Pre-post assessment of PMTCT in Kouga LSA

Tags: PMTCT, Mlambo, G., Baseline assessment, Nancy Phaswana-Mafuya, Phaweni, K., HIV infection, Kouga LSA Presenter, Ladzani, R., health care, Davids, A., access to health care facility, VCT, HIV counseling, Infant feeding, Exclusive breastfeeding, Mixed feeding, health care facility, HIV test results, Friend/family member
Content: Pre-post assessment of PMTCT in Kouga LSA Presenter: Prof Nancy Phaswana-Mafuya, PhD Co-authors: Phaswana-Mafuya,N.;Peltzer,K.; Ladzani, R.; Davids, A.; Mlambo, G.; Phaweni, K.; Dana, P, Ndabula, M CDC/PEPFAR award: "Programme to Improve Capacity of an Indigenous Statutory Institution to Enhance M&E of HIV/AIDS in RSA
Presentation Overview · Background · Baseline assessment: missed opportunities in Kouga LSA · Goals to address missed opportunities · Interventions · Methods · Results · Key improvements · Key issues emerging · Conclusion
Background UNAIDS, 2005/2008: · 38 000 children in South Africa acquired HIV infection at birth · 26 000 children infected with HIV through breastfeeding · Globally only 9% of HIV Pregnant women were receiving ARVs · By December 2005, PMTCT program had been implemented in 77% of SA public health facilities · Large portion of pregnant women still do not receive an HIV test during pregnancy · <50% of pregnant women known to be HIV+ receive NVP at the time of delivery. · Need for improved coverage and PMTCT strengthening
National Strategic Plan on HIV & AIDS and STIs: 2007 ­ 2011 (DoH, 2007) Priority area 1: Reduce HIV incidence rate by 50% by 2011
Goal 1: Goal 2: Goal 3: Goal 4:
Reduce vulnerability to HIV infection & the impact of AIDS Reduce sexual transmission of HIV Reduce mother-to-child transmission of HIV Minimise the risk of HIV transmission through blood and blood products
Baseline Assessment: Missed Opportunities in Kouga LSA Rispel, L.C., Peltzer, K., Phaswana-Mafuya, N., Metcalf, C.A., & Treger, L. 2009. Assessing missed opportunities for PMTCT in the Kouga LSA, EC. SAMJ, 99 (3): 174-179 1. 74% were offered HIV Counseling & Testing 2. Only 43% had been tested for HIV at pregnancy 3. Only 40% were aware of PMTCT program 4. Only 19%had been given NVP at 28 weeks 5. Only 53% received FP Counseling 6. 27% incorrectly believed that an HIV+ woman would always infect her baby 7. Discrepancies between DHIS and clinic records
Goals to address missed opportunities in Kouga LSA · Strengthening PMTCT in existing sites in Kouga LSA · Training health workers in PMTCT/VCT · Increase # of pregnant women who receive confidential HIV counseling and testing (CT) and receive their results · Increase # of pregnant women provided with a complete course of NVP · Monitor # of children who become infected with HIV during the first year of life · Increase # of eligible women of childbearing age enrolled in wellness programs and/or treatment programs · Strengthening M&E System
Interventions
GOAL: Strengthen programmes to prevent HIV transmission from mother to child in Kouga LSA of the Eastern Cape Province
Objectives
Outputs Number of · PMTCT service sites · health workers trained on PMTCT provision · pregnant women who received CT and result; · ARV prophylaxis; CD4 test or referred to a wellness and/or an ART programme · women eligible for HAART referred and enrolled into a treatment program · infants who receive NVP; tested for HIV by PCR at 6 to 14 weeks; and at 12 months 18 months and referred
BASELINE ASSESSMENT
Formal health sector ·Key informants interviews and observation ·Client interviews
Traditional Health Sector ·Traditional health practitioners ·Determine KAP and training needs ·THP clients
Community · Interviews with NGOs active in the field of HIV and AIDS ·Focus groups with HIV+ women who delivered
INTERVENTIONS INTERVENTIONS · Health worker training:THPs, lay counsellors, nurses, health promoters, etc · Provision of guidelines, policies and development of operational plans · Establishment of support groups · Appointment of staff to fill vacant positions · Technical Support to increase provision of ARV prophylaxis
M & E ­ Post intervention assessment in the formal health sector
Methods · This paper focuses on PMTCT pre-post assessment in as far as formal sector is concerned (interviews with clinic managers and PMTCT clients ­ ANCs/PNCs · Pre-post results for Lay counsellors, support group members and traditional healers are not included · A pre-post design was used employing structured questionnaires for: · Health service assessment: · pre - 20 clinics/post -22 clinics · PMTCT programme coordinator or clinic manager at each PMTCT site was interviewed · Exit interviews had purposive samples: · pre - 296 ANCs/ post - 239 ANCs; · pre ­ 70 HIV+ PNCs; post ­ 142 HIV+ PNCs
Improvements in compliance to national PMTCT criteria were observed: n=20/n=22
On-site counseling for HIV testing On-site HIV testing Private room in which VCT can be conducted Daily availability of VCT Referral to an ART site CD4 count testing
Pre test % 18(100) 17(94) 17(94) 16(89) 18(100) 17(94)
NVP given to HIV+ pregnant women at 28 weeks NVP given to neonates within 72 hours of birth Antenatal counseling on infant feeding
17(94) 5(28) 15(83)
Postnatal counseling and support for infant feeding Adequate supply of free infant formula PCR testing for infants for HIV infection 2 health workers trained in PMTCT per facility A support group specific to HIV+ and pregnant women
15(89) 10(63) 13(72) 7(41) 6(35)
Post test % 22(100) 22(100) 14(64) 22(100) 22(100) 22(100) 22(100) 2(9) 22(100) 22(100) 20 (91) 22(100) 15(68) 15(68)
No significant changes were observed in access to health care facility
Transport mode
Pre N (%)
(n=296)
Walking
256 (86.6)
Taxi
23 (7.8)
Friend/family member's transport
16 (5.4)
Time to clinic
< Ѕ hour
260 (87.8)
Ѕ to 1 hour
29 (9.8)
> 1 hour
7 (2.4)
In labour during the day
292 (98.6)
In labour at night
285 (96.3)
Would use ambulance during the day to health care 271 (91.6) facility Would use ambulance at night to health care facility 257 (86.8)
About 1 hour to get to health care facility during the 168 (56.7) day About 1 hour to get to health care facility during the 160 (54.2) night
Post N (%) (n=239) 222 (92.9) 11 (4.6) 4 (1.7) 202 (84.5) 31 (13) 6 (2.5) 231 (96.6) 232 (97.1) 202 (84.5) 197 (82.4) 118 (49.5) 110 (46)
Significant decline in the proportion of women who were
delivered by a doctor
Pre: N (%) Post: N (%)
(n=296)
(n=239)
Items Place of delivery Hospital At home Person who delivered previous baby Doctor Midwife TBA Family member Other Intention to give birth at hospital/clinic *p<0.005
N (%)
N (%)
170 (93.4) 12 (6.6)
135 (90.6) 14 (9.4)
70 (38.3) 89 (48.6) 3 (1.6) 3 (1.6) 18 (9.8) 291 (98.3)
35 (23.6)* 102 (69.4 2 (1.4) 6 (4.1) 2 (1.4) 235 (99.2)
Significant increase in # of women who were tested for HIV during the previous pregnancy, who knew HIV test results and HIV counseling <30 min
Pre: N (%) Post: N (%)
HIV testing during last pregnancy
(n=296) N (%)
(n=239) N (%)
Tested for HIV during last pregnancy
79 (27.0)
98 (66.7)*
Knew the results of HIV test during last 79 (27.0) pregnancy
How long did the nurse (or other staff) talk to you during the HIV counseling?
<1/2 hour
174(58.7)
98 (66.7)* 71 (33.4)*
Ѕ - 1 hour
20(13.4)
135 (63.4)
1-2 hours
6(2.0)
4 (1.9)
> 2 hours
1(0.3)
3 (1.4)
Offered HIV counseling upon arrival
217 (73.6) 227 (95.4)
* p<0.000
Significant differences were observed regarding educating the community about available health services and HIV/AIDS counselling and reducing waiting time
Pre N (%)
Spent less than one hour for an ANC visit (n=296)
The amount of time spent was reasonable 186 (62.8)
Would come back to this facility for care 294 (99.3)
The reasons why they would come back to
facility were:
No alternative facility
156 (52.6)
The nursing staff are friendly and kind
106 (35.8)
Increase number of staff including doctors, 95 (33.2) nurses and counselors Educate community about the available 35 (12.2) health services and HIV/AIDS counseling
Increase number of ambulances available Extension of service hours at the clinic Reduce waiting time Extension of the clinic/ hospital buildings
19 (6.6) 13 (4.5) 13 (4.5) 7 (2.4)
Improve privacy
4 (1.4)
p<0.001
Post N (%) (n=239) 123 (51.5) 222 (92.9) 39 (16.4) 27 (11.3) 57 (23.8) 2 (0.8)* 8 (3.2) 0 33 (13.8)* 8 (3.2) 3 (.0)
Significant increase in # number of women who were aware of the PMTCT programme at post assessment
Pre N (%) (n = 70)
Have you heard about the PMTCT program? 28 (40.0)
If so, where did you hear about it?
At the clinic
24 (34.3)
At the hospital
1 (1.4)
Other (Radio/community)
Can an HIV-positive mother infect her baby 37(54.4) with HIV during pregnancy?
Can an HIV-positive mother infect her baby 43(63.2) with HIV during delivery?
*p<0.001
Post N (%) (n = 142) 112 (77.8)* 111 (92.5) 6 (5.0) 3 (2.5) 153(69.9) 159(72.6)
Significantly more women felt relaxed about pre-test counselling at post assessment
Pre N (%)
(n = 70)
Experience/Feelings about HIV pre-test
counseling
Nervous
41 (58.6)
Relaxed
21 (30.0)
Never received HIV pre-test counseling
8 (11.4)
Experience/Feelings about HIV post-test
counseling
Miserable
29 (41.4)
Confident/good
23 (32.8)
Did not want to accept the result
5 (7.4)
Accepted the situation with little panic
7 (10.0)
Never received post-test counseling
6 (8.5)
Post N (%) (n = 142) 67 (49.3) 65 (47.8)* 4 (2.9) 34 (26.8) 54 (42.5) 2 (1.5) 5 (3.9) 17 (13.4)
*p=0.001
The proportion of women who disclosed their status to someone did not seem to improve
Pre N (%)
(n = 70)
Had disclosed their HIV-test result to someone Person who they had disclosed to:
63 (92.6)
Partner/Husband
32 (50.8)
Mother
11 (17.5)
Sister
5 (7.9)
Other family members
5 (7.9)
Friends
6 (9.5)
Other (specify)
4 (6.3)
Experience following disclosure
Relieved
47 (67.1)
Devastated
12 (17.1)
Nothing
5 (7.1)
Had not disclosed their HIV status to anybody
6 (8.5)
Post: N (%) (n = 142) 118 (84.3) 77 (30.9) 43 (17.3) 40 (16.1) 51 (20.5) 26 (10.4) 4 (1.6) 68 (62.9) 30 (27.7) 4 (3.7) 6 (5.5)
A health facility was the preferred place of delivery. Most deliveries were done by nurses but significant differences were not observed
Pre N (%)
Place of delivery
(n = 70)
Home or another person's home
1 (1.4)
Health facility
66 (94.3)
Other
3 (4.3)
Person who assisted with the delivery of baby
Doctor
14 (20.3)
Nurse/midwife
54 (78.3)
Other
1 (1.4)
Post N (%) (n = 142) 10 (7.1) 131 (92.9) 0 (0.0) 33 (23.4) 95 (67.4) 13 (9.2)
No significant differences were observed on NVP intake
Items
N (%)
(n = 70) Whether provided with a drug to prevent 60 (88.2) mother to child transmission of HIV
N (%) (n = 142) 125 (89.3)
Whether partner/husband informed that 41 (66.1) drug must be taken When did you take (or were given) the drug? N (%) Before labour began 50 (82.0) Onset of labour 10 (16.4) When baby was born 1 (1.6) Did this baby receive a syrup medicine within 51 (77.3) 3 days after s/he was born to prevent mother to child transmission?
96 (74.4) N (%) 97 (77.0) 25 (19.8) 3 (2.4) 127 (90.7)
No significant differences observed on infant feeding
Whether infant feeding options given during N (%)
counseling
(n = 70)
No, not offered
9 (12.8)
Yes, Formula exclusively
18 (25.7)
Yes, Breastfeeding exclusively
41 (58.6)
Yes, cup feeding only
2 (2.6)
Reported feeding option practiced
N(%)
Exclusive breastfeeding
15 (21.4)
Exclusive formula feed (bottle with nipple) 57 (82.6)
Mixed feeding (breast feeding & plain water or 1 (1.5) other liquids or solid or mushy food)?
N (%) (n = 142) 6 (4.8) 20 (14.3) 120 (85.7) 7(5)
Awareness of of VCT before coming increased significantly
Aware of VCT before coming to clinic Offered HIV counseling at clinic Prenatal visit time in minutes [M, SD] HIV counseling time in minutes [M, SD] Was the counseling time enough -too much -just enough -too short
Pre N (%) (n = 70)
Post N (%) (n = 142)
186 (63.1) 174 (72.8)*
217 (73.6)
Not asked 149 (101)
Not asked 32 (24)
98 (33.1) 186 (62.8) 12 (4.1)
123 (51.7) 103 (43.3) 12 (5.0)
Key Improvements · Clinics' compliance to national PMTCT criteria · Delivery and counseling experiences improved · Increase in # of women tested for HIV in previous pregnancy · Increase in # of women who knew HIV test results · Improved awareness of PMTCT/VCT and HIV/AIDS services
Key issues emerging · Access to health care (mode of transport, time to clinic) · Disclosure (spouse, relative, friend) · Waiting time to be reduced · Infant feeding Practices · NVP given to pregnant women at onset of labour and within 3 days of birth · Counselling time
Conclusion · After approximately 12 months of PMTCT strengthening activities in Kouga LSA, our results demonstrate the feasibility of implementing PMTCT interventions in a rural and relatively remote setting in South Africa. · More research is needed to address key emerging issues · The lessons learnt from strengthening PMTCT programme may contribute to the design of the national expansion strategy for PMTCT in South Africa and elsewhere.
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