Pregnant women’s access to PMTCT and ART services in South Africa and implications for universal antiretroviral treatment

  • PLoS ONE, Volume 6, No. 12, Year 2011

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Study Justification:
– The study aims to describe pregnant women’s access to PMTCT (Prevention of Mother-to-Child Transmission) and HAART (Highly Active Antiretroviral Therapy) services in South Africa.
– It also examines the associated birth outcomes among HIV-positive pregnant women.
– The study is important because it provides insights into the current state of PMTCT and HAART services and their implications for universal antiretroviral treatment.
Study Highlights:
– The study found that 39% of the women tested HIV-positive during their pregnancy.
– Among the HIV-positive women, 2.9% did not have a CD4 count done and 31.3% did not receive their CD4 results.
– The majority (96.8%) of HIV-positive women started dual ART (Antiretroviral Therapy) at their first antenatal visit, regardless of their CD4 count.
– During the study period, 48.0% of women with a CD4 result were eligible for HAART, and 29.1% of them initiated HAART during pregnancy.
– Under the current South African PMTCT guidelines, 71.1% of HIV-positive pregnant women could be eligible for HAART.
– Preterm births were more common among HIV-positive women, but there was no increased risk of preterm deliveries among women who received HAART compared to those who received dual ART.
– The in-utero transmission rate was highest among women who required HAART but did not initiate treatment.
Recommendations:
– Improve access to CD4 results during pregnancy to ensure timely initiation of appropriate treatment.
– Strengthen implementation of the current South African PMTCT guidelines to ensure that more HIV-positive pregnant women receive HAART.
– Enhance efforts to reduce preterm births among HIV-positive women.
– Increase awareness and adherence to PMTCT and HAART services among pregnant women.
Key Role Players:
– Ministry of Health: Responsible for policy development and implementation.
– Healthcare Providers: Involved in delivering PMTCT and HAART services.
– Community Health Workers: Play a crucial role in educating and mobilizing pregnant women.
– NGOs and Civil Society Organizations: Support implementation and advocacy efforts.
Cost Items for Planning Recommendations:
– Training and capacity building for healthcare providers.
– Procurement and distribution of CD4 testing kits.
– Provision of antiretroviral drugs.
– Information, education, and communication materials.
– Monitoring and evaluation activities.
– Support for community engagement and mobilization efforts.

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is fairly strong, but there are some areas for improvement. The study provides specific data on pregnant women’s access to PMTCT and HAART services in South Africa, including the percentage of HIV-positive women who did not receive CD4 results and the percentage of women eligible for HAART. The study also compares birth outcomes between different categories of women. However, the abstract does not provide information on the sample size or the methodology used to collect and analyze the data. To improve the evidence, the authors could include more details on the study design, sample size, and statistical analysis methods used. Additionally, providing more context on the limitations of the study would be helpful.

Objectives: We describe pregnant womens’ access to PMTCT and HAART services and associated birth outcomes in South Africa. Methods: Women recuperating in postnatal wards of a referral hospital participated in an evaluation during February-May 2010 during which their maternity records were examined to describe their access to VCT, CD4 Counts, dual ART or HAART during pregnancy. Results: Of the 1609 women who participated in this evaluation, 39% (95%CI36.7-41.5%) tested HIV-positive during their pregnancy. Of the HIV-positive women 2.9% did not have a CD4 count done and an additional 31.3% did not receive their CD4 results. The majority (96.8%) of the HIV-positive women commenced dual ART at their first antenatal visit independent of their CD4 result. During February-May 2010, 48.0% of the women who had a CD4 result were eligible for HAART (CD4<200 cells/mm 3) and 29.1% of these initiated HAART during pregnancy. Under the current South African PMTCT guidelines 71.1% (95%CI66.4-75.4%) of HIV positive pregnant women could be eligible for HAART (CD4<350 cells/mm 3). There were significantly more preterm births among HIV-positive women (p = 0.01) and women who received HAART were no more at risk of preterm deliveries (AOR 0.73;95%CI0.39-1.36;p = 0.2) as compared to women who received dual ART. Nine (2.4%; 95%CI1.1-4.5%) HIV exposed infants were confirmed HIV infected at birth. The in-utero transmission rate was highest among women who required HAART but did not initiate treatment (8.5%) compared to 2.7% and 0.4% among women who received HAART and women who were not eligible for HAART and received PMTCT prophylaxis respectively. Conclusion: In this urban South African community the antenatal HIV prevalence remains high (39%) and timeous access to CD4 results during pregnancy is limited. Under the current South African guidelines, and assuming that access to CD4 results has improved, more than 70% of HIV-positive pregnant women in this community would be requiring HAART. © 2011 Hussain et al.

This is a cross-sectional evaluation of PMTCT and HAART services and birth outcomes in Umlazi, the second largest township in South Africa with an estimated HIV antenatal prevalence of 40%. The evaluation conducted postnatally comprised of a maternity chart audit conducted in the post delivery wards of Prince Mshiyeni Memorial Hospital during a four month period between February and May 2010. Prince Mshiyeni Hospital is a District/Regional Hospital, supports 17 primary health care clinics and has an annual birth rate of 12,000. A written informed consent from all potential participants was obtained prior to any research activity. The informed consent (Zulu and English) were administered by two trained research assistants. Maternity records of consenting study participants were examined to describe their antenatal attendance, access to voluntary counseling and testing and access to CD4 Counts, AZT/NVP and HAART. Birth outcomes such as stillbirth rate, Low birth weight rate, preterm delivery rate and inutero HIV transmission rates were compared between the 3 categories of women viz. HAART ineligible, HAART eligible/untreated and HAART eligible/treated. A dried blood spot was collected from a subsample of HIV exposed infants at birth for HIV diagnosis by DNA PCR. The following data were collected by chart review: Stata version 10 (StataCorp, Texas, U.S.A) was used to analyse the data. A general descriptive analysis was conducted to address all objectives using median, mean, range and 95%CI where applicable. Maternal characteristics presented as categorical data were compared using the Pearson's chi square test. A multivariate analysis was performed in determining independent associations between birth outcomes, HIV status and exposure to HAART. A p value of <0.05 was considered statistically significant. Data were analysed according to stratification of the study population with CD4200 cells/mm3, HAART ineligible, HAART eligible/untreated and HAART eligible/treated. The study was approved by the Ethics Committee of the Nelson R Mandela School of Medicine. All patient details remained confidential and a written informed consent was obtained from eligible participants.

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Based on the provided information, here are some potential recommendations for innovations to improve access to maternal health:

1. Strengthening Antenatal Care: Implement strategies to improve antenatal attendance, such as community outreach programs, mobile clinics, and transportation support for pregnant women.

2. Improving HIV Testing and Counseling: Enhance access to voluntary counseling and testing (VCT) services by integrating them into routine antenatal care visits. This can help identify HIV-positive pregnant women earlier and ensure they receive appropriate care and treatment.

3. Streamlining CD4 Testing and Results: Develop systems to ensure timely access to CD4 testing and results during pregnancy. This can involve improving laboratory infrastructure, training healthcare providers, and implementing electronic medical record systems for efficient data management.

4. Expanding Access to Antiretroviral Therapy (ART): Increase availability and accessibility of ART for pregnant women living with HIV. This can be achieved by strengthening supply chains, training healthcare providers on ART initiation and management, and ensuring consistent drug availability.

5. Enhancing PMTCT Prophylaxis: Improve coverage and adherence to PMTCT prophylaxis regimens for HIV-positive pregnant women who do not meet the criteria for ART initiation. This can involve providing education and counseling to pregnant women, ensuring consistent drug supply, and monitoring adherence.

6. Addressing Birth Outcomes: Implement interventions to reduce preterm delivery rates and in-utero HIV transmission. This can include providing comprehensive prenatal care, promoting healthy lifestyle choices during pregnancy, and ensuring access to appropriate medical interventions.

7. Utilizing Technology: Explore the use of telemedicine and mobile health applications to provide remote consultations, support, and monitoring for pregnant women in underserved areas. This can help overcome geographical barriers and improve access to maternal health services.

8. Strengthening Health Systems: Invest in healthcare infrastructure, human resources, and training programs to build a robust and sustainable maternal health system. This can involve improving healthcare facilities, increasing the number of skilled healthcare providers, and implementing quality assurance mechanisms.

It is important to note that these recommendations are general and may need to be tailored to the specific context and needs of the community in South Africa.
AI Innovations Description
Based on the information provided, the following recommendation can be developed into an innovation to improve access to maternal health:

1. Strengthening Antenatal Care Services: Implementing a comprehensive antenatal care program that includes routine testing for HIV, CD4 count, and access to antiretroviral therapy (ART) for pregnant women. This can be achieved by training healthcare providers on the importance of early testing and treatment initiation, ensuring availability of testing kits and medications, and improving the overall quality of antenatal care services.

2. Improving Access to CD4 Count Results: Develop innovative solutions to ensure timely access to CD4 count results for pregnant women. This can include implementing point-of-care CD4 testing at antenatal clinics, utilizing mobile technology for result delivery, or establishing a system for rapid result turnaround time.

3. Expanding Access to HAART: Increase the availability and accessibility of HAART for eligible pregnant women. This can be done by strengthening the supply chain management system to ensure consistent availability of medications, establishing satellite clinics or mobile clinics in underserved areas, and providing transportation support for women to access treatment centers.

4. Enhancing Birth Outcome Monitoring: Implement a robust system for monitoring and tracking birth outcomes, including stillbirth rate, low birth weight rate, preterm delivery rate, and in-utero HIV transmission rates. This can involve the use of electronic medical records, data collection tools, and regular reporting mechanisms to identify areas for improvement and measure the impact of interventions.

5. Community Engagement and Education: Conduct community outreach programs to raise awareness about the importance of antenatal care, HIV testing, and treatment for pregnant women. This can involve partnering with community leaders, local organizations, and peer educators to disseminate information, address misconceptions, and promote positive health-seeking behaviors.

By implementing these recommendations, it is expected that access to maternal health services, particularly PMTCT and ART services, can be improved, leading to better birth outcomes and reduced HIV transmission rates among infants.
AI Innovations Methodology
To improve access to maternal health in South Africa, here are some potential recommendations:

1. Strengthening antenatal care services: This can include increasing the number of antenatal care visits, ensuring availability of essential services such as HIV testing and counseling, CD4 count testing, and access to antiretroviral treatment (ART) for HIV-positive pregnant women.

2. Improving access to CD4 count results: Efforts should be made to ensure timely and accurate CD4 count testing and delivery of results to pregnant women. This can involve streamlining laboratory processes, improving communication between healthcare providers and laboratories, and implementing electronic systems for result delivery.

3. Expanding access to ART: Increasing the availability and accessibility of ART for HIV-positive pregnant women can significantly reduce the risk of mother-to-child transmission of HIV. This can be achieved by training healthcare providers on ART initiation and management, ensuring a reliable supply of antiretroviral drugs, and addressing barriers to ART adherence.

4. Enhancing community engagement and awareness: Community-based interventions can play a crucial role in improving access to maternal health services. This can involve community mobilization, education campaigns, and involvement of community health workers to promote antenatal care attendance, HIV testing, and adherence to treatment.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could include the following steps:

1. Define the target population: Identify the specific population group that will be the focus of the simulation, such as pregnant women in a particular region or healthcare facility.

2. Collect baseline data: Gather relevant data on the current status of access to maternal health services, including antenatal care attendance, HIV testing rates, CD4 count testing rates, and ART initiation rates.

3. Develop a simulation model: Create a mathematical or computational model that represents the population and the various factors influencing access to maternal health services. This model should incorporate variables such as antenatal care utilization, HIV testing rates, CD4 count testing rates, ART initiation rates, and birth outcomes.

4. Input intervention scenarios: Introduce the recommended interventions into the simulation model and adjust the relevant variables accordingly. For example, increase the number of antenatal care visits, improve CD4 count testing rates, and expand access to ART.

5. Run simulations: Use the simulation model to simulate the impact of the interventions on access to maternal health services. This can involve running multiple scenarios with different combinations of interventions to assess their individual and combined effects.

6. Analyze results: Analyze the simulation results to determine the impact of the interventions on access to maternal health services. This can include evaluating changes in antenatal care attendance, HIV testing rates, CD4 count testing rates, ART initiation rates, and birth outcomes.

7. Interpret findings: Interpret the findings of the simulation to understand the potential benefits and limitations of the recommended interventions. This can help inform decision-making and prioritize interventions for implementation.

It is important to note that the methodology for simulating the impact of recommendations may vary depending on the specific context and available data.

Statistics:
Citations: 27
Authors: 4
Identifiers:
DOI: 10.1371/journal.pone.0027907
Research Areas:
Community Interventions, Genetics and Genomics, Health System and Policy, Infectious Diseases, Maternal Access, Maternal and Child Health, Quality of Care, Sexual and Reproductive Health, Social Determinants
Study Countries:
South Africa
Study Design:
Cross Sectional Study
Study Approach:
Quantitative
Participants Gender:
Female
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