Browsing by Subject "PMTCT"

Now showing 1 - 9 of 9
  • Thumbnail Image
    Item
    Open Access
    Challenges to delivering quality care in a prevention of mother-to-child transmission of HIV programme in Soweto, South Africa
    (2013) Mnyani, Coceka Nandipha; McIntyre, James
    Objectives: There has been little focus on quality of care provided in prevention of mother-to-child transmission of HIV (PMTCT) services in South Africa. We assessed quality of care in PMTCT services in Soweto, South Africa, focusing on knowledge and experiences of healthcare workers and HIV-infected pregnant women accessing the services. Methods: A cross-sectional survey was conducted between November and December 2009. A total of 201 HIV-infected pregnant women and 80 healthcare workers, from 10 antenatal clinics, were interviewed using standardised questionnaires. Results: The median gestational age at first antenatal visit was 20 weeks and 32 weeks at the time of the interview. The majority of the women, 71.5%, discovered that they were HIV-infected in the index pregnancy, and 87.9% disclosed their HIV status. Overall, 97.5% received counselling and 33.5% were members of a support group. Knowledge of antenatal and intrapartum PMTCT interventions was correct in 62.7% and 43.3% of the women, respectively. Support group membership and current use of antiretroviral prophylaxis did not impact on the quality of knowledge. Of the healthcare workers, 43.8% were professional nurses and 37.5% were lay counsellors. The majority, 80.0%, felt satisfied with their knowledge of PMTCT guidelines and 96.3% felt competent in managing HIV-infected pregnant women. Yet, there were important deficiencies in knowledge of the guidelines. Conclusion: In our study, knowledge of PMTCT interventions was low in both clients and healthcare workers. These findings point to a need to improve quality of care in PMTCT services, especially with increasingly complex PMTCT interventions recommended by international policies.
  • Thumbnail Image
    Item
    Open Access
    Economic evaluation of models of prevention of mother-to-child transmission of HIV intervention for large scale implementation
    (2021) Cunnama, Lucy; Sinanovic, Edina; Myer, Benjamin
    Background: Huge successes have been seen in the prevention of mother-to-child transmission of HIV (PMTCT) towards its elimination. Now amidst a landscape of universal antiretroviral therapy (ART), focus has been placed on different models of care to support and retain mother-infant pairs in the vulnerable postpartum phase. Methods The aim was to establish economic evidence for scaling-up approaches and models of care for PMTCT particularly during the postpartum period in Southern Africa. The economic data were collected during three studies, Safe Generations (Eswatini), MCH-ART and PACER (South Africa), using mixed bottom-up and top-down methodology. Outcomes of these studies were used to estimate the cost-effectiveness using an incremental cost effectiveness ratio (ICER, calculated by the difference in cost divided by the difference in effects) of lifelong ART in comparison to Option A (the standard of care at the time) in Eswatini; and to estimate the annual costs, costeffectiveness and budget impact of three models of care (Model I: Routine Care - mothers in general ART and infants in well-baby clinics; Model II: Integrated Care - mothers-infant pairs in integrated care in midwife obstetric unit; and Model III: Community Care - mothers in community adherence clubs and infants in well-baby clinics) in South Africa, from the provider and patient's perspectives. Costs are presented in 2019 United States Dollars (US $). Results Lifelong ART can be considered cost-effective in Eswatini with an ICER of US $984 per mother retained in care to six months postpartum. In Cape Town, South Africa, Routine Care cost US $226 per mother-infant pair per annum; Integrated Care cost US $341; and Community Care cost US $254. Annual patient costs (direct and indirect costs) for Models I-III, were US $30-55, US $23-45 and US $76 per mother-infant pair respectively. Comparatively Community Care was the most cost-effective model with an ICER of US $97 per mother-infant pair retained and mother virally suppressed. Scaling-up Community Care nationally in South Africa would require US $5 720 096 more than Routine Care, 0.2% of the total health budget for 2020/21. Conclusions This work has generated novel empirical data in the form of new cost estimates and cost comparisons across different models of care. It has also provided a unique comparison of the different models of care using a cost-effectiveness analysis; and further a novel budget impact analysis of different approaches to rolling these strategies out. This data has helped to fill the gap in the evidence base for instance lifelong ART was implemented in Eswatini as a direct result of the Safe Generations study findings. Community Care was found to be cost-effective and if scaled up nationally in South Africa would only require a small increment of the total health budget. However, we recommend a mixture of models of care to cater for the needs and preferences of patients. Decision makers can use the empirical findings to help set realistic budgets in Southern Africa and explore ideal model implementation to support mother-infant pairs in the crucial postpartum phase.
  • Thumbnail Image
    Item
    Open Access
    Examining the association between future pregnancy intentions, contraceptive use and repeat pregnancies among women living with HIV in Cape Town, South Africa
    (2020) Mubangizi, Lilian; Brittain, Kirsty; Myer, Landon
    Background: Given the rapid expansion of antiretroviral therapy (ART) services in South Africa, there is growing recognition of the importance of fertility intentions, contraceptive use and childbearing among women living with HIV (WLHIV). With the integration of family planning services in the prevention of mother-to-child transmission of HIV (PMTCT) services, understanding fertility intentions and contraceptive use is crucial in evaluating such programs. We investigated the relationship between future fertility intentions, contraceptive use and repeat pregnancies among WLHIV in Cape Town, South Africa. Methodology: We analyzed data from the MCH-ART study conducted at the Gugulethu Midwife Obstetric Unit (MOU) in Cape Town, South Africa, which followed women initiating ART during pregnancy through 36-60 months postpartum. Self-report data were collected using standardized questionnaires at repeated study visits. Data on repeat pregnancies were abstracted from the Western Cape Provincial Data Centre. Associations between maternal characteristics and repeat pregnancies were examined using Cox proportional hazards models. Results: Overall, 109 incident repeat pregnancies were recorded among the 471 women included in this analysis. The median time at risk per individual was 4.27 years. The rate of repeat pregnancies was 5.72 per 100 person-years (PY). This rate was significantly lower among women aged 35-45 years (2.11/100PY) compared to women aged 18-24 years [7.56/100 PY; adjusted hazard ratio (aHR), 0.26: 95% confidence interval [CI], 0.09, 0.81). A total of 333 women contributed data on future fertility intentions and contraceptive use at 12 months postpartum, with 9% reporting that they wanted another child in the future, and 82% reporting current contraceptive use; 16% (n=54) reported not wanting another child but no contraceptive use. The rate of repeat pregnancies was 3 folds higher among women who reported wanting a child in the future (12.59/100 PY) compared to women who did not want 5 a child in the future (4.31/100 PY; aHR, 3.46: 95% CI, 1.83, 6.50). Contraceptive use at 12 months postpartum was not associated with repeat pregnancies. Women who did not want a child and used contraceptives had a 45% decreased hazard of repeat pregnancies compared to women who did not want a child and did not use contraceptives (aHR 0.55: 95% CI [0.32, 0.94]. Conclusion: Among women initiating ART during pregnancy, a repeat pregnancy incidence rate of 5.72/100 PY was observed through 36-60 months postpartum, with the incidence lower among older women. At 12 months postpartum, a notable proportion of women reported not wanting another child but no contraceptive use. Wanting a child in the future was associated with a higher rate of repeat pregnancy, but contraceptive use at 12 months postpartum was not associated with repeat pregnancies. These results highlight the importance of understanding factors associated with the dissonance between fertility intentions and contraceptive use and childbearing to ensure delivery of quality integrated reproductive health services in the PMTCT framework.
  • Thumbnail Image
    Item
    Open Access
    Factors impacting knowledge and use of long acting and permanent contraceptive methods by postpartum HIV positive and negative women in Cape Town, South Africa: a cross-sectional study
    (BioMed Central Ltd, 2012) Credé, Sarah; Hoke, Theresa; Constant, Deborah; Green, Mackenzie; Moodley, Jennifer; Harries, Jane
    BACKGROUND: The prevention of unintended pregnancies among HIV positive women is a neglected strategy in the fight against HIV/AIDS. Women who want to avoid unintended pregnancies can do this by using a modern contraceptive method. Contraceptive choice, in particular the use of long acting and permanent methods (LAPMs), is poorly understood among HIV-positive women. This study aimed to compare factors that influence women's choice in contraception and women's knowledge and attitudes towards the IUD and female sterilization by HIV-status in a high HIV prevalence setting, Cape Town, South Africa. METHODS: A quantitative cross-sectional survey was conducted using an interviewer-administered questionnaire amongst 265 HIV positive and 273 HIV-negative postpartum women in Cape Town. Contraceptive use, reproductive history and the future fertility intentions of postpartum women were compared using chi-squared tests, Wilcoxon rank-sum and Fisher's exact tests where appropriate. Women's knowledge and attitudes towards long acting and permanent methods as well as factors that influence women's choice in contraception were examined. RESULTS: The majority of women reported that their most recent pregnancy was unplanned (61.6% HIV positive and 63.2% HIV negative). Current use of contraception was high with no difference by HIV status (89.8% HIV positive and 89% HIV negative). Most women were using short acting methods, primarily the 3-monthly injectable (Depo Provera). Method convenience and health care provider recommendations were found to most commonly influence method choice. A small percentage of women (6.44%) were using long acting and permanent methods, all of whom were using sterilization; however, it was found that poor knowledge regarding LAPMs is likely to be contributing to the poor uptake of these methods. CONCLUSIONS: Improving contraceptive counselling to include LAPM and strengthening services for these methods are warranted in this setting for all women regardless of HIV status. These study results confirm that strategies focusing on increasing users' knowledge about LAPM are needed to encourage uptake of these methods and to meet women's needs for an expanded range of contraceptives which will aid in preventing unintended pregnancies. Given that HIV positive women were found to be more favourable to future use of the IUD it is possible that there may be more uptake of the IUD amongst these women.
  • Thumbnail Image
    Item
    Open Access
    ‘Feedback: Where data finally get thrilling’ – tools for facility managers to use data for improved health outcomes in the prevention of mother-to-child transmission of HIV and antiretroviral therapy
    (2013) Murphy, J; Mershon, C-H; Struthers, H; McIntyre, J
    Data use and data quality continue to be a challenge for government sector health facilities and districts across South Africa. Led by the National Department of Health, key stakeholders, such as the Anova Health Institute and district health management teams, are aligning efforts to address these gaps. Coverage and correct implementation of existing tools – including TIER.net, routine data collection forms and the South African District Health Information System – must be ensured. This conference report provides an overview of such tools and summarises suggestions for quality improvement, data use and systematic evaluation of data-related interventions.
  • Thumbnail Image
    Item
    Open Access
    Infant feeding knowledge, perceptions and practices among women with and without HIV in Johannesburg, South Africa: a survey in healthcare facilities
    (2016) Mnyani, Coceka N; Tait, Carol L; Armstrong, Jean; Blaauw, Duane; Chersich, Matthew F; Buchmann, Eckhart J; Peters, Remco P H; McIntyre, James A
    BACKGROUND: South Africa has a history of low breastfeeding rates among women with and without Human Immunodeficiency Virus (HIV). In this study, we assessed infant feeding knowledge, perceptions and practices among pregnant and postpartum women with and without HIV, in the context of changes in infant feeding and Prevention of Mother-to-Child Transmission of HIV (PMTCT) guidelines. METHODS: This was a cross-sectional survey conducted from April 2014 to March 2015 in 10 healthcare facilities in Johannesburg, South Africa. A total of 190 pregnant and 180 postpartum women (74 and 67, respectively, were HIV positive) were interviewed using a semi-structured questionnaire. Multiple regression analyses assessed factors associated with an intention to exclusively breastfeed, and exclusive breastfeeding of infants less than six months of age. RESULTS: Women with HIV had better overall knowledge on safe infant feeding practices, both in general and in the context of HIV infection. There were however gaps in knowledge among women with and without HIV. Information from healthcare facilities was the main source of information for all groups of women in the study. A greater percentage of women without HIV 80.9% (93/115), reported an intention to exclusively breastfeed, compared to 64.9% (48/74) of women with HIV, p = 0.014. Not having HIV was positively associated with a reported intention to breastfeed, Adjusted Odds Ratio (AOR) 3.60, 95% CI 1.50, 8.62. Other factors associated with a reported intention to exclusively breastfeed were prior breastfeeding experience and higher knowledge scores on safe infant feeding practices in the context of HIV infection. Among postpartum women, higher scores on general knowledge of safe infant feeding practices were positively associated with reported exclusive breastfeeding, AOR 2.18, 95% CI 1.52, 3.12. Most women perceived that it was difficult to exclusively breastfeed and that cultural factors were a barrier to exclusive breastfeeding. CONCLUSIONS: While a greater proportion of women are electing to breastfeed, HIV infection and cultural factors remain an important influence on safe infant feeding practices. Healthcare workers are the main source of information, and highlight the need for accurate and consistent messaging for both women with and without HIV.
  • Thumbnail Image
    Item
    Open Access
    Infrastructural and human-resource factors associated with return of infant HIV test results to caregivers: secondary analysis of a nationally representative situational assessment, South Africa, 2010
    (2019-09-16) Ngandu, Nobubelo K; Maduna, Vincent; Sherman, Gayle; Noveve, Nobuntu; Chirinda, Witness; Ramokolo, Vundli; Lombard, Carl; Goga, Ameena E
    Abstract Background In June 2015, South Africa introduced early infant HIV diagnosis (EID) at birth and ten weeks postpartum. Guidelines recommended return of birth results within a week and ten weeks postpartum results within four weeks. Task shifting was also suggested to increase service coverage. This study aimed to understand factors affecting return of EID results to caregivers. Methods Secondary analysis of data gathered from 571 public-sector primary health care facilities (PHCs) during a nationally representative situational assessment, was conducted. The assessment was performed one to three months prior to facility involvement in the 2010 evaluation of the South African programme to prevent mother-to-child HIV transmission (SAPMTCTE). Self-reported infrastructural and human resource EID-related data were collected from managers and designated staff using a structured questionnaire. The main outcome variable was ‘EID turn-around-time (TAT) to caregiver’ (caregiver TAT), measured as reported number of weeks from infant blood draw to caregiver receipt of results. This was dichotomized as either short (≤3 weeks) or delayed (> 3 weeks) caregiver TAT. Logit-based risk difference analysis was used to assess factors associated with short caregiver TAT. Analysis included TAT to facility (facility TAT), defined as reported number of weeks from infant blood draw to facility receipt of results. Results Overall, 26.3% of the 571 PHCs reported short caregiver TAT. In adjusted analyses, short caregiver TAT was less achieved when facility TAT was > 7 days (versus ≤7 days) (adjusted risk difference (aRD): − 0.2 (95% confidence interval − 0.3-(− 0.1)), p = 0.006 for 8–14 days and − 0.3 (− 0.5-(− 0.1)), p = 0.006 for > 14 days), and in facilities with staff nurses (compared to those without) (aRD: − 9.4 (− 16.6-(− 2.2), p = 0.011). Conclusion Although short caregiver TAT for EID was only reported in approximately 26% of facilities, these facilities demonstrate that achieving EID TAT of ≤3 weeks is possible, making timely ART initiation within 3 weeks of diagnosis feasible within the public health sector. Our adjusted analyses underpin the need for quick return of results to facilities. They also raise questions around staff mentoring: we hypothesise that facilities with staff nurses were likely to have fewer professional nurses, and thus inadequate senior support.
  • Thumbnail Image
    Item
    Open Access
    Prevalence and determinants of unplanned pregnancy in HIV-infected and uninfected pregnant women seeking antenatal care in Cape Town, South Africa
    (2016) Iyun, Victoria; Myer, Landon
    Background: Prevention of unplanned pregnancy is a crucial aspect of preventing mother-to-child HIV transmission (PMTCT). However, we have little understanding of how HIV status and antiretroviral therapy (ART) may influence pregnancy planning. There are few data on pregnancy planning in HIV-infected South African women, and no comparative data with HIV-uninfected women. Methods: We conducted a cross-sectional study of 2105 pregnant women (1512 HIV-infected; 593 HIV-uninfected) ages 18-44 making their first antenatal clinic visit at a primary-level health care facility in Gugulethu, Cape Town. All women completed structured questionnaires including the London Measure of Unplanned Pregnancy (LMUP), a 6-item scale that categorizes pregnancies into planned, ambivalent and unplanned. Analyses examined LMUP results across 4 groups of participants: HIV-infected established on ART; known HIV-infected but not currently on ART; newly diagnosed HIV-infected; and HIV-uninfected. Results: Overall, the mean age was 29 years (SD: 5.63), 43% of women were married or cohabiting and 20% were nulliparous. The LMUP performed well across all groups (Cronbach's α=0.84). Levels of unplanned pregnancy were higher in HIV-infected versus HIV-uninfected women (50% vs. 33%, p<0.001); and highest in women not on ART. Overall, 69% of women reported contraceptive use in the year before pregnancy; this was strongly associated with unplanned pregnancy (p<0.001). Compared to HIV-uninfected women, HIV-infected women had significantly higher odds of unplanned pregnancy, even after adjusting for age, parity and cohabiting status. The odds were greatest among women newly-diagnosed with HIV and previously diagnosed but not on ART (OR: 1.43; 95% CI: 1.05-1.94 and OR: 1.56; 95% CI: 1.13-2.15, respectively). Increased parity and age <24 years were also associated with unplanned pregnancy (OR 1.83; 95% CI: 1.24-2.74 and OR 1.42; 95% CI: 1.25- 1.60 respectively). Conclusions: These data indicate high levels of unplanned pregnancy in a high HIV prevalence setting, highlighting missed opportunities for family planning and counselling services for HIVpositive women. Possible explanations for the high level of unplanned pregnancy observed include contraceptive failure and/or misuse thereof. Therefore, women living with HIV require additional support to avoid unplanned, particularly those who are younger and have one or more children.
  • Thumbnail Image
    Item
    Open Access
    Stepped care to optimize pre-exposure prophylaxis (PrEP) effectiveness in pregnant and postpartum women (SCOPE-PP) in South Africa: a randomized control trial
    (2022-07-07) Joseph Davey, Dvora L.; Dovel, Kathryn; Cleary, Susan; Khadka, Nehaa; Mashele, Nyiko; Silliman, Miriam; Mvududu, Rufaro; Nyemba, Dorothy C.; Coates, Thomas J.; Myer, Landon
    Background HIV incidence among pregnant and postpartum women remains high in South Africa. Pre-exposure prophylaxis (PrEP) use remains suboptimal in this population, particularly during the postpartum period when women’s engagement with routine clinic visits outside PrEP decreases. Key barriers to sustained PrEP use include the need for ongoing contact with the health facility and suboptimal counseling around effective PrEP use. Methods Stepped Care to Optimize PrEP Effectiveness in Pregnant and Postpartum women (SCOPE-PP), is a two-stepped unblinded, individually randomized controlled trial (RCT) that aims to optimize peripartum and postpartum PrEP use by providing a stepped package of evidence-based interventions. We will enroll 650 pregnant women (> 25 weeks pregnant) who access PrEP at a busy antenatal clinic in Cape Town at the time of recruitment and follow them for 15 months. We will enroll and individually randomize pregnant women > 16 years who are not living with HIV who are either on PrEP or interested in starting PrEP during pregnancy. In step 1, we will evaluate the impact of enhanced adherence counselling and biofeedback (using urine tenofovir tests for biofeedback) and rapid PrEP collection (to reduce time required) on PrEP use in early peripartum compared to standard of care (SOC) (n = 325 per arm). The primary outcome is PrEP persistence per urine tenofovir levels and dried blood spots of tenofovir diphosphate (TFV-DP) after 6-months. The second step will enroll and individually randomize participants from Step 1 who discontinue taking PrEP or have poor persistence in Step 1 but want to continue PrEP. Step 2 will test the impact of enhanced counseling and biofeedback plus rapid PrEP collection compared to community PrEP delivery with HIV self-testing on PrEP use (n = up to 325 postpartum women). The primary outcome is PrEP continuation and persistence 6-months following second randomization (~ 9-months postpartum). Finally, we will estimate the cost effectiveness of SCOPE-PP vs. SOC per primary outcomes and disability-adjusted life-years (DALYs) averted in both Step 1 and 2 using micro-costing with trial- and model-based economic evaluation. Discussion This study will provide novel insights into optimal strategies for delivering PrEP to peripartum and postpartum women in this high-incidence setting. Trial registration NCT05322629 : Date of registration: April 12, 2022.