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Background: South Africa’s National Department of Health adopted WHO’s 2013 consolidated guidelines on ARVs for HIV treatment and prevention in 2015, including changes for Prevention from Mother-to-Child Transmission (PMTCT) through Option B+, aimed to reduce the HIV prevalence rate amongst women by placing them on lifelong treatment, irrespective of their CD4 count. As a result, these guidelines were implemented for the PMTCT program at Rahima Moosa Hospital. Little is known about the impact of these guidelines on the work of healthcare workers (HCWs) and no research had focused on how these changes have affected adherence for the patients. Objectives: The purpose of this research project was (1) to explore the impact of the Option B+ PMTCT program on the work of healthcare professionals, and (2) to understand pregnant HIV-positive women views and experiences with ART for life, as a way to better manage the Option B+ PMTCT program. Design: Qualitative semi-structured interviews with a phenomenological approach was used. Setting: Data collection at the antenatal/postnatal clinics/wards, OBGYN and Department of Pediatrics at RMMCH in Johannesburg. Method: A qualitative study design is used with a phenomenological approach. The methodology used semi-structured interviews with healthcare professionals and patients. The thematic analysis was used within an Accessibility Framework to guide the identification of domains that emerged from all transcribed data. A convenience sample in the antenatal clinic, postnatal clinic, antenatal ward, OBGYN, and Department of Pediatrics and Child Health at RMMCH. The study is situated in Johannesburg, South Africa. Results: The findings demonstrated that work has become difficult to manage for all healthcare professionals because of (1) the need for strengthening indicators for tracking to decrease loss to follow-up (LTFU); (2) inconsistency in delivery of counseling and support services and the need for communication across clinical departments; and (3) the lack of compassion and understanding by service providers. The difficult healthcare environment has affected overall views and experiences of pregnant HIV-positive women going on ART for life. All patient participants (n = 55) responded that they chose to take the fixed-dose combination (FDC) for life to protect the health of the baby and felt ART for life can be stopped after giving birth, unaware of the long-term benefits to the mother. Conclusion: The Option B+ program emphasized a need for the provision of continuous counseling and support services for women with same day initiation of ART. There is a need for better internal communication and collaboration amongst HCWs across all units of RMMCH for attainment in treatment outcomes. HCWs communication to patients is essential in helping patients build trust in service delivery, decreasing the LTFU and promoting adherence. The ability to understand functions of the work environment in which a PMTCT program operates in is essential in addressing policy implementation and program issues for ease of adaptability of Option B+ programming on a larger scale across all units of RMMCH. Implications for future research include the need to address changes within the healthcare system at both clinical and management levels. It is crucial to incorporate the perspective of patients in policy implementation; uptake and adherence are key indicators in informing whether the Option B+ PMTCT program is being adapted into state hospitals effectively. There needs to be extensive research on how to strengthen indicators for long term scalability and sustainability of the program. Future evaluations need to address how interdisciplinary collaboration within healthcare facilities improves the management and understanding of Option B+ program.
One of the regional public sector hospitals that was first to implement Option B+ PMTCT was Rahima Moosa Mother and Child Hospital (RMMCH), the study site that will provide insight to explore perceptions of women first going onto the lifelong treatment program. RMMCH provides healthcare specialist services for women and children. The institution has 110 general pediatric beds, 30 neonatal beds and a six-bed intensive care unit. The healthcare workers (HCWs) see more than 36,000 outpatients and have more than 12,000 births annually. Approximately 25 clinics refer patients to the ANC service at RMMCH, creating a busy maternal healthcare environment (11, p. 8–10). RMMCH is located in the suburb of Coronationville comprised of 2,500 people living in informal settlements of which 60.8% are females, many women with poor health outcomes (11, p. 8–10). Ethics approval for the study was granted by The Hamilton Integrated Research Ethics Board (HiREB) at McMaster University located in Hamilton, Canada. Authorization was obtained from the Human Research Ethics Committee (HREC) at the University of Witwatersrand, South Africa in 2015 and from RMMCH, Johannesburg to conduct the study in Coronationville (approval HiREB Number: 15-264-S/HREC Number: M150495). This qualitative study conducted 67 semi-structured, audio-recorded interviews with pregnant HIV-positive women (n = 55) and HCWs (n = 12). A phenomenological approach was used to investigate lived experiences of HIV-positive pregnant women and HCWs under the Option B+ PMTCT program. Patients and HCWs perceptions of HIV were investigated to learn more about their perspectives and stories prior to the implementation of Option B+. For example, patients were asked “How did you feel when you first found out you were HIV-positive?” Whereas, HCWs were asked, “What are some of the challenges with adherence to Option B+ with your patients?” This study explored the specific phenomenon between HCWs (nurses, physicians and healthcare management) and patients, providing in depth understanding of how the Option B+ program is now impacting the work of HCWs and the adherence of patients (13). The Accessibility Framework (see Figure 1) has been adapted by McIntyre et al. (12, p. 179–193) for access to PMTCT lifelong treatment based on three dimensions of accessibility; affordability, availability, and acceptability to help guide the research. Each dimension represents a potential barrier to PMTCT care. However, the framework has an additional concept of “adaptability” of PMTCT services in healthcare settings. It is important to explore the concept of adaptability because there is a literature gap that exists when determining whether Option B+ is successful in policy implementation in terms of scalability and sustainability. The enhanced accessibility framework [adapted from (12)]. The adaptability concept has been added to figure. Accessibility evaluation framework. Study participants were selected to gain a selected representation of views from the identified groups of; pregnant HIV-positive women and HCWs at RMMCH. Participants were not excluded based on race or language. The inclusion criteria included pregnant women between 15 and 49 years old, be HIV-positive and either newly enrolled or on Option B+. Newly enrolled HIV positive women on the program had to have at least their first dose of the FDC pill or been on treatment for at least one month and were included to provide insight on their experience with switching or starting on a new treatment regimen. HCWs had to have involvement with patients on Option B+ or/and the initiation of the program at RMMCH for at least the past six months since its inception (January 2015). HIV-positive patients were recruited through convenience sampling, a non-probability technique by the principal investigator (PI) to select subjects because of their accessibility and proximity in the antenatal (ANC) and postnatal clinics (PNC) and wards, Obstetrics and Gynecology and, Department of Pediatrics and Child Health at RMMCH (14, p. 42–45). To control for differences in age and levels of education, scoping was completed within the ANC and PNC clinics and wards to obtain a sampling weight to account for the demographics of women at the hospital. Assistance from the nurses was provided, who would first attend to the patients, those who were on Option B+ were asked if they’d like to meet with the PI and informed that their participation was completely voluntary in the study. Staff from selected units and departments, which included HCWs and executive management at RMMCH, were recommended by the Director of the Pediatric unit and contacted via email by the PI. HCWs and patients were provided with information letters and consent forms for recruitment into the study. Individuals that provided informed consent were then asked to participate in an interview with the PI. Potential participants that were illiterate were provided an oral consent form and a witness to sign that the PI has read and clarified any questions. Participants were recruited consecutively until data saturation occurred where the PI is no longer hearing or seeing new information emerging from the data (14, p. 42–45). Thus, a total number of 67 interviews were conducted with 55 patients and 12 HCWs, which consisted of nine females (5 nurses, 1 pediatrician, 1 OBGYN, 1 neonatologist, 1 executive manager) and three males (2 pediatricians and 1 OBGYN). The reported mean for the experience in profession (number of years) for nurses is 21 years, pediatrician is 10 years, OBGYN is 6 years, neonatologist is 7 years, and executive manager is 8 years.
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