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      Progress of preventing mother-to-child transmission of HIV at primary healthcare facilities and district hospitals in three South African provinces

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          Abstract

          Improving national prevention of mother-to-child transmission (PMTCT) services in South Africa has been challenging. PMTCT outcomes were analysed at 58 primary- and secondary-level antenatal facilities across seven high HIV burden sub-districts in three provinces, over an 18-month period during which new South African PMTCT clinical guidelines were implemented and a nurse quality mentor programme was expanded. Early infant HIV DNA polymerase chain reaction test positivity reduced by 75.2% from 9.7% (95% confidence interval (CI) 8.1 - 11.5%) to 2.4% (95% CI 1.9 - 3.1%) (p<0.0005). HIV test positivity at 18 months of age decreased by 64.5% from 10.7% (95% CI 7.2 - 15.1%) to 3.8% (95% CI 2.4 - 5.6%) (p<0.0005). PMTCT outcomes have improved substantially at these facilities.

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          Saving the lives of South Africa's mothers, babies, and children: can the health system deliver?

          South Africa is one of only 12 countries in which mortality rates for children have increased since the baseline for the Millennium Development Goals (MDGs) in 1990. Continuing poverty and the HIV/AIDS epidemic are important factors. Additionally, suboptimum implementation of high-impact interventions limits programme effectiveness; between a quarter and half of maternal, neonatal, and child deaths in national audits have an avoidable health-system factor contributing to the death. Using the LiST model, we estimate that 11,500 infants' lives could be saved by effective implementation of basic neonatal care at 95% coverage. Similar coverage of dual-therapy prevention of mother-to-child transmission with appropriate feeding choices could save 37,200 children's lives in South Africa per year in 2015 compared with 2008. These interventions would also avert many maternal deaths and stillbirths. The total cost of such a target package is US$1.5 billion per year, 24% of the public-sector health expenditure; the incremental cost is $220 million per year. Such progress would put South Africa squarely on track to meet MDG 4 and probably also MDG 5. The costs are affordable and the key gap is leadership and effective implementation at every level of the health system, including national and local accountability for service provision.
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            Health system weaknesses constrain access to PMTCT and maternal HIV services in South Africa: a qualitative enquiry

            Background HIV remains responsible for an estimated 40% of mortality in South African pregnant women and their children. To address these avoidable deaths, eligibility criteria for antiretroviral therapy (ART) in pregnant women were revised in 2010 to enhance ART coverage. With greater availability of HIV services in public health settings and increasing government attention to poor maternal-child health outcomes, this study used the patient's journey through the continuum of maternal and child care as a framework to track and document women's experiences of accessing ART and prevention of mother-to-child HIV transmission (PMTCT) programmes in the Eastern Cape (three peri-urban facilities) and Gauteng provinces (one academic hospital). Results In-depth interviews identified considerable weaknesses within operational HIV service delivery. These manifested as missed opportunities for HIV testing in antenatal care due to shortages of test kits; insufficient staff assigned to HIV services; late payment of lay counsellors, with consequent absenteeism; and delayed transcription of CD4 cell count results into patient files (required for ART initiation). By contrast, individual factors undermining access encompassed psychosocial concerns, such as fear of a positive test result or a partner's reaction; and stigma. Data and information systems for monitoring in the three peri-urban facilities were markedly inadequate. Conclusions A single system- or individual-level delay reduced the likelihood of women accessing ART or PMTCT interventions. These delays, when concurrent, often signalled wholesale denial of prevention and treatment. There is great scope for health systems' reforms to address constraints and weaknesses within PMTCT and ART services in South Africa. Recommendations from this study include: ensuring autonomy over resources at lower levels; linking performance management to facility-wide human resources interventions; developing accountability systems; improving HIV services in labour wards; ensuring quality HIV and infant feeding counselling; and improved monitoring for performance management using robust systems for data collection and utilisation.
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              Update on successes and challenges regarding mother-to-child transmission of HIV.

              There is an unprecedented global commitment to reverse the pediatric HIV epidemic by making prevention of mother-to-child transmission (PMTCT) services accessible in all countries. This review outlines the successes made and the challenges that remain. In resource-rich countries, mother-to-child transmission rates of HIV as low as 1% have been achieved. The efficacy of short-course antiretrovirals for PMTCT in Africa is estimated at 50%. Coinfections with herpes simplex virus type 2, other sexually transmitted infections resulting in genital ulcers, and endemic infectious diseases (e.g., malaria) may increase the risk of mother-to-child transmission of HIV. Vertical transmission of drug-resistant viruses has been reported; the prevalence and effect of transmitted resistant virus on treatment outcomes are under investigation. Obstacles facing PMTCT in resource-limited countries include the lack of healthcare infrastructure, limited manpower, and competing public health priorities with the limited healthcare budget. Although the birth of an HIV-infected child in a resource-rich country is now a sentinel health event, in most resource-limited countries the birth of an HIV-infected child continues to be the status quo. Comprehensive PMTCT, including antiretroviral treatment for HIV-infected women and children, should be paramount in resource-limited countries.
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                Author and article information

                Contributors
                Role: ND
                Role: ND
                Role: ND
                Role: ND
                Role: ND
                Journal
                samj
                SAMJ: South African Medical Journal
                SAMJ, S. Afr. med. j.
                Health and Medical Publishing Group (Cape Town )
                2078-5135
                February 2012
                : 102
                : 2
                : 81-83
                Affiliations
                [1 ] Kheth'Impilo AIDS free living
                [2 ] Kheth'Impilo AIDS free living
                [3 ] Kheth'Impilo AIDS free living
                [4 ] Red Cross War Memorial Children's Hospital South Africa
                [5 ] University of Western Cape South Africa
                Article
                S0256-95742012000200016
                22310438
                a350f363-5f3b-438c-9b99-581c128f6e21
                Product
                Product Information: website
                Categories
                Health Care Sciences & Services
                Health Policy & Services
                Medical Ethics
                Medicine, General & Internal
                Medicine, Legal
                Medicine, Research & Experimental

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