africa is implementing a national action framework for PMTCT that covers the 5 years from 2012 to 2016.14 The framework was tailored to individual districts and provinces and aims to provide a clear understanding of the operational issues that influence the continuous improvement of PMTCT programmes. In addition, there are on-going efforts to increase the ability of local health-care workers to collect high-quality data and use those data to improve the PMTCT programme.
If the national action framework for PMTCT is implemented in tandem with the envisaged strengthening of the health-care system, there is a high probability that, within the next 5 years, South Africa will be on the path to achieving the global goal of eliminating mother-to-child HIV transmission by 2015.
- The 2010 national antenatal sentinel HIV and syphilis prevalence survey in South Africa. Pretoria: Department of Health; 2011.
- Johnson LF. Access to antiretroviral treatment in South Africa, 2004–2011. South Afr J HIV Med 2012; 13: 22-7.
- Department of Health. Saving mothers 2008–2010: fifth report on confidential enquiries into maternal deaths in South Africa. Pretoria: Department of Health; 2012. Available from: http://www.doh.gov.za/docs/reports/2012/savingmothersshort.pdf [accessed 29 October 2012]
- Stephen CR, Bamford LJ, Patrick ME. Saving children 2009. Five years of data. A sixth survey of child healthcare in South Africa. Pretoria: Tshepesa Press & Medical Research Council & Centers for Disease Control and Prevention; 2011.
- McCoy D, Besser M, Visser R, Doherty T. Interim findings on the national PMTCT pilot sites: summary of lessons and recommendations. Durban: Health Systems Trust; 2002. Available from: http://www.hst.org.za/sites/default/files/pmtctsummary.pdf [accessed 29 October 2012].
- UNICEF. Consultative meeting on evaluating the impact of prevention of mother-to-child transmission of HIV (PMTCT) services in low- and middle-income countries in averting new HIV infections in children and improving child survival. Nashville: Vanderbilt University; 2009. Available from: http://www.unicef.org/aids/files/Final_Vanderbilt_Meeting_Report_March30Resized6.pdf [accessed 16 November 2012].
- Mate KS, Bennett B, Mphatswe W, Barker P, Rollins N. Challenges for routine health system data management in a large public programme to prevent mother-to-child HIV transmission in South Africa. PLoS ONE 2009; 4: e5483- doi: 10.1371/journal.pone.0005483 pmid: 19434234.
- Mphatswe W, Mate KS, Bennett B, Ngidi H, Reddy J, Barker PM, et al., et al. Improving public health information: a data quality intervention in KwaZulu-Natal, South Africa. Bull World Health Organ 2012; 90: 176-82 doi: 10.2471/BLT.11.092759 pmid: 22461712.
- Ngubane G. National PMTCT accelerated plan (A-plan) status report. Pretoria: Department of Health; 2010. Available from: http://www.sarrahsouthafrica.org/LinkClick.aspx?fileticket=Qt5CxiOrHFc%3D&tabid=2326 [accessed 3 October 2012].
- Sherman G, Lilian R, Barron P, Candy S, Robinson P, Bhardwaj S. Laboratory information system (LIS) data is useful for monitoring the prevention of mother-to-child transmission program (PMTCT) in South Africa. In: XIX International AIDS Conference; 2012 22–27 July; Washington, United States. Available from: http://www.iasociety.org/Abstracts/A200745523.aspx [accessed 12 November 2012].
- Goga A, Dinh T, Jackson D. Evaluation of the effectiveness of the national prevention of mother-to-child transmission (PMTCT) programme on infant HIV measured at six weeks postpartum in South Africa. Cape Town: Medical Research Council; 2012. Available from: http://www.doh.gov.za/docs/reports/2012/pmtcteffectiveness.pdf [accessed 12 November 2012].
- Goga A, Dinh TH, Jackson D, Dlamini N, Mosala T, Lombard T et al. Impact of the national prevention of mother-to-child transmission of HIV (PMTCT) program on perinatal mother-to-child transmission of HIV (MTCT) measured at six weeks postpartum, South Africa (SA). In: XIX International AIDS Conference; 2012 22–27 July; Washington, United States. Available from: http://pag.aids2012.org/abstracts.aspx?aid=8933 [accessed 12 November 2012].
- Doherty T, Chopra M, Nsibande D, Mngoma D. Improving the coverage of the PMTCT programme through a participatory quality improvement intervention in South Africa. BMC Public Health 2009; 9: 406- doi: 10.1186/1471-2458-9-406 pmid: 19891775.
- Draft national action framework for ‘No child born with HIV by 2015 and improving the health and wellbeing of mothers, partners and babies in South Africa’. Pretoria: Department of Health; 2011.
- Protocol for providing a comprehensive package of care for the prevention of mother-to-child transmission of HIV (PMTCT) in South Africa. Pretoria: Department of Health; 2001.
- National antiretroviral treatment guidelines. Pretoria: Department of Health; 2004. Available from: http://www.doh.gov.za/docs/facts/2004/intro.pdf [accessed 12 November 2012].
- New guidance on prevention of mother-to-child transmission of HIV and infant feeding in the context of HIV. Geneva: World Health Organization; 2010. Available from: http://www.who.int/hiv/pub/mtct/PMTCTfactsheet [accessed 12 November 2012].
- Clinical guidelines: PMTCT (prevention of mother-to-child transmission). Pretoria: Department of Health; 2010. Available from: http://www.fidssa.co.za/images/PMTCT_Guidelines.pdf [accessed 12 November 2012].