There are no good reasons for delaying the gradual and phased expansion of prevention of mother-to-child transmission (PMTCT) services in all provinces, a research report commissioned by the health department has revealed.

But the report also highlights that given the difference in capacity and infrastructure, it is reasonable for provinces to expand the provision of PMTCT services at different speeds

“What is important is that the expansion is done in a structured and properly planned manner, taking into account the many lessons that have been learned,” the report states.

The report, which is to be released this week, was written by the non-governmental organisation Health Systems Trust, and looks in great detail at the 18 pilot sites in the nine provinces. Currently, 21 hospitals (4 tertiary, 8 regional and 9 district), 12 day hospitals, maternity units, poly-clinics and community health centers and about 160 clinics are part of the national PMTCT programme.

They cover about 6 090 ante-natal bookings per month.

With additional political and senior management commitment at both the national and provincial level, it should be possible for all provinces to begin implementing PMTCT services in new sites by the mid-year, according to the researchers.

They also point out that a phased and systematic expansion of comprehensive PMTCT services should be combined with the immediate provision of nevirapine to pregnant women already known to be HIV positive.

The report praises the National Directorate of HIV/AIDS and their provincial counterparts who have “worked hard and tirelessly” to initiate the national PMTCT programme. Nonetheless, many constraints and difficulties have been experienced. These include

• The fact that the health care system is still undergoing significant transformation, re-organisation and structural change;
• The challenge of having to work with and through nine separate and different provincial departments of health;
• Insufficient co-ordination and communication between different units and divisions of the public health care system;
• A bureaucratic environment that hinders rapid implementation of new programmes;
• Understaffing and poor infrastructrure of the health care system in many parts of the country;
• Low morale and poor motivation among many front-line health care providers;
• The continued denial and stigma about HIV/AIDS in the public as a whole.

Sites that are struggling are generally operating within a poorly functioning health care system.

“Expanding and sustaining an effective PMTCT programme across the country will require the infrastructure of the health care system in the under-resourced parts of the country to be improved,” the researchers find.

There were several keys lessons and recommendations discussed in the lengthy report.

Some of the human resources issues identified include inadequate staff to sustain the programme, no lay counsellors and a lack of participation from doctors, midwives and other specialist staff.

Where senior managers have taken an active interest in the PMTCT programme, faster and more effective implementation has often followed.

Inadequate physical space and privacy has hampered the ability to provide adequate counselling and HIV testing services in many facilities, the report revealed.

The report also highlights the neglect of the serious issue of infant feeding and providing free formula milk.

“Although the long-term aim is to make it possible for all HIV positive women to provide safe and affordable exclusive formula feeding, under the current circumstances, the policy may lead to higher rates of mortality and morbidity due to other diseases, as well as higher rates of mixed feeding,” the researchers warn.

The report calls for a national commission of experts to be set up to review the current policy and guidelines on infant feeding and MTCT.

“An option that must receive serious and urgent attention is the post-natal administration of short-course anti-retroviral treatment to mothers and/or babies as a strategy to make breastfeeding safe,” it adds.

The researchers also noted that no significant side-effects had been recognised in either mothers or babies taking single-dose nevirapine as part of the PMTCT regimen.

The report concludes by saying that the18 learning sites must continue with in-depth research and on-going evaluation for the next 18 months so that more lessons can be learnt.

Related stories:

“Two nurses behind Rietvlei’s PMTC success” and “Problems, challenges and successes at the pilot sites”

To read the report, click here