In January 2015, the South African National Department of Health released new consolidated guidelines for the prevention of mother to child transmission (PMTCT) of HIV, in line with the World Health Organization's (WHO) PMTCT Option B+. Implementing these guidelines should make it possible to eliminate mother to child transmission (MTCT) of HIV and improve long-term maternal and infant outcomes. The present article summarises the key recommendations of the 2015 guidelines and highlights current gaps that hinder optimal implementation; these include late antenatal booking (as a result of poor staff attitudes towards ‘early bookers’ and foreigners, unsuitable clinic hours, lack of transport to facilities, quota systems being applied to antenatal clients and clinic staff shortages); poor compliance with rapid HIV testing protocols; weak referral systems with inadequate follow-up; inadequate numbers of laboratory staff to handle HIV-related monitoring procedures and return of results to the correct facility; and inadequate supply chain management, leading to interrupted supplies of antiretroviral drugs. Additionally, recommendations are proposed on how to address these gaps. There is a need to evaluate the implementation of the 2015 guidelines and proactively communicate with ground-level implementers to identify operational bottlenecks, test solutions to these bottlenecks, and develop realistic implementation plans.
South Africa has the highest HIV incidence rates globally, and is the largest provider of antiretroviral therapy in the world.
Key changes between the 2013 and January 2015 South Africa prevention of mother to child transmission guidelines.
2013 South African PMTCT guideline | New January 2015 South African PMTCT guideline |
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No mention of HIV testing amongst children. | Children aged ≥ 12 years may self-consent to an HIV test if they are of sufficient maturity to understand the benefits, risk and social implications. |
3-monthly through pregnancy at labour/delivery at 6-week infant immunisation visit (to identify newly exposed babies who need HIV testing) 12-weekly throughout breastfeeding till 24 months if breastfeeding continued. |
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ART prioritisation (CD4 < 200 cells/μL) cotrimoxazole (CD4 < 200 cells/μL) tests to diagnose Cryptococcus infection (CD4 < 100 cells/μL). |
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CD4 cell count used for monitoring of ART at 12 months post initiation. | |
in all pregnant women with CD4 cell count ≤ 350 or stage 3/4 disease all HIV-positive children < 5 years old – immediately for infants and within 2 weeks for children between 1 and 5 years TB/HIV co-infected pregnant women. |
HIV-positive pregnant, breastfeeding women, or women within 1 year post partum for life HIV-positive women who attend for choice of termination of pregnancy (CTOP) (included in the 2015 PMTCT training package) HIV-positive children < 5 years (discussed in more detail in the paediatric guidelines) HIV/TB or HIV/hepatitis B co-infected women. |
Efavirenz (EFV) not used in first trimester of pregnancy amongst women on ART. | Efavirenz (EFV) used in first trimester of pregnancy amongst women on ART. |
As for 2013 plus |
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birth in symptomatic infants failing to thrive (includes low birth weight, haematological abnormality such as anaemia or thrombocytopaenia, congenital pneumonia, hepatosplenomegaly, extensive oral candidiasis, significant lymphadenopathy, any opportunistic infections) 6 weeks in all HIV-exposed infants 6 weeks post cessation of breastfeeding if aged < 18 months and rapid HIV test if aged ≥ 18 months rapid HIV testing at 18 months. |
birth, or as soon as possible after birth amongst all HIV exposed infants 6 weeks in all HIV-exposed infants not testing positive at birth 10 weeks in infants not testing HIV positive at birth 16 weeks in infants receiving 12 weeks nevirapine 6 weeks post cessation of breastfeeding if aged < 18 months and rapid HIV tests if aged ≥ 18 months rapid HIV testing at 18 months for all HIV-exposed infants, for infants born to mothers of unknown HIV status, and for infants breastfed by a woman of unknown HIV status. |
PMTCT, prevention of mother to child transmission; ART, antiretroviral treatment; ANC, antenatal care; PCR, polymerase chain reaction; ELISA, enzyme-linked immunosorbent assay.
In our opinion, there are five main requirements for successful implementation of the 2015 PMTCT guidelines: (1) early presentation at the health facility to access care (i.e. early antenatal booking), (2) universal antenatal HIV testing based on high-quality standardised operating procedures, with repeat testing of HIV-negative women, (3) immediate referral into appropriate care and retention in care, (4) adequate coverage of appropriate laboratory systems and (5) uninterrupted drug supplies. These require appropriate actions within the health system and amongst sufficiently informed and empowered individual mother-infant pairs.
Summary of impediments to optimal prevention of mother to child transmission guideline implementation.
poor staff attitudes towards ‘early bookers’ and foreigners unsuitable clinic hours lack of transport to facilities quota systems applied to antenatal clients clinic staff shortages and insufficient capacity. |
inadequate quality control poor supervision incomplete handling of discordant results poor data quality/documentation. |
lack of service integration between (1) HIV-related care and routine maternal and child health services and (2) antenatal and postnatal services poor information systems and documentation hinder tracking those lost to follow-up weak referral systems. |
insufficient staff training limited staff capacity to handle increased demand as monitoring and numbers increase limited staff capacity to challenges with quickly communicating positive infant PCR results (e.g. facility Internet access and working telephones). |
inadequate supply chain management limited staff capacity to corruption. |
late antenatal booking: > 50% book after 5 months’ gestation limited staff capacity to fear of HIV diagnosis limited staff capacity to stigma associated with HIV infection and with teenage pregnancy limited staff capacity to lack of demand for antiretroviral services owing to lack of awareness of benefits of treatment. |
PCR, polymerase chain reaction.
Since 2001, South Africa has improved access to antenatal care, HIV testing and ART provision for pregnant women. Currently, antenatal care uptake is over 95%; HIV testing is offered by over 95% of health facilities, and more than 87% of HIV-positive pregnant women receive some form of ART.
There are grave concerns about quality control of HIV counselling and testing (HCT) at facilities, as shown by a study conducted in 455 sites (primary health care clinics, community healthcare centres and hospital gateway clinics) in Limpopo Province (Adrian Puren, personal communication, 11 March 2015). Poor quality control increases the risk of false-positive and -negative HIV results within the PMTCT programme. Concerns identified included inadequate training, frequent rotation of staff, lack of supervision and on-site quality control, incorrect storage of control samples, poor adherence to standard operating procedures (SOP) and improper stock control (Adrian Puren, personal communication, 11 March 2015). Anecdotal information gathered during healthcare provider (HCP) PMTCT guideline training found that HCPs are not waiting the required time before reading the HIV result, increasing the risk of false-negatives.
Appropriate, timely referrals and linkages to care are needed antenatally and post delivery to facilitate uptake of and retention in care. Over 90% of facilities assessed during a national South African Medical Research Council (SAMRC) review conducted in 2010 had a referral system for infant and adult ART clients.
Laboratory capacity is needed for (1) viral load monitoring to identify poor adherence and treatment failure – a vitally important step in PMTCT programme success, (2) CD4 cell count to identify women who need cryptococcal antigen screening or cotrimoxazole prophylaxis, (3) routine antenatal bloods for ART toxicity monitoring and (4) repeated polymerase chain reaction (PCR) testing of HIV-exposed infants from birth (for symptomatic infants) to 18 months;
By mid-2014, an estimated 2.6 million people were on ART in South Africa.
In light of the gaps identified above, we make several recommendations for optimal 2015 guideline implementation (
Recommendations for optimal 2015 guideline implementation.
provide standardised training regarding benefits of early booking for all women, regardless of nationality provide adolescent-friendly sexual and reproductive health services review clinic opening times and conduct local situational assessments to match the demand and supply of services review clinic accessibility (physically and opening hours) and public transport routes provision of more or more frequent mobile facilities/services review use of quota systems in antenatal clinics. |
improve the competence and expertise of all levels of staff conducting HCT establish supervision and monitoring systems for rapid HIV testing quality assurance. |
strengthen service integration establish patient tracking systems, utilising ward-based outreach teams, unique patient identifiers and/or e-systems such as MomConnect improve referral systems with pre-booking and feedback, using a unique identifier and engaging District Specialist Teams. |
increase staffing levels and training improve communication (working telephones, computers, Internet access) to expedite results access. |
ensure that all facilities are trained in stock management, re-ordering procedures and lag times to avoid ART stock-outs increase capacity at facility level to use DHIS data to identify gaps and address them through quality improvement processes facility managers and district coordinators to be held accountable where the PMTCT programme and maternal and child health outcomes are suboptimal. |
Improve awareness on importance of uptake of early antenatal care Eliminate prejudice and discrimination by healthcare workers against people who test HIV-positive, and educate communities about the importance of knowing one's HIV status Advocate at community levels to reduce fear and stigma around HIV and teenage/unwanted pregnancy and educate HIV-infected women regarding the treatment they should be able to access/demand Increase awareness about PMTCT/antenatal and postnatal care at community level |
ANC, antenatal care; HCT, HIV counselling and testing; ART, antiretroviral treatment; DHIS, District Health Information System; PMTCT, prevention of mother to child transmission.
The January 2015 PMTCT guideline recommendations are of a very high standard and based on the best intentions to improve the management of both HIV-positive and HIV-negative women. By implementing these guidelines, it should be possible to eliminate MTCT, improve maternal and infant outcomes, and ensure that women remain virologically suppressed and engaged in lifelong ART care. However, the implementation challenges might have been underestimated. Evaluation of the implementation process is needed to identify key bottlenecks and develop realistic implementation plans. A proactive process of communicating with ground-level implementers is needed to understand their challenges and to address these through well recognised, quality improvement processes.
Our sincere thanks to Professor Adrian Puren from the National Institute of Communicable Diseases for help with data on the Internal Quality Control (IQC) Implementation Report in Limpopo (April 2014). This work was supported by funds from the South African Medical Research Council.
The authors declare that they have no financial or personal relationships which may have inappropriately influenced them in writing this article.
P.N. (South African Medical Research Council) conceptualised and designed, drafted, wrote and finalised the article. N.D. (Wits Reproductive Health and HIV Institute) designed, contributed to and assisted with finalisation of the article. G.S. (National Institute for Communicable Diseases); S.B. (The United Nations Children's Fund) and V.R. (South African Medical Research Council), N.K.N. (South African Medical Research Council), T.R. (South African Medical Research Council), N.N. (South African Medical Research Council), V.M. (South African Medical Research Council), Y.S. (South African Medical Research Council) and D.N. (South African Medical Research Council) reviewed, commented on and approved the final version of the article. A.E.G. (South African Medical Research Council) conceptualised and designed, contributed to and assisted with finalisation of the article.