Programme to improve implementation of the Prevention of Mother to Child Transmission of HIV in Gert Sibande district in Mpumalanga, South Africa: baseline report: Gert Sibande PMTCT programme implementation

Abstract

Background: A baseline assessment of the PMTCT programme was conducted in the Gert Sibande district of Mpumalanga province in 2008-9 to gather information on the status of PMTCT programme implementation at all Gert Sibande health facilities prior to initiating programme strengthening activities. Identified gaps in the PMTCT programme were staff shortage, lack of guidelines, stock outs, no monitoring and evaluation system, lack of training and poor data collection methods. Interventions to address identified gaps are currently in progress. This report presents the baseline assessment results. The assessment comprised * Facility and * Client assessments

Methods: A baseline rapid assessment was conducted by trained researchers in the formal health sector with pregnant mothers and mothers with infants between 3 months and 8 months of age. (a) Interventions to strengthen PMTCT programme implementation (b) Monitoring and evaluation support.

Key findings

Facility assessments

Few facilities had all the required national guidelines/protocols/policies on HIV management. More than half of facilities did not have all provincial guidelines/protocols/policies. 48 out of 75 facilities had the updated PMTCT guideline. Facilities generally had IEC materials. Seventy out of 75 facilities conducted on-site HIV testing and 68 had VCT services daily. Refusals on HIV testing by clients was reported by 62 facilities. Reasons stated by clients for refusal of testing were: * fear of the outcome, * client not ready for results, * client scared of the test and * some needed time to think.

Refusal of testing needs further investigation as the case registers does not distinguish clients who were tested during the previous pregnancy from new clients. Therefore, some clients might have refused because they have been tested before. All facilities had at least one PN responsible for HIV testing, except in Lekwa and Albert Luthuli. The need for training of staff on PMTCT/VCT was high in all sub-districts. Staff needed training on dual therapy. Most facilities generally had at least two lay counsellors, with a few exceptions, but there was no work schedule for lay counsellors. Lack of space made it difficult for some facilities to have a counselling room. More than half of facilities promoted family planning during VCT. Several facilities did not do PCR testing on site, and they did not have PCR testing kits.

Shortage of infant formula was reported by 64 facilities. A significant number of facilities did not have a follow-up system for infants born to HIV-positive mothers. Programme managers expressed concerns about staff shortage, untrained staff, space problem and lack of supervision. Women who opted to deliver their babies at home posed a challenge to health care facilities. Another challenge was women knew their HIV status did not disclose to their families. As a result of not disclosing, they mixed fed their infants. Clients manipulated ANC coding cards and some were reluctant to take the prophylaxis drug. A large number of PNs reported a need for community awareness on PMTCT issues.

M & E

With regards to the recording of client data on case registers, a number of concerns were observed. Data were recorded on loose A3 sheets that may be misplaced. Data recorded on case registers differed from that recorded on monthly summary sheets and DHIS data. Data elements recorded in case registers did not tally with those on DHIS. More elements were recorded in case registers. However, there were facilities that had good data recording as evidenced by concordant records in case registers, monthly summary sheets and DHIS. Poor data recording was attributed to staff shortage and heavy workload of PNs.

HIV knowledge and attitude

A high percentage of women were aware that HIV could be transmitted during pregnancy, delivery and through breast feeding. Disclosure of the HIV status was a challenge as 285 had not discussed their status with their partners. A concern that was reported by clients was ARV shortage at facilities. Some clients indicated that they were not given after testing for HIV. Lay counsellors proved to be valuable members of the health team as more clients received their HIV test results from lay counsellors than nurses.

Conclusion and recommendations: Findings of the rapid assessment reveal a need to strengthen PMTCT service delivery at Gert Sibande. Staff shortage compromises service delivery and the quality of service as the PNs are overwhelmed with a heavy workload. Bound case registers or electronic data recording would ease the problem of tallying data at the end of the month. The number of PNs needs to be increased as some facilities served a large population. A follow-up system for infants born to HIV mothers is crucial. Shortages of infant formula might lead to mixed feeding. Poor data might contribute to under stocking of infant formula. All clients who have been tested should receive their test results.