Abstract:
BACKGROUND. Ninety percent of the world’s HIV-positive pregnant women live in 22 countries. These 22 countries, including South Africa
(SA) have prioritised the elimination of mother-to-child transmission of HIV (EMTCT). Since 2016 all 22 countries recommend lifelong
antiretroviral treatment for all HIV-positive pregnant and lactating women. To measure South African national, provincial and district-level
progress towards attaining EMTCT, we analysed the number of in utero (IU) paedatric HIV infections per 100 000 live births (IU case rate),
and synthesised factors hindering the monitoring of EMTCT progress and attainment from the viewpoint of provincial and district-level
healthcare managers and implementers. We highlight potential innovations to strengthen health systems and improve EMTCT programme
delivery.
METHODS. We reviewed national-, provincial- and district-level birth HIV testing data from routine National Health Laboratory Services
(NHLS) records between April 2016 and March 2017. To obtain a qualitative perspective from healthcare managers and implementers, we
synthesised information from the nine 2016 provincial-level EMTCT stock-taking workshops. These workshops involve key provincial and
district-level staff, mentors and supporting partners. Lastly, we highlight potential innovations presented at these workshops to overcome
operational challenges.
RESULTS. The national IU mother-to-child transmission (MTCT) rate was 0.9%, which translated to an IU case rate of 245 HIV-positive
neonates per 100 000 live births. Provincial IU percent MTCT risk ranged from 0.6% to 1.3%, with IU case rates ranging between 168
and 325 cases per 100 000 live births. District-level IU percent MTCT risk ranged from 0.4% to 1.9%. Potential game changers include:
pre-conception counselling to optimise maternal-partner health, weekly dissemination of HIV polymerase chain reaction (PCR) and viral
load reports from the NHLS to specific individuals who trace mothers and infants needing care, use of ward-based outreach teams and
community caregivers to trace HIV-infected mothers and their infants to link them into care, inclusion of a unique identifier in patient-held
infant Road to Health booklets to facilitate infant tracing and continuous quality improvement (CQI) processes within facilities and districts
and implementation of an HIV-positive baby tool to understand the characteristics and risks of HIV-positive infants. On an ecological level,
provinces and districts using community-based approaches and CQI methodology seemed to have lower MTCT and IU case rates.
CONCLUSIONS. More quantitative analyses are needed to understand what proportion of the success can be attributed to community-based
and CQI approaches and the impact of the potential game changers on progress towards EMTCT.
