A situation analysis of the PMTCT programme between 2013 and 2014 in the eThekwini Municipality.
Background The contribution of the human immunodeficiency virus (HIV) epidemic to morbidity and mortality in pregnancy has been well documented. Effective antiretroviral treatment (ART) improves maternal and newborn health as well as preventing mother-to-child transmission (PMTCT); yet access to ART for PMTCT in low and middle income countries only reached 62% (66-85%) in 2012. Of the pregnant women who required ART for their own health, 58% accessed treatment. Provider initiated HIV counseling and testing in a number of health care facilities including antenatal clinics, was recommended in an attempt to improve health outcomes within the expanding HIV epidemic. Further, screening for tuberculosis and initiation of isoniazid prophylaxis is advised in high risk groups. The main aim of the study was to explore the implementation of guidelines for the management of both seropositive and seronegative pregnant women as limited information is available in three key areas in the continuum of care for pregnant women: firstly, time to initiation of ART in women living with HIV; secondly, the implementation of the TB screening processes during pregnancy; and thirdly, follow-up (HIV) testing in uninfected pregnant women. Methods An exploratory, observational, cross sectional study design presenting both descriptive and analytic statistics was used. A two stage cluster sampling using a 30X7 strategy was applied in the selection of antenatal clinics within the metropolitan district. Data from records of eligible women between 32 and 36 weeks gestation was captured onto a data collection sheet. Demographic data and details of ART initiation, TB screening and repeat HIV testing practices were collected. All data was then entered onto a Microsoft Excel spreadsheet for importing into SPSS for processing and analysis. Measures of central tendency were used and chi squared tests and the Mann Whitney tests were applied for the analytic component of the study. Results Data was collected from records of 420 women, 210 were recorded seropositive and 210 were recorded seronegative at initial presentation. Overall, records show 202 women (48%) presented before 20 weeks gestation. Nurse initiation of ART occurred upon diagnosis of HIV infection was documented in 97% of women; TB screening practices however did not appear to be consistent and differed statistically according to administrative authority. The offer of a repeat HIV test to those women who initially tested uninfected was recorded to be offered at a standard rather than an individualised time point. Acute seroconversion was recorded in eight women. Statistically significant associations between HIV status and both median gestational age at first antenatal contact and age (in years) as well as between administrative authority and TB screening practices were found. Discussion, conclusion and recommendations Implementation of national guidelines for the management of pregnant women does not appear to be consistent within or across sampled clinics. Successful integration of HIV services was documented; however TB screening processes and feedback mechanisms following referral require strengthening. Deferment and delays in repeat testing in women who initially test seronegative are particularly concerning. Training and support of health care workers on the value of complete medical records for the overall management and continuity of care of a pregnant female is essential. Further, the benefit in implementation of national guidelines in relation to PMTCT must be highlighted.
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