UNIVERSITY OF VENDA

EVALUATION OF THE IMPLEMENTATION OF PREVENTION OF MOTHER-TO-

CHILD TRANSMISSION OF HIV INTERVENTIONS IN MAFIKENG SUB-DISTRICT
CLINICS, NORTH WEST PROVINCE, SOUTH AFRICA


By

Ndivhuho Mangale
(Student no: 11532664)


Submitted in fulfilment of the requirements for the degree of Masters in Public Health
at the University of Venda


in the

SCHOOL OF HEALTH SCIENCES

DEPARTMENT OF PUBLIC HEALTH



SUPERVISOR: Professor LO Amusa

CO-SUPERVISOR: Mrs NS Mashau


2012
i


DECLARATION

I, Ndivhuho Mangale hereby declare that the dissertation for the Masters In Public
Health degree at the University of Venda hereby submitted by me has not previously
been submitted for a degree at this or any other university, and that it is my own work
in design and in execution and that all referenced material contained therein has
been duly acknowledged.




_________________________ _______________________
Signature Date






ii

DEDICATION

I dedicate this work to my wife, Nakiseni Themeli-Mangale, and to my children,
Pfunzo and Ndamulelo Mangale. Alsotomy parents, two Sisters and brother for their
understanding and prayers althoughout my studies.

In loving memory of my late brother, Khuliso Michael Tshigoba and my friend,
Shumani Robert Ralebona, whose energy and love for life inspire me even today.


Phil 4:13: I can do all things through Christ who gives me strength.




















iii

Acknowledgements
I am grateful to God for His grace and strength and for allowing me the opportunity to
complete this study. I give Him praise and thanks.

I would also like to express my thanks to the following people for their invaluable
support and encouragement:

My supervisors, Mrs NS Mashau and Professor LO Amusa, Professor HA Akinsola
from the University of Venda, Annette Gerritsen (from Epi Results) and Glenrose
Kraai, from the Wits Reproductive Health & HIV Institute (WRHI). Thank you for your
guidance and for all I learnt from you.

My sincere thanks also to the following people for their effort and support, which
contributed immensely to the success of this research: Badirilwe Magano, Godfrey
Manyama, Dr Mavis Jay, Pauline Masike and Sydney Ncube who helped with the
process of instrument design, data collection and statistical analysis.

My thanks also to the Research Leadership Group (RLG) of Wits Reproductive
Health and HIV Institute (WRHI) of the University of the Witwatersrand, as well as Mr
Dr Jude Igumbor, James Takalani and Matimba Ngonyama for their valuable inputs
and suggestions.

My thanks go also to the National Research Foundation and UNIVEN for financial
assistance, the North West Department of Health for allowing me to conduct this
research study and Alexa Barnby for language and technical editing.

Thanks also to Dr Anna-Marie Radloff, Head of Department: PEPFAR Fellowship
Programme under FPD, Derek Kunaka, County Director, John Snow incorporated inc
(ESI), Mr Cornelius Lebeloe, and Joan Lesetedi from the North West Provincial
Department of Health for their understanding in allowing me to take study leave days
from work. Without them I would not have been able to conduct this research.

To you all, my sincere gratitude, and I wish you well in all your endeavours.

iv

TABLE OF CONTENTS
CONTENT PAGE
1. Declaration i
2. Dedication ii
3. Acknowledgements iii
4. Table of contents iv
5. List of tables vii
6. List of figures viii
7. List of abbreviations and acronyms ix
8. Abstract ix-xii

1. CHAPTER ONE: INTRODUCTION
1.1. Introduction and Background to the Study 1
1.2. Problem Statement 6
1.3. The Purpose of the Study 7
1.4. Delimitations of the Study 8
1.5. Significance of the Study 8
1.6. Definitions of Key Terms 9


2. CHAPTER TWO: LITERATURE REVIEW
2.1. Introduction 10
2.2. Background to PMTCT 10
2.3. Global Trends in the PMCT of HIV and AIDS 13
2.4. Trends in HIV and AIDS among the Antenatal patients in
South Africa 14
2.5. Global Situation of MTCT 17
2.6. Situation of MTCT in African Countries 20
2.7. Challenges involved in the Implementation of PMTCT 29
2.8. Barriers to the Implementation of the PMTCT programme 31
2.9. PMTCT guideline Interventions in South Africa 31
2.10. Situation of PMTCT in the North West Province 35
2.11. Conceptual Framework 37
2.11.1. John Hopkins University Social Ecological Model 37
v

2.11.2. Public Health Approach to Unifying HIV Monitoring
and Evaluation 37
2.12. Summary 38

3. CHAPTER THREE: RESEARCH METHODOLOGY
3.1. Introduction 41
3.2. Study Design 41
3.3. Study Setting 41
3.4. Study Population and Sampling 43
3.4.1. Population 43
3.4.2. Sampling 43
3.4.3. Sampling Criteria 44
3.4.4. Sampling Frame 44
3.5. Data Collection Instrument 44
3.6. Reliability 46
3.7. Validity 46
3.7.1 Face Validity 47
3.7.2 Content Validity 47
3.8. Pre-Testing 48
3.9. Method of Data Collection 48
3.10. Method of Data Analysis 49
3.11. Ethical Consideration 49
3.12. Summary 50

CHAPTER FOUR: RESULTS 51

4.1. Introduction 51
4.2. Biographical Information of the Respondents 53
4.3. Availability of Resources, Infrastructure and Equipment 54
4.4. Trainings Received and Knowledge of Health Care Workers 62
4.5. Challenges faced by Health Care Workers 64
4.6. Availability of Mechanisms and Systems with which to monitor
PMTCT Programme 66
4.7. Evaluation of the Implementation of PMTCT Interventions during
vi

Pregnancy and at Post-Delivery 67

CHAPTER FIVE: DISCUSSION OF STUDY FINDINGS 85

CHAPTER SIX: SUMMARY, CONCLUSION AND RECOMMENDATIONS 115

6.1. Summary 116
6.2. Conclusion 117
6.3. Recommendations and suggestions for further research 121
6.4. Limitations of the study 125

REFERENCES 126


















vii

LIST OF TABLES PAGE
Table 1.1: HIV prevalence among antenatal women by district, North West Province 4
Table 2.2: Sampling frame 44
Table 4.3.: Respondents length of experience in PMTCT services 51
Table 4.4: Demographic information of the respondents 52
Table 4.5: Availability of Human resources, infrastructure and equipment 54
Table 4.6: Availability of infrastructure and equipment 56
Table 4.7: Guidelines and policies available within the clinic 57
Table 4.8: Availability of related PMTCT supplies within the clinic 58
Table 4.9: Time required to obtain PMTCT related supplies available in the clinic 58
Table 4.10: Availability of PMTCT related services 60
Table 4.11: Availability of services providing PMTCT interventions to ANC 61
Table 4.12: Knowledge, training and skills transfer among Nurses 62
Table 4.13: Challenges and barriers that contribute to the failure of the PMTCT 64
Table 4.14: Availability of systems to monitor and evaluate PMTCT programme 66
Table 4.15: PMTCT stage one: antenatal clients bookings and testing 68
Table 4.16: PMTCT phase two: ANC retesting 69
Table 4.17: PMTCT phase three: ANC initiation on HAART 70
Table 4.18: PMTCT phase four: PMTCT at post natal care 71















viii

LIST OF FIGURES PAGE
Figure 4.1: Participants job titles 53
Figure 4.2: Participants years of experience in PMTCT services 53
Figure 4.3: Types of clinic in Mafikeng Sub-District 54
Figure 4.4: Turnaround time for the HIV test and CD4 test results 59
Figure 4.5: Knowledge to provide PMTCT interventions 63
Figure 4.6: PMTCT indicators performance as against 2012- to 2013 targets 67
Figure 4.7: Implementation of PMTCT Interventions at 3 and 6 month intervals 73
Figure 4.8: Implementation of PMTCT Interventions at 6 month intervals 73
Figure 4.9: Performance in terms of PMTCT maternal health indicators 75
Figure 4.10: Baby PCR positivity rate for Mafikeng Sub-District 76
Figure 4.11: PMTCT child health indicators 77
Figure 4.12: Mafikeng Sub-District baby PCR positivity rate using NHLS data 78
Figure 4.13: Number of HIV positive antenatal clients who received dual therapy 79
Figure 4.14: Number of babies tested for HIV antibody at 18 months 80
Figure 4.15: Antenatal clients initiated into HAART 80
Figure 4.16: Antenatal clients initiated on AZT and NVP dual therapy 81
Figure 4.17: Number of babies in Mafikeng receiving PMTCT interventions at six weeks 81
Figure 4.18: ANC first visit v/s first test 82
Figure 4.19: ANC retest rate at 32 weeks 83












ix

APPENDICES
RESEARCH PROJECT GANTT CHART


APPENDIX A: RESEARCH QUESTIONNAIRE

APPENDIX B: RESEARCH PROJECT WORKPLAN
APPENDIX C: RESEARCH BUDGET ESTIMATE
APPENDIX D: CONSENT LETTER
APPENDIX E: PARTICIPANTS CONSENT FORM
APPENDIX F: LETTER OF APPROVAL TO CONDUCT THE RESEARCH

x

LIST OF ABBREVIATIONS AND ACRONYMS
AIDS: Acquired immunodeficiency Syndrome
ANC: Antenatal clients
ART: Antiretroviral treatment
ARV: Antiretroviral
CBO: Community-based organisation
CSW: Commercial sex workers
DHIS: District Health Information System
DOH: Department of Health
HAART: Highly Active Antiretroviral Treatment
HIV: Human immunodeficiency virus
HSRC: Human Sciences Research Council
HTA: High transmission area
M&E: Monitoring and evaluation
MTCT: Mother-to-child transmission
MRC: Medical Research Council
MSM: Men who have sex with men
NEPAD: New Partnership for African Development
NHLS: National Health Laboratory Services
NSP: National Strategic Plan (on HIV, AIDS and STIs)
OVC: Orphans and vulnerable children
PEP: Post-exposure prophylaxis
PLHIV: Person/people living with HIV
PMTCT: Prevention of mother to child transmission (of HIV)
SABCOHA: South African Business Coalition against HIV and AIDS
SADC: Southern African Development Community
SANAC: South African National AIDS Council
STI: Sexually transmitted infection
TB: Tuberculosis
VCT: Voluntary counselling and testing
UNAIDS: Joint United Nations Program on AIDS
UNGASS: United Nations General Assembly Special Session
WHO: World Health Organization
SPSS: Statistical Package for the Social Sciences
xi

ABSTRACT
Background: South Africa implemented a Prevention of Mother to Child Transmission
(PMTCT) programme in 2001 and the impact of this programme has been significant. This
impact includes a breakthrough regarding PMTCT intervention findings arising from the study
conducted by South Africas Medical Research Council (MRC), which showed that a
reduction in vertical HIV transmission to infants and, in turn, that HIV prevalence had come
down to 3,5% at the first immunisation visit between 4 to 8 weeks postpartum.

Purpose: The purpose of this study was to evaluate the implementation of prevention of
mother-to-child transmission (PMTCT) interventions both during pregnancy and at post-
delivery at clinics in Mafikeng in the Mafikeng Sub-district in the North West province, South
Africa.

Methods: The study adopted quantitative, cross sectional descriptive study design
conducted between November 2011 and March 2012. Senior Nurses at each primary health
care clinic were asked to complete a questionnaire on PMTCT interventions. Separate
instrument with list of PMTCT indictors was used to collect Retrospective routine data from
DHIS database and NHLS monthly reports from July 2010 to December 2011. DHIS Data
was confirmed in routine clinics monthly statistics forms. The research data was captured on
Microsoft Excel 2010 and the descriptive statistics analysed using Statistical Package for the
Social Sciences (SPSS) V20.0.

Results: Only 5 out of 28 clinics were doing antenatal deliveries. Nurses were aware
guidelines and clinics have required guidelines. Nurses were trained and have knowledge on
PMTC interventions. Supplies of critical items were available within clinics. There were miss-
opportunities on PMTCT interventions on antenatal re-testing of at 32 week (43%) and baby
antibody testing (21%), ANC CD4 testing (70%), ANC initiated on HAART (73%). Almost all
babies were issued with NVP (98%). PCR positivity rate for babies at 6 weeks was
performing at 4% for the period of 12 month from January to December 2011 and at 1% at 6
month intervals from July to December 2011. In this study most clinics (71%) had inadequate
human and physical resources and this was identified as a major challenge that fails PMTCT
programme implementation. This study also highlighted challenges and barriers such as
lack of training and skills transfer, poor training of health care workers, lack of understating
of PMTCT guideline and protocols, fear and stigma attached to patient, shortage of
equipment, and resources to deliver PMTCT services, lack of coordination and integration of
PMTCT with other programmes, poor data quality and management, poor management of
programmes, traditional beliefs, long waiting time in a queue for consultation was also
xii

highlighted as one of the major challenges that contribute to failure of PMTCT programme.
Twenty five percent ( 7/28) clinics indicated that they receive PCR test results in less than
one week, 8 (29%) indicted that it takes them 1 to 2 weeks to receive PCR results, 12 (43%)
it takes them between 4 to 6 weeks to receive their PCR test results.

Conclusion: There is still a challenge as PCR test results are not available immediately.
There is high level of miss opportunities on PMTCT interventions. Despite poor recording
clinics are doing well to give HIV expose babies with NVP. The sub-district has met the
National target as less than 5% babies are reported positive. There is lack of standardised
systems to monitor the implementation of PMTCT and poor implementations of referral
systems for both ANC and Children.

Recommendations: If access to PMTCT interventions is to be improved then it is essential
that the formal health sector, liaison with stakeholders, and community support be
strengthened. In addition, much still needs to be done to encourage Antenatal clients to book
for their visits before 20 weeks while there is a need to focus on HV testing and counselling.
There also needs to a more extensive integration of family planning and PMTCT services
while more accredited public health facilities should be offering comprehensive PMTCT
services, including antenatal deliveries and HAART interventions. The on-going training and
mentoring of health care workers would ensure that health care workers are equipped with
ART and PMTCT relevant knowledge and skills. In addition, there should be more focus on
strengthening the National Health Laboratory Services (NHLS) to ensure that laboratory
results, including polymerase chain reaction-enzyme (PCR) and Enzyme-linked
immunosorbent assay (Elisa) test results, are available immediately while ongoing support to
and monitoring of Antenatal clients after delivery should be provided through home based
care.
1


CHAPTER ONE: INTRODUCTION

1.1. Introduction and Background to the Study
The World Health Organisation Report of 2000 reveals that the transmission of HIV
and AIDS from mother to child (MTCT) may occur during pregnancy, labour, delivery,
and breastfeeding with approximately 5 to 8% of babies becoming infected through
transmission via the placenta during pregnancy. However, labour and delivery pose
the greatest risk for transmission with approximately 10 to 20% of exposed infants
becoming infected. In addition, breastfeeding also exposes the infant to the
possibility of HIV transmission, particularly if prolonged to 18 to 24 months. The
additional risk of HIV infection when an infant is breastfed is about 15 to 25% (World
Health Organization, 2000).

The first projects aimed at preventing vertical HIV transmission to infants were
launched in South Africa in 2001. A review of the records at the Helen Joseph
Hospital from 2001 to 2002 reported an 8.7% HIV transmission rate in exposed
infants at six weeks postpartum (Smart, 2011). Similarly, an assessment of the
PMTCT programme implemented in Khayelitsha in 2003 and which used AZT
prophylaxis from week 34 of pregnancy, reported that a similar percentage of 8.8% of
exposed infants were HIV infected when tested at week 6-10 postpartum (Smart,
2011). Subsequently, the Good Start Study, conducted from October 2002 to
November 2004 at three sites in Paarl (Western Cape), Umlazi (KwaZulu-Natal), and
Umzimkulu (Eastern Cape), reported highly varied PMTCT programme results.
However, the poorer outcomes were partly as a result of feeding practices, as well as
factors such as maternal viral load, prematurity, socioeconomic score, access to
antenatal care and the quality of counselling received (Smart, 2011).

HIV and AIDS pose a major public health care problem with MTCT as the primary
source of HIV infection in children under the age of 15. In 2006 and 2007, a third of
all HIV-positive women were not receiving Nevirapine despite the fact that the
country had an antenatal coverage rate of approximately 90%, with 84% of births
being assisted by trained health personnel (Doherty, Chopra, Nsibande & Mngoma,
2

2009). In Kenya the prevalence rate of HIV infection among pregnant mothers is
estimated to be 13% and is reversing the recent gains achieved of child survival
programmes with a concomitant increase in infant and child mortality rates (Moth,
Ayayo & Kaseje, 2005).

Despite the fact that there are strategies and guidelines in place, HIV/AIDS is still
having a devastating effect on pregnancy as well as constituting a common
complication of pregnancy worldwide. An estimated 430 000 new HIV infections
occurred among children under the age of 15 in 2008, while UNAIDS estimates that,
in 2007, approximately 370 000 children were infected with HIV. In early 2001 there
were more than 600 000 children being infected annually (UNAIDS, 2009).

UNAIDS estimated that, in 2007, approximately 33 million people were living with HIV
globally. In the same year, 2,7 million people became infected with HIV and 2 million
people died of HIV-related causes. Of the 2,7 million new infections it was estimated
that 1,9 million had occurred in sub-Saharan Africa (UNAIDS, 2008). This region
accounts for over two-thirds (70%) of the global total of 33 million people living with
HIV with Southern Africa continuing to bear a disproportionate share of the global
burden of HIV with 33% of HIV infections occurring in this sub-region (UNAIDS,
2009).

The majority of these new infections are believed to stem from transmission in utero,
during delivery or postpartum as a result of breastfeeding. In sub-Saharan Africa the
number of children newly infected with HIV in 2008 was approximately 18% lower
than in 2001. However, sub-Saharan Africa remains the region most heavily affected
by HIV in the world (UNAIDS, 2009). In 2008, sub-Saharan Africa accounted for 67%
of HIV infections worldwide, 68% of new HIV infections among adults and 91% of
new HIV infections among children. It was estimated that, in 2008, approximately 2,1
million children globally were living with HIV and AIDS and approximately 31,3 million
adults of whom 15,7 million were women. In other words, in 2008 there were 33,4
million people living with HIV and AIDS (UNAIDS, 2009).

HIV and AIDS is still one of the major challenges facing health care systems in South
Africa today. Among adults aged between 15 and 49, the HIV prevalence was 18,3%
3

in 2006 with adult women between the ages of 25 and 34 bearing the brunt of the
disease (UNAIDS, 2009). In the most severely affected countries, such as South
Africa, Botswana and Zimbabwe, HIV is the underlying cause of more than one third
of all deaths among children under the age of five and is, thus, reversing previous
gains in terms of child survival (Doherty et al., 2009). It emerged from certain
research and pilot studies conducted in sub-Saharan Africa that prevention of mother
to child transmission (PMTCT) interventions, such as antiretroviral (ARV) prophylaxis,
have dramatically reduced the risk of vertical transmission from approximately 40% to
less than 5% (Doherty et al., 2009). Governments had committed themselves to
reducing the proportion of infants infected with HIV by 50% by 2010 by ensuring that
80% of women had access to PMTCT interventions. However, recent data shows
that the overall coverage of ARVs for HIV-positive pregnant women is 33% only with
particularly poor coverage in those countries with the highest number of pregnant
women living with HIV, for example, South Africa with 50% coverage, Nigeria with 3%
coverage and Tanzania with15% coverage (Doherty et al., 2009).
An estimated 5,7 million people were living with HIV and AIDS in South Africa in
2009, more than in any other country. Furthermore, it is believed that, in 2008, more
than 250,000 South Africans died of AIDS. The national HIV and AIDS prevalence in
South Africa is approximately 11%, with some age groups being particularly severely
affected. Almost one in three women aged 25 to 29, and over a quarter of men aged
30 to 34, are living with HIV. The HIV prevalence among those aged two and older
also varies according to the province with the Western Cape (3,8%) and Northern
Cape (5,9%) being the least affected, and Mpumalanga (15,4%) and KwaZulu-Natal
(15,8%) at the other end of the continuum (South African Department of Health,
2010).
South Africas HIV and AIDS epidemic has had a devastating effect on children in a
number of ways. It was estimated that, by 2007, 280 000 under-15 year olds were
living with HIV a figure that had almost doubled since 2001. In South Africa, HIV is
transmitted predominantly heterosexually between couples, with mother-to-child
transmission being the other main infection route. The national transmission rate of
HIV from mother to child is approximately 11% (South Africa Department of Health,
2010).
4

Table 1.1: Estimated HIV prevalence among antenatal women by district, North West province
District 2006

2007

2008

2009

2010

Provincial 29,0 30,6 31,0 30,0 29,6
Bojanala 33,6 33,3 31,8 34,9 29,3
Dr RS Mompati 21,8 26,8 28,1 25,7 24,3
Ngaka M Molema 23,6 27,0 28,2 25,1 25,9
Dr K Kaunda 31,5 32,4 35,2 29,2 37,0
Source: National HIV & Syphilis Antenatal Sero-prevalence Survey, South Africa, 2010

In 2008, the North-West provincial HIV prevalence among antenatal women aged
between 15 and 49 was 31% with this figure dropping to 29,6% in 2010. The HIV
prevalence in North West province appeared to be increasing from 29% in 2006, to
30,6% in 2007 and 31% in 2008, but with a decrease of 1 to 30% in 2009 and
another decrease in 2010 to 29,6%. However, three out of the four districts in the
North West province have shown an increase in the past three years, with the
exception of Bojanala where the prevalence appears to be stabilising. In 2008 the
highest HIV prevalence of 35,2% was recorded in the Dr Kenneth Kaunda district,
although this had dropped to 29,2% in 2009. On the other hand, the lowest
prevalence of 24,3% was recorded in Dr Ruth S Mompati district in 2010 (South
African Department of Health, 2010).

Based on modelled estimates from Spectrum, the data show that, for 2009, the total
number of people living with HIV was estimated to be 5,62 million with fewer new
infections among adults (344 000) and children (42 700) being estimated for 2009
compared to the 2008 estimates. Using the Spectrum model, in 2009, the HIV
prevalence in the adult population aged between 15 and 49 was estimated to be
17,8% or 5,63 million (both adults and children) infected with HIV and AIDS. Of this
total, 5,3 million were adults aged 15 years and older, of which 3,3 million were
females, and an estimated 334 000 children. In 2009, an estimated 1 584 million
South Africans aged 15 and older were in need of anti-retroviral therapy (ART) with
approximately 158 000 children needing ART and approximately 214 000 mothers
requiring PMTCT services (South African Department of Health, 2010).

5

According to UNAIDS, the 2009 estimated national and provincial HIV prevalence in
the general population, including children and those above 49 years, was as follows:
the national HIV prevalence in the general population for 2009 was 17,8% while the
provincial HIV prevalence in the general population for 2009 was as follows: Eastern
Cape 18,5%; Free State 19,5%; Gauteng 16,6%; KwaZulu-Natal 25%; Limpopo
13,8%; Mpumalanga 21,8%; North West 19,2%; Northern Cape 9,3% and Western
Cape 6,2% (Department of Health, 2010).

In 2010, approximately 390 000 children aged under 15 became infected with HIV
(UNAIDS, 2011). Almost all of these infections occurred in low and middle income
countries, and more than 90% were the result of mother to child transmission during
pregnancy, labour and delivery, or breastfeeding. Without interventions, there is a 20
to 45% chance that a baby born to an HIV-infected mother will become infected
(UNAIDS, 2011) with the major problem being that very few pregnant women are
able to access any prevention of PMTCT services (UNAIDS, 2011).

According to the North West Provincial Council on AIDS & North West Department of
Health: End Term Review: North West Province, 7 October 2011, PMTCT
programming in the North West province has improved steadily from 2005 to 2011.
Nevertheless, some of the 2011 targets were not met: For the indicator HIV-positive
pregnant women receiving ART the province attained 67% against a target of >70%
initiated on Highly Active Antiretroviral Treatment (HAART); 59% against a target of
95% initiated on Azidothymidine (AZT); and 64% against a target of > 95% NVP
(Nevirapine) uptake (North West Province Strategic Plan for HIV AND AIDS, STIs
and TB, for 20122016). The province performed extremely well in terms of the 95%
proportion of the infants in national PMTCT programme receiving PCR. There is
also a decreasing number of infants born HIV positive an important outcome of
PMTCT programming. In addition, the proportion of HIV-positive pregnant woman
initiated on ART rose dramatically from 15% in 2008 to 65% in 2011 (South Africa
North West Department of Health, 2012).

The target of the South Africa National Strategic Plan (NSP) of 2007 to 2011 was to
reach 95% of HIV positive pregnant women with PMTCT services by 2011 and to
scale up coverage of PMTCT in order to reduce MTCT to less than 5% for children by
6

2011. Currently, however, South Africa is still far from reaching some of the NSP
targets which were set in terms of PMTCT with a National Antenatal Prevalence of
29,3% and an estimated HIV perinatal transmission rate of 25% (South Africa North
West Department of Health, 2012). The national PMTCT target is that less than 5%
of the babies born to HIV positive mothers should test positive. This would, in turn,
reduce the overall prevalence of HIV in South Africa and also enable Health care
facilities to evaluate their contribution to reducing HIV prevalence in the North West
province (South Africa North West Department of Health, 2012).

Despite the fact that the National Department of Health is managing to attain of its
targets to reduce mother to child transmission by 5 to 3.5%, the department is still not
performing well in terms of certain indicators and data elements such as retesting
pregnant women at 32 weeks, the rate of antenatal bookings at first visits, antenatal
testing for CD4 rate and antibody testing at 18 months. In other words, there are still
some gaps which need to be addressed, including health system challenges, PMTCT
missed opportunities for infant care and poor liaison with civil society (South Africa
North West Department of Health, 2012).

1.2. Problem Statement

South Africa first implemented a PMTCT programme in 2002. However, although
there are guidelines and policies in place, including targets that were set in order to
address mother-to-child transmission (MTCT), South Africa continues to have a high
prevalence rate of HIV for both women and children. Despite the fact that a recent
study conducted by the MRC and presented at the Fifth South African Aids
Conference in Durban in 2011 indicated a breakthrough in terms of PMTCT,
indicating reductions in vertical HIV transmission to infants and, thus, showing that
the HIV prevalence has been reduced to 3.5% at the first immunisation visit between
4 to 8 weeks postpartum. However, there still needs to be greater effort as regards
the early bookings for pregnancy consultation, retesting of antenatals at 32 weeks,
and follow up for Babies born exposed to HIV positive mothers at 18 month.
.
The findings from a study conducted by the Medical Research Council of South
Africa (MRC) found that infants in South Africa are at extremely high risk of HIV
7

exposure (Smart, 2011). However, although recent data does show an improvement
in PMTCT, there is still an unacceptably high number of babies, approximately 70
000, who are born with HIV every year, reflecting poor PMTCT. HIV and AIDS is one
of the main contributors to South Africas infant mortality rate, which barely declined
from 49 deaths per 1000 infants in 1990 to 46 per 1000 in 2007. This lack of
improvement in child mortality in South Africa is largely as a result of the HIV
epidemic and, specifically, the transmission of HIV from mother to child (MTCT)
(National Department of Health & South African National AIDS Council, 2010).

It is imperative to assess some of the bottlenecks facing health care workers in the
implementation and scaling up of PMTCT and it was, in fact, this imperative that
stimulated the researcher to evaluate the implementation of the Prevention of Mother
to Child Transmission Programme. The researcher intends to evaluate whether
PMTCT targets are being met and also the implementation of the PMTCT in
Mafikeng clinics.

1.3. The Purpose of the Study

The main objective of the study was to evaluate the implementation of the prevention
of mother to child transmission (PMTCT) interventions both during pregnancy and at
post-delivery in clinics in Mafikeng in the Mafikeng Sub-district in the North West
province, South Africa.

The specific objectives of this study were to;

i. assess the availability of human resources, infrastructure and equipment as
regards the implementation of PMTCT services
ii. assess the availability PMTCT-related services
iii. assess the training received and knowledge of nurses with regards the
implementation of PMTCT services.
iv. describe challenges faced by nurses with regard to the implementation of the
PMTCT programme
v. assess the availability of systems to monitor and evaluate the PMTCT
programme implementation
8

vi. evaluate the implementation of PMTCT interventions during pregnancy and at
post-delivery.

1.4 Delimitation of the Study
The study was conducted in the Mafikeng Local Municipality in the Ngaka Modiri
Molema District Municipality only and did not include the neighbouring municipality. In
addition, the study included one health care professional per clinic only and did not
include other health care workers in each clinic. As a result, certain individuals were
left out of the study. The researcher did not take into account the gender, age or
ethnic group of the respondents.


1.5 Significance of the Study

It is crucial to evaluate the implementation of PMTCT services in health care facilities.
This is of particular importance in the South African situation where health resources
are unevenly distributed between the rural areas, including the distribution of health
care providers. It is envisaged that the study will assist the Department of Health
North West Province, through district, sub-district and facilities, to understand the
dynamics associated with the implementation process and to develop an insight into
those factors that affect the implementation process and to measure the programme
outcomes.

The study will assist both the policy makers and the policy implementers within the
Department of Health both to introduce measures that will reinforce existing policies
on PMTCT and to develop strategies that will assist the making of informed decisions
that may strengthen the health care system in the province in the future. The study
will also contribute to the existing body of knowledge on the implementation of
PMTCT interventions while the study results will provide health care workers with
information regarding the knowledge that other health care workers have on PMTCT.
Health care workers will then be able to use the information they have acquired to
render improved services to their patients. In addition, the study will enable the
Ministry of Health to provide resources, including human resources, and
infrastructures in order to strengthen the health care services.
9


1.6 Definitions of Key Terms
Programme evaluation In this study programme evaluation refers to the
systematic assessment of the operation, inputs, process, outputs, outcomes and
impact of a programme or policy, as compared to a set of either explicit or implicit
standards, as a means of contributing to the improvement of the programme or
policy.

Implementation In this study implementation refers to the carrying out, execution,
or practise of a plan, method or any design for doing something.

HIV HIV is the human immunodeficiency virus which destroys a persons immune
system, making it impossible for the body to fight off disease or illness.

AIDS AIDS is the acquired immunodeficiency syndrome which is the last phase of
a deadly disease caused by HIV.

STI STIs are sexually transmitted infections which are caused by micro-organisms
that are passed on from one person to another through sexual intercourse.

Mother to child transmission (MTCT) MTCT occurs when the HIV infection is
transmitted from an HIV-infected mother to her child during pregnancy, labour,
delivery or breastfeeding (World Health Organisation 2010).

Evaluation In this study evaluation is defined as the episodic assessment of
results that may be attributed to programme inputs, processes, outputs, outcomes
and impacts.



10


CHAPTER TWO: LITERATURE REVIEW

2.1 Introduction

Chapter 2 reviews the literature which is relevant to this research study. Access to
the Prevention of Mother to Child Transmission PMTCT programmes is critical if the
goal of the National Strategic Plan of HIV and AIDS and STIs 2007-2011 is to be
realised. According to this goal, Comprehensive Care Management and Treatment
CCMT services, including the provision of ARVs, should be made accessible to 80%
of those people requiring them and also ensure that, at the very least, less that 5% of
the babies tested for HIV should test positive (National Department of Health and
South African National AIDS Council (SANAC, 2007).

The type of literature consulted in this review comprised mainly articles from journals
and reports produced by government departments and developmental partners
providing aid relief in HIV and AIDS programmes. The chapter also includes a
literature review on the experiences of health care workers in implementing the
prevention of mother to child transmission programme. The following aspects were
reviewed: Global and national responses to PMTCT of HIV and AIDS, trends in HIV
and AIDS among antenatal clients in South Africa, the global Situation regarding
MTCT, challenges involved in the implementation of PMTCT, barriers to the
implementation of the PMTCT programme, South African PMTCT guideline
interventions and the current status of PMTCT in South Africa, including various
conceptual framework that may be used to improve PMTCT.

2.2 Background to the Prevention of Mother to Child Transmission

In 1994, researchers in France and the USA collaborated on a major study and found
that monotherapy with AZT dramatically reduced the risk of MTCT (UNICEF, 2009).
However, as a result of the cost of AZT at the time as well as resistance on the part
of the South African government to using AZT, some time elapsed after 1994 before
the national PMTCT programme was implemented in South Africa. In 2001, the
Treatment Action Campaign (TAC), Save Our Babies, and the Childrens Rights
11

Centre took the government to court. The court found in favour of the organisations
and ordered the government to develop a comprehensive national programme for
PMTCT (UNICEF, 2009). The first PMTCT policy was drafted in 2001. As a result of
the operational and political factors, the PMTCT programme was implemented at pilot
sites in 2001, but only nationally in 2002. Currently the national PMTCT programme
is available in 3 000 primary healthcare facilities throughout the country. It has been
estimated that 35 000 babies were born with HIV because a feasible and timely ARV
programme had not been implemented in South Africa. The Department of Health
published new guidelines for PMTCT in 2010, based on the 2008 PMTCT guidelines.
The Western Cape became the first province to roll out dual therapy regimens
(UNICEF, 2009).

The most widely acknowledged shortcoming in South Africas response to the
HIV/AIDS epidemic has been the countrys delay in making available treatment for
the prevention of mother-to-child transmission (PMTCT) of HIV as well as
antiretroviral therapy (ARV) for those with advanced HIV infection (UNICEF, 2008). It
is estimated that, by August 2005, PMTCT services were available to HIV positive
pregnant mothers at 2 525 sites nationwide although 51,7% only of mothers who had
been identified as HIV positive received treatment. Further studies indicate that 90%
of districts in South Africa now offer PMTCT, although coverage varies substantially
from 48 to100% between districts and provinces (South Africa National Department
of Health and South African National AIDS Council (SANAC), 2007). As a result of
the introduction of PMTCT in South Africa, the percentage of HIV positive pregnant
women receiving antiretroviral treatment increased from 30% in 2005 to 57% in 2007
(UNAIDS, 2008). Improved results were also apparent in Botswana where the
percentage of women accessing PMTCT services increased from 58% in 2003 to
more than 95% in 2007 (UNICEF, 2008).

In the 2005/2006 financial year 60% only of pregnant women who tested positive for
HIV/AIDS received Nevirapine. It is estimated that 290 000 pregnant, HIV-positive
women in South Africa are in need of ARVs for PMTCT (UNICEF, 2009). In 2002, the
estimated HIV prevalence among children between the ages of 2 and 14 was 5,6%,
dropping to 3,3% by 2005. However, despite this decrease, data from 2005 confirms
a high HIV prevalence among South African children. The HIV prevalence among 2
12

to 4 year olds is 4,9% for males and 5,3% for females and the prevalence among 5 to
9 year olds is 4,2% for males and 4,8% for females (UNICEF, 2009). In addition,
South Africa continues to have one of the highest under five mortality rates in the
world and, in 2007, it was estimated that the under-five mortality rate in South Africa
was 59 deaths per 1 000 live births. Of the 84 countries which are described as less
developed, South Africa has the fourteenth highest under-five mortality rate. Despite
the fact that there is evidence to show that PMTCT programmes are acceptable,
feasible and cost effective, these programmes have not been widely implemented in
low and middle income countries. There is an urgent need for renewed efforts to offer
quality PMTCT services in South Africa and to ensure that these services are offered
routinely and that the rates of uptake increase (UNICEF, 2009).

A study conducted by the Medical Research Council (MRC) in 2011 and which was
presented at the 5th South African AIDS Conference held June, 2011 in Durban,
showcased the recent remarkable achievements of the countrys response to
HIV/AIDS. This included breakthroughs in PMTCT intervention findings which show
that HIV prevalence is down to 3,5% at the first immunisation visit at 4 to 8 weeks
postpartum. However, the study also revealed that the percentage of children who
will, ultimately, become infected will increase as a significant proportion of the
children are not being fed safely by their caregivers with either exclusive
breastfeeding or exclusive formula feeding (Smart, 2011).

Reducing vertical transmission was one of the highest priorities in the South African
National HIV/AIDS Strategic Plan of 2007 to 2011 with the goal being to reduce HIV
transmission to 5% in HIV exposed infants by 2011. However, if this is to
accomplished, it is essential that performance be improved at each step of what has
been termed the PMTCT cascade or the separate interventions involved in the
programme including coverage, HIV testing uptake, results delivery, intervention
delivery, follow up and support (Smart, 2011).




13

2.3. Global trends in the Mother-to-Child Transmission (MTCT) of HIV AND
AIDS.

The prevention of mother to child transmission (PMTCT) of HIV has been at the
forefront of global HIV-prevention activities since 1998 with research and programme
experience over the past ten years demonstrating newer and more effective ways in
which to prevent new paediatric infections, particularly in high burden, low resource
settings (World Health Organization, 2010). According to the UNGASS report (2010),
data show that significant progress has been made in delivering PMTCT services in
low and middle income countries. However, much work still remains to be done. An
estimated 430 000 children were newly infected with HIV in 2008 while over 90% was
through mother-to-child transmission (MTCT). Most of these new infections are
believed to stem from transmission in utero, during pregnancy or postpartum as a
result of breast feeding (World Health Organization, 2010).

In 2007, an estimated 270 000 HIV-infected children younger than 15 years died as a
result of AIDS and more than 90% of them were in sub-Saharan Africa (UNAIDS,
2008). Without treatment, approximately half of these infected children will die before
their second birthdays. Without PMTCT interventions, the risk of MTCT ranges from
20 to 45% while, with specific interventions in the non-breastfeeding populations, the
risk of MTCT may be reduced to less than 2%, and to 5% or less in the breastfeeding
populations. In 2008, 45% of the estimated HIV-infected pregnant women in low- and
middle-income countries received at least some antiretroviral (ARV) drugs to prevent
HIV transmission to their children. This figure was up from 35% in 2007 and 10% in
2004 (World Health Organization, 2010).

The percentage of pregnant women infected with HIV rand receiving at least some
ARVs for PMTCT in Latin America increased from 47% in 2007 to 54% in 2008, and
in the Caribbean from 29% to 52%. In Europe and Central Asia, coverage increased
from 74% in 2007 to 94% in 2008. In addition, in 2008, an estimated 21% of pregnant
women giving birth in low- and middle-income countries were tested for HIV, as
compared to the 15% who were tested in 2007 (World Health Organisation, 2010).

14

Globally, HIV/AIDS is now the leading cause of mortality among women of
reproductive age and, in several high burden countries such as South Africa and
Zimbabwe, HIV is the leading cause of maternal mortality. Even in those countries
which are rapidly scaling up PMTCT services, the major challenge is to provide more
effective ARV interventions, including the provision of antiretroviral treatment (ART)
to pregnant women and to mothers eligible for treatment, and to demonstrate the
impact of these interventions by a decrease in paediatric infections, HIV-free survival,
and improved maternal and child health (World Health Organization, 2010).

Globally, the number of children newly infected with HIV in 2008 was approximately
18% lower than in 2001. On the other hand, globally, the number of children younger
than 15 years living with HIV increased from 1,6 million in 2001 to 2 million in 2007
with almost 90% living in sub-Saharan Africa. Since 2003, the rate of annual AIDS
deaths among children has also begun to fall, mainly as a result of treatment scale up
and PMTCT. A recent study in Uganda found an 81% reduction in child mortality
among the uninfected children of adults receiving antiretroviral therapy. It is
estimated that more than 90% of children living with HIV acquired the virus during
pregnancy, birth or breastfeeding all forms of HIV transmission that may be
prevented. In the most severely affected countries, such as Botswana and
Zimbabwe, HIV is the underlying cause of more than one-third of all deaths among
children under the age of five. Without ART large numbers of children die at a young
age (UNAIDS, 2008).

2.4 Trends in HIV and AIDS among the Antenatal in Africa

Sub-Saharan Africa remains the region most severely affected by HIV in the world. In
2008, sub-Saharan Africa accounted for 67% of HIV infections worldwide, 68% of
new HIV infections among adults and 91% of new HIV infections among children. In
addition, the region also accounted for 72% of the worlds AIDS-related deaths in
2008. An estimated 1,9 million people were newly infected with HIV in sub-Saharan
Africa in 2007, bringing to 22 million the number of people living with HIV in the
region. Two-thirds (67%) of the global total of 33 million people with HIV live in this
region, and three-quarters (75%) of all AIDS deaths in 2007 occurred in the region
(World Health Organization, 2009).
15


Adult national HIV prevalence is below 2% in several countries in West and Central
Africa, as well as in the horn of Africa, but, in 2007, it exceeded 15% in seven
southern African countries, including Botswana, Lesotho, Namibia, South Africa,
Swaziland, Zambia, and Zimbabwe. In addition, it was above 5% in seven other
countries, mostly in Central and East Africa, and included countries such as
Cameroon, the Central African Republic, Gabon, Malawi, Mozambique, Uganda, and
the United Republic of Tanzania. ART coverage is significantly higher in East and
Southern Africa (48%) than in West and Central Africa (30%), while treatment
coverage for adults (44%) remains higher than for children at 35% in West and
Central Africa (World Health Organization, 2009).

Sub-Saharan Africa has made remarkable progress in expanding access to services
preventing mother-to-child HIV transmission and, in 2008, 45% of HIV-infected,
pregnant women received antiretroviral drugs to prevent transmission of the disease
to their newborns, as compared with 9% in 2004. However, the coverage of 64% is
far higher in East and Southern Africa than in West and Central Africa, with a
coverage of 27% (UNAIDS & World Health Organization, 2009). In 2008, an
estimated 390 000 children were infected in sub-Saharan Africa. As services
preventing MTCT have been measured, the annual number of new HIV infections
among children has declined fivefold in Botswana, from 4 600 in 1999 to 890 in 2007.
There is also evidence that MTCT programmes are contributing to the declining
proportion of new infections in Lesotho. Despite the fact that the vast majority of
infections in children are the result of mother to child transmission, there are
indications suggesting that a small proportion of infections in children under the age
of 15 may be the result of either rape or other forms of sexual abuse (UNAIDS &
World Health Organization, 2009).

Southern Africa continues to bear a disproportionate share of the global burden of
HIV, as 35% of all HIV infections and 38% of all AIDS deaths in 2007 occurred in that
sub-region. In total, sub-Saharan Africa is home to 67% of all people living with HIV.
Women account for half of all people living with HIV worldwide and nearly 60% of HIV
infections in sub-Saharan Africa. An estimated 370 000 children younger than 15
years became infected with HIV in 2007 globally. Globally, the number of children
16

younger than 15 years living with HIV increased from 1,6 million in 2001 to 2 million
in 2007 with almost 90% living in sub-Saharan Africa. In Swaziland, children were
estimated to account for nearly one in five (19%) of new HIV infections in 2008, while
prenatally acquired infection accounted for 15% of new HIV infections in Ugandan
Children in 2008. In the United Republic of Tanzania, 53% of women and 44% of
men only reported awareness that medication and other services are available to
reduce the risk of mother to child HIV transmission (UNAIDS, 2009).

In Southern Africa, the reduction in HIV prevalence is especially significant in
Zimbabwe, where the HIV prevalence in pregnant women attending antenatal clinics
fell from 26% in 2002 to 18% in 2006. In Botswana, a drop in HIV prevalence among
pregnant 15 to 19 year olds from 25% in 2001 to 18% in 2006 suggests that the rate
of new infections may be slowing. The epidemics in Malawi and Zambia also appear
to have stabilised, amid some evidence of favourable behaviour changes and signs
of declining HIV prevalence among women using antenatal services in some urban
areas. However, in Lesotho and parts of Mozambique, the HIV prevalence among
pregnant women is increasing and, in some of the provinces in the central and
southern zones of the Mozambique, adult HIV prevalence has reached or exceeded
20%, while the number of infections continues to increase among young people.
After dropping dramatically in the 1990s, adult national HIV prevalence in Uganda
has stabilised at 5,4% (UNAIDS, 2009).

The PMTCT interventions such as antiretroviral (ARV) prophylaxis have dramatically
reduced the risk of vertical transmission from approximately 40% to less than 5% in
some research and pilot settings in sub-Saharan Africa. Governments have
committed themselves to reducing the proportion of infants infected with HIV by 50%
by 2010 by ensuring that 80% of women have access to PMTCT interventions.
However, recent data show that the overall coverage of ARVs for HIV positive
pregnant women is 33% in South Africa and there is particularly poor coverage in
those countries with the greatest number of pregnant women living with HIV,
including South Africa with 50% coverage, Nigeria with 3% coverage and Tanzania
with 15% coverage (Doherty, Chopra, Nsibande & Mngoma, 2009).


17

2.5. Global Situation on PMTCT intervention

In Asia an estimated 21 000 children under the age of 15 were newly infected with
HIV in 2008. However, since 2009, MTCT has been responsible for a relatively
modest share of the new HIV infections in the region. In 2007, perinatal transmission
accounted for an estimated 1,1% of incidence in China. As from December 2008,
25% of HIV-infected pregnant women in Asia have been receiving antiretroviral drugs
for the prevention of MTCT. The number of new HIV infections among children of 0 to
14 years remains relatively stable in South and South-East Asia, although the rate of
MTCT is still increasing in East Asia (UNAIDS, 2009).

In Eastern Europe and Central Asia MTCT has played a relatively small role in the
spread of the epidemic. However, with the rapid growth of sexual transmission of the
disease, the risk of transmission to newborns may increase. Among previously
untested pregnant women admitted to maternity hospitals in St Petersburg in the
Russian Federation, 6,5% were found to be HIV positive. However, one of the signal
achievements in the response to AIDS in the Eastern Europe and Central Asia region
has been the high coverage achieved of services aimed at preventing mother to child
transmission and, in December 2008, the estimated coverage for the prevention of
mother to child transmission in Eastern Europe and Central Asia exceeded 90%
(World Health Organization, 2009).

In the Caribbean the paediatric antiretroviral coverage of 55% was higher in 2008
than the global treatment coverage level for children of 38%. From 2008, 52% of HIV
infected pregnant women in the Caribbean have been receiving antiretroviral drugs
for the PMTCT while the regional prevention coverage in antenatal settings in the
Caribbean exceeds the global average of 45% and is an improvement on the
regional coverage of 22% in 2003 (UNAIDS, 2009).

In Latin America an estimated 6 900 children under the age of 15 were newly
infected with HIV in 2008. However, from December 2008, 54% of HIV infected,
pregnant women in the region were receiving antiretroviral drugs to prevent
transmission of the disease to their newborns, as compared with the global coverage
of 45% and in 2004 coverage of 23% in Latin America (UNAIDS, 2009). In North
18

America and Western and Central Europe, the implementation of measures to
prevent MTCT has virtually eliminated this source of infection with no new HIV
infections as a result of MTCT being reported in the Netherlands in 2007 or in
Switzerland in 2008. In the United Kingdom, perinatally exposed infants accounted
for 1,4% of new HIV infections in 2007. For Europe as a whole, the share of new HIV
infections among newborns is approaching zero, while declines in the HIV incidence
among infants have been reported in North America. In Canada, the HIV infection
rate among perinatally exposed infants fell from 22% in 1997 to 3% in 2006. In 25
states in the USA with longstanding HIV infection reporting systems, the number of
annual HIV diagnoses among infants dropped from 130 in 1995 to 64 in 2007 while,
in New York City, the number of newly diagnosed infants fell from 370 in 1992 to 20
in 2005 (UNAIDS , 2009).

In 2008, in the Middle East and North Africa, 4 600 children became newly infected
with HIV. Prevention coverage in antenatal settings remains virtually nonexistent in
these regions, with a regional coverage of below 1% from December 2008 (World
Health Organisation, 2009). In Oceania, the national authorities in Papua New
Guinea report that rates of MTCT are increasing and that they are expected to rise
further as the epidemic continues to escalate. Papua New Guinea has, however,
taken steps to expand access to the services preventing MTCT, although, in 2007,
prevention coverage in antenatal settings was 2,3% only. In high-income countries
where the epidemic is driven primarily by sex between men, the rates of MTCT are
extremely low and three infants only in Australia were diagnosed with HIV in 2006
while one child born in New Zealand was diagnosed in 2008 (UNAIDS, 2009).

In order to achieve wide coverage, it is essential that PMTCT programmes be
integrated into existing public health systems with services being provided by all
antenatal and delivery clinics. However, thus far, a few low and middle income
countries only have achieved this goal (UNICEF, 2003). Shortages of HIV test kits,
preventive drugs and other supplies may limit the efficiency of PMTCT programmes
and it is, therefore, important to have in place reliable supply chains that are
integrated into those systems which are serving maternal and child health clinics
(UNICEF, 2003).

19

A study conducted on 800 pregnant women in Botswana showed that an estimated
2% of pregnant women who had previously taken part in routine testing for HIV and
had tested negative, had later developed HIV either during pregnancy or postpartum.
Thus, those women who had acute HIV infection and those who had become
infected after routine testing were missed through routine follow up visits. However,
by integrating HIV counselling and testing into all aspects of the maternal and child
health system, including family planning clinics, labour and delivery services,
postpartum care and even immunisation clinics, PMTCT programmes would be able
to reach significantly more women (World Health Organization, 2006).

One study conducted in Cte d'Ivoire found that a significant number of pregnant
women who had been diagnosed with HIV were unwilling to take part in follow-up
visits because they had had bad experiences in their dealings with health workers.
These problems included distrust of the staff and the medicines they prescribed,
dissatisfaction with the counselling, disbelief in the test results and the fear of hostility
on the part of staff members (Painter, 2004).

If such concerns are to be allayed it is essential that clinic staff make every effort to
be approachable and supportive while programmes should seek to raise community
awareness of PMTCT services and their benefits. This promotion of the PMTCT
services may take the form of videos, talks, brochures, radio programmes or songs
while working with community leaders, perhaps by setting up advisory boards, may
help promote the concept of collective ownership of PMTCT programme as well as
increasing acceptance of PMTCT services (UNICEF, 2003).

HIV may be transmitted through breast milk and, therefore; a mother's method of
infant feeding has a strong bearing on the likelihood of her baby becoming infected
with the disease. Thus, the only certain way in which to avoid transmission is to
abstain from breastfeeding and to provide replacement foods. However, this solution
is not available to women living in areas where the water supply is unsafe or the
quality of the formula milk inconsistent. In such situations women should be advised
to breastfeed in conjunction with an extended drug regimen. However, there is the
concern that, by distributing formula milk, clinics may inadvertently encourage
mothers to give up breastfeeding, even if they are not infected with HIV (Linkages
20

Project, 2004). In addition, in situations in which free infant formula has been
provided, there have been instances where supplies have been reported to have
been stopped, leaving several HIV-positive women facing a difficult dilemma (All
Africa, 2010).

2.6. Situation of Mother to Child Transmission in African Countries

The Botswana government established the first national Prevention of Mother to
Child Transmission (PMTCT) programme in Africa in 1999. The PMTCTs primary
goal is to prevent the transmission of HIV to unborn babies by their infected mothers.
Pregnant women who present themselves to antenatal care services (ANC) are
offered HIV testing and those found to be HIV positive are advised to enrol in the
programme. The PMTCT achieved a significant uptake in Botswana in 2002 following
the commencement of the ARV programme with the numbers enrolled in the
programme increasing as lay counsellors were deployed to ANC clinics in 2003, and
routine HIV testing became national policy in 2004 (Botswana Ministry of Health,
2010).

Data from the Botswana Ministry of Health reveals that the proportion of pregnant
women in the country tested for HIV infection during antenatal care has increased
from 49% in 2002 to 91% in 2009 while the uptake of PMTCT interventions among
those testing positive has increased from 27% in 2002 to 94% in 2009. In addition,
the percentage of HIV-positive pregnant women in Botswana who received
antiretroviral drugs to reduce the risk of mother to child transmission was 94,2% in
2010 as compared with 34,3% in 2004, 60,3% in 2005, and 91% in 2008 (Botswana
Ministry of Health, 2010).

The 2008 Botswana AIDS Impact Survey estimated that 17,6% of the population
aged 18 months and above was HIV positive in 2008. In the same vein, the
preliminary results of the 2009 HIV and AIDS Sentinel Surveillance show that the HIV
prevalence among pregnant women aged 15 to 49 years has been approximately
33% since 2005 while the corresponding figure for children living with HIV and Aids
aged 0 to 14 years was 19,13%. In 2010, the percentage of infants born to HIV-
21

infected mothers and who became infected was 3,8% as compared to 4,8% in 2008,
11,5% in 2005, and 20,7% in 2003 (Botswana Ministry of Health, 2010).

The Mother to child transmission rates were estimated as the weighted average of
the estimated transmission rate from those women who had received ARVs (2,5%)
and the estimated transmission rate from those women who had not received ARVs
(25%). The overall rate was weighted by the percentage of HIV-infected pregnant
women who received ARVs in order to reduce the risk of MTCT. Of the estimated
350 557 people living with HIV in Botswana at the end of 2009, 19 125 were children
aged between age 0 to 14 years and approximately 331 432 were adults aged 15
years and above. On the other hand, the prevalence of pregnant women aged 15 to
49 years presenting to an antenatal clinic for the first visit for their current pregnancy
has been approximately 33% since 2005 (Botswana Ministry of Health, 2010).

The Prevention of Mother to Child Transmission of HIV (PMTCT) programme
represents a major success with over 90% of HIV-positive women receiving ARVs in
order to prevent the transmission of HIV to their children. The programme has
averted an estimated 10 000 child infections since its inception in 1999 while the
combined effects of the PMTCT programme and the child treatment programme have
averted an estimated 11 000 child AIDS deaths (Botswana Ministry of Health, 2010).

In Zimbabwe there were an estimated 1 187 822 adults and children living with HIV
and AIDS in 2009. However, the HIV prevalence among pregnant women aged
between 15 and 49 years declined from 17,7% in 2006 to 16,1% in 2009. In addition,
the HIV prevalence in Zimbabwe was estimated to be 23,7% in 2001, 18,4% in 2005
and further declining to 14,3% in 2009. The epidemic in Zimbabwe is believed to be
declining as a result of both prevention programmes, in particular, programmes
aimed at behavioural change and PMTCT, as well as mortality. The number of
patients on ART increased from 99 408 (9 594 children) at the end of 2007 to
148 144 (13 278 children) in December 2008 and 218 589 (21 521 children) by the
end of December 2009 (Zimbabwe Ministry of Health Country UNGASS, 2010).

In 2005 and 2006 there was a high level of knowledge about HIV and AIDS
prevention with 75,7% women (1549 years) and 81,3% men (1554 years) being
22

aware that it was possible to use condoms to reduce the risk of contracting HIV. A
decline in HIV prevalence among all pregnant women (159 years) in 2004 was
reported by the Ministry of Health and Child Welfare. This trend continued with the
prevalence among antenatal clinic attendees, 15 to 49 years, decreasing from 25,8%
in 2002, 21,3% in 2004, 17,7% in 2006 to 16,1% in 2009. Similar trends were also
observed among younger pregnant women (1524 years) with the prevalence
declining from 20,8% in 2002, 17,4% in 2004, and 12,5% in 2006 to 11,6% in 2009
(Zimbabwe Ministry of Health, 2010).

It was estimated that 1 187 822 adults and Children below 15 years that were HIV
infected in 2009 were nearly 10% at 152 189. However, the slight decrease in the
number of HIV-infected children in 2009 was reflecting increased mortality as a result
of limited access to ART. The proportion of women living with HIV and AIDS
remained at 60% in 2008 and 2009 respectively. However, the numbers of adults and
children accessing ART increased from 148 144 (39.7%) in December 2008 to
215 109 (56,8%) in November 2009 while the number of children accessing ART
increased from 8 627 (24,8%) in 2007, 13 287 (38,7%) in 2008 to 20 003 (57,1%) in
2009. Until 2009, the comprehensive PMTCT services were based on the single dose
Nevirapine aimed at reducing mother to child transmission (MTCT) (Zimbabwe
Ministry of Health, 2010).

However, by 2008 the Zimbabwe government had started rolling out a multiple dose
PMTCT regimen with comprehensive PMTCT sites increasing from 710 in 2007 to
920 in 2008 and 960 in 2009. PMTCT coverage increased from 22% in 2007 to
42,6% in 2008. Early HIV infant diagnosis was introduced in 2008 using the HIV DNA
PCR testing at the National Medical Reference Laboratory and, in 2008, 76 primary
care counsellors were trained in PMTCT, counselling and infant feeding. However,
more still needs to be done to train primary counsellors and carers certified to
perform rapid testing in order to strengthen the PMTCT programme. In promoting
optimal and safer infant feeding practices, 6 797 infants exposed to HIV were
provided with alternative feeding in 2008 (Zimbabwe Ministry of Health, 2010).

In Zimbabwe, the percentage of infants born to HIV-infected mothers who became
infected was estimated to be 32,3% in 2007, 31,1% in 2008 and 30% in 2009. This
23

high percentage of infected infants may be attributed both to breastfeeding which
extends to 20 months and a relatively ineffective PMTCT regimen (single dose
Nevirapine). However, the marginal decline in infection rates may be as a result of
increase in PMTCT services uptake between 2007 and 2009. The HIV prevalence
among women aged between 15 and 24 attending ANC was 19,9% in 2002, 17% in
2004, 12,5 % in 2006 and 11,6% in 2009. This, in turn, signifies a decline of 41,7%
over a period of 7 years. According to the 2010 HIV estimates, the HIV prevalence
among young women aged between 15 and 24 was 3,3% in 2007, 3,3% in 2008 and
3,2% in 2009 (Zimbabwe Ministry of Health, 2010).

In Swaziland the HIV prevalence in adults aged 50 and older is 14% and 4% in
young children aged 2 to 14 years, while the prevalence rate in pregnant women
attending ANC aged 15 to 49 years is 42%. The number of centres providing PMTCT
services increased from 110 in 2007 to 132 in 2008 while the number of pregnant
women who received a course of ARV prophylaxis in order to reduce MTCT is 65% in
2008. In 2009, PMTCT services were offered in 79% of the 172 health facilities
providing ANC. In addition, with the introduction of the PMTCT programme in 2003,
the percentage of HIV-positive infants born to HIV-infected mothers has been
lowered to 16,9%. There are more adults receiving ART than children, at a need-
receive coverage of 92,8% and 66,1%, respectively (Swaziland Ministry of Health,
2010).

In 2009, of a total of 36 882 estimated pregnancies in Swaziland, 69,9% were tested
for HIV with 39,8% of those tested testing HIV positive. Of the HIV-positive women,
8 182 received ARVs for PMTCT: 1 831 single dose NVP, 4 507 dual therapy (NVP
and AZT) and 1 844 ART. The programme has witnessed an upward trend from
2007, when 64% of pregnant mothers received ARVs for PMTCT, to 69% in 2009. In
addition, the percentage of HIV-positive pregnant women who received ARVs to
reduce the risk of MTCT in 2009 was 69%, as compared to 65% in 2008 and 64% in
2007. The HIV prevalence among pregnant women aged 15 to 49 years was 42% in
2008 while the HIV prevalence in women aged 15 to 19 was 26,3% and women aged
20 to 24 was 44,7%. In Swaziland the percentage of infants born to HIV-infected
mothers and who, in turn, became infected is 16,9% in 2009. The HIV Estimates and
Projections Report 2009 estimated the number of new infant infections to be 1 651 in
24

2009 and the number of mothers in need of PMTCT to be 9 329, resulting in 16,9%
of infants being born HIV positive to HIV-infected mothers (Swaziland Ministry of
Health, 2010).

Lesothos PMTCT programme was launched in 2003. Between 2007 and 2009,
significant progress was made in making PMTCT services available at the health
centre level and a national scale-up plan was approved in 2007 and implemented
during 2008 and 2009. PMTCT coverage rates increased from 6% in 2005 to 71% in
2009 (Lesotho Ministry of Health, 2009).

The estimated adult HIV prevalence rate in Lesotho for 2008 was 23,6% an
increase of 0,4% from 2007. The most recent estimates show that there are
approximately 260 000 HIV-positive adults aged 15 to 49 years in Lesotho and an
estimated 21 000 HIV-positive children aged 0 to 14 years, thus bringing the total
HIV-positive population to approximately 280 000. At the end of 2009, there was a
total of 62 190 adults and children receiving ART, representing 51% of the total
estimated need (122 818). In 2009, it was estimated that 280 000 adults and children
were living with HIV & AIDS with approximately 122 818 (44%) being in immediate
need of ART. Of this number, 7 433 (6%) were children under the age of 15. In
addition, these adults and children also require community-based care and support
programmes to assist them to stay on ARTs and to cope with the impacts of HIV &
AIDS on their families and on their households. Approximately 180 of 216 ART
service points have been accredited and accreditation of the remaining 36 sites is
underway (Lesotho Ministry of Health, 2009).

Between 2008 and 2009, significant progress was made in making PMTCT services
available at the health centre level. A national scale-up plan was approved in 2007
and implementation of the programme is continuing. The programme expanded from
180 health facilities providing PMTCT in 2008 to 186 in 2009. This expansion was
mainly the result of both expanded training and the decentralisation of PMTCT
interventions to health centres (Lesotho Ministry of Health, 2009).

The PMTCT coverage rate increased from 6% in 2005 to 58,2% in 2008 and 71% in
2009. HIV testing and counselling is a routine component of the ANC services offered
25

at hospitals and health centres. After a group counselling session, individual HIV
tests are performed. This has resulted in over 90% of the women attending ANC
clinics undergoing HIV testing. However, despite the fact that over 90% of pregnant
women attend ANC at least once, there are too many women who do not return for
additional visits and give birth outside of health facilities. Consequently, these women
may not be aware of their HIV status and also not know about PMTCT interventions.
However, the on-going training of community health workers is helping to address
this issue. There are, nevertheless, broader, more complex factors affecting the
utilisation of maternal and child health services in Lesotho, including staffing and the
accessibility of local health centres. The prevalence rate for the 15 to 24 year old age
group was about 18,7% to 19,7% respectively. HIV prevalence remains the high in
the 20 to 35 year age group, ranging from 27,8 to 45,2% nationally (Lesotho Ministry
of Health, 2009).

In South Africa, when comparing the HIV prevalence in 2005 with the 2008 estimates
for each of the nine provinces, it was found that KwaZulu-Natal had had the largest
reduction in HIV prevalence among children from 7,9 to 2,8% followed by
Limpopo with a decrease from 4,7 to 2,5% and Mpumalanga with a decrease from
5,4 to 3,8%. In the Western Cape there was, however, a small increase in the HIV
prevalence amongst children over this period, despite the fact that the Western Cape
continued to have the lowest HIV prevalence in 2008. In contrast, four provinces,
namely, the Eastern Cape, Northern Cape, Free State and North West, experienced
increases in the HIV prevalence in children between 2005 and 2008 (Shisana, Rehle,
Simbayi, Zuma, Jooste, Pillay-van-Wyk, Mbelle, Van Zyl, Parker, Zungu, Pezi & the
SABSSM III Implementation Team, 2009).

A provincial estimate presented the HIV prevalence by province for 2002, 2005, and
2008 for the age group of two plus years. Three patterns emerge when 2002 is used
as a base for comparison against 2008. In the Western Cape the prevalence
difference was 6,9%; in Gauteng 4,4%; in the Northern Cape 2,5% and in the Free
State 2,3%. In contrast three other provinces showed increases in HIV prevalence
with KwaZulu-Natal showing 4,1% and Eastern Cape a relatively small increase of
2,4%. In the remaining three provinces, namely, North West, Mpumalanga and
Limpopo, there was no marked change (Shisana et al., 2009).
26


The HIV prevalence in the total population of South Africa has stabilised at a level of
approximately 11% although a decline in the HIV prevalence at national level was
observed among children aged two to 14, from 5,6% in 2002 to 2,5% in 2008. On the
other hand, the HIV prevalence for all people aged two years remain at 11% from
2002 to 2008. However, in children aged two to 14 years, the prevalence decreased
by 3,1% from 2002 to 2008 (Shisana et al., 2009).

A study conducted in South Africa by the HSRC in 2008 indicated that there had
been a steady decline in the HIV prevalence among children, with a significant
reduction in the national HIV prevalence by 3,1% among children aged two to 14
between 2002 and 2008. This reduction occurred in all the provinces except for
Mpumalanga where the rate remained at a high level of 3,8%. This change in the HIV
prevalence in children has been accompanied by a reduction in the incidence of HIV
and may, perhaps, be attributed to the successful implementation of several HIV
prevention interventions related to addressing HIV in early childhood, particularly
programmes aimed at preventing mother to child transmission in the Western Cape,
where the largest decline of 6 percentage points occurred (Shisana et al., 2009).

The overall national HIV prevalence among antenatal women aged 15 to 49 years is
29,3% in 2009. In 2006 and 2007, the HIV prevalence was 29% and 29,4%,
respectively. The Western Cape reported the lowest estimate of 16,1% while
KwaZulu-Natal reported the highest HIV prevalence in the country of 38,7%.
Mpumalanga has shown an increase in HIV infection from 32,1% in 2006, to 34,6% in
2007 and 35,5% in 2008. The HIV prevalence has stabilised at approximately 11% in
the population of over two years of age (South Africa Department of Health, 2010).

In South Africa the proportion of HIV-positive pregnant women receiving ARVs to
reduce the risk of MTCT was 83% in 2009 and 86% in 2008. The PMTCT programme
is now almost universally available in public primary health facilities, and South Africa
had achieved the NSP target of > 95% coverage in public sector antenatal service
sites in 2008, while a dual therapy regimen of Nevirapine and AZT was adopted in
2008. The estimate for 2008 is that 86% of HIV-positive, pregnant women received
ART to prevent MTCT of HIV, although this figure had declined to 83% in 2009.
27

However, in Gauteng province the introduction of dual therapy has not been well
recorded in the antenatal service and it is for this reason it is likely that the figures for
2009 were an underestimate of the PMTCT coverage in the province. The overall
goal of the PMTCT programme is 100% coverage of all pregnant women who need
PMTCT. Given the UNAIDS estimates, this could range from 110 000 to 280 000
women (South Africa Department of Health, 2010).

Of all the ANC clients presenting for services, the rate of those agreeing to undergo
HIV testing has increased from 88 to 96% in the last two years. In addition,
approximately 90% of those testing HIV positive received a Nevirapine dose either in
ANC services or during labour. The District Health Information System (2011)
PMTCT indicators show first antenatal visits of 101% in 2008 and 88% in 2009 and,
among those antenatal clients tested for HIV, 88% in 2008 and 96% in 2009 with a
statistics of 22% in 2008 and 23% in 2009 for antenatal clients testing HIV positive. In
addition, antenatal client Nevirapine uptake was 110% in 2008 and 90% in 2009
(South Africa Department of Health, 2010).

According to South Africa Department of Health National Antenatal Sentinel HIV and
Syphilis Prevalence Survey report, (2009) of the 52 health districts in South Africa,
38% recorded a HIV prevalence of between 30% and 40%. Eight of these districts
were in KwaZulu-Natal, four in Gauteng, three in the Free State, two in North West
and Eastern Cape and one in Mpumalanga. On the other hand, 30% of the health
districts recorded a HIV prevalence of between 20% and 30%, with five of these
districts being located in the Eastern Cape, three in Limpopo, two in the Free State,
North West and Gauteng and one each in the Northern Cape, Mpumalanga and the
Western Cape. However, 19% only (10 out of 52) of the 52 health districts recorded a
prevalence of between 10 and 20%. Of these, five were located in the Western Cape,
three in the Northern Cape and two in Limpopo. The HIV prevalence in the Capricorn
district significantly decreased from 24,2% in 2006 to 19,8% in 2007, while the
Namakwa district in the Northern Cape recorded the lowest HIV prevalence in the
country, despite the fact that the HIV prevalence in this district had increased from
5,3% in 2006 to 7,3% in 2007 (South Africa Department of Health, 2009b).

28

In 2008, the North West provincial HIV prevalence amongst antenatal women
between the ages of 15 and 49 was 31.0% with the HIV prevalence in this province
appearing to be increasing from 29% in 2006, 30,6% in 2007 and 31% in 2008
(South Africa Department of Health National Antenatal Sentinel HIV and Syphilis
Prevalence Survey report, 2009). Three of the four (3 out of 4) districts in the North
West province have shown an increase in the past three years, except for Bojanala
where the prevalence is beginning to show stabilisation. In 2008, the highest HIV
prevalence (35,2%) was recorded in the district of Dr. Kenneth Kaunda, while the
lowest (28,1%) was recorded in the district Dr Ruth S Mompati (South Africa
Department of Health, 2009b).

The prevention of new HIV infections remains a major public health challenge in
South Africa. It has been estimated that in a group of 108 low- and middle-income
countries, approximately 1,5 million women who gave birth in 2006 were living with
HIV. In South Africa it is estimated that, in 2007, approximately 707 948 pregnant
women were tested for HIV, while 290 000 pregnant women living with HIV needed
ARVs for the sake of PMTCT. It was further estimated that nearly 200 000 children
aged 0 to 4 years in South Africa were infected with HIV in 2007 (South Africa
Department of Health, 2008).

It was estimated in 2005 that each year at least 75 000 children in South Africa die,
with the most common cause of HIV infection in children under the age of five years
being MTCT. Without any interventions, between 20 and 45% of infants may become
infected with HIV through MTCT, with an estimated risk of 5 to 10% of the infections
occurring during pregnancy, 10 to 20% during labour and delivery, and 5 to 20%
through breastfeeding. The overall risk of HIV transmission may possibly be reduced
to less than 2% of births to HIV-positive mothers if a package of evidence-based
interventions is made available to and used by HIV-positive pregnant women and
mothers (UNICEF, 2009).





29

2.7 Challenges Involved in the Implementation of PMTCT

The study conducted in South Africa by Doherty & Besser (2003) indicated that the
management of lay counsellors has been both haphazard and unsatisfactory
(Doherty et al., 2003). The study further explains that space appears to be an issue
at many clinics. Deficiencies in the proper supply and distribution of consumables,
such as Nevirapine (NVP), test kits and formula milk, seem to be a persistent and
universal challenge in terms of the successful implementation of the PMTCT
programme (Doherty et al., 2003), with the unreliable supply of formula, in particular,
exacerbating one of the greatest challenges in infant feeding. The study further
indicated that disruptions in supplies result in mixed feeding. Other challenges to
infant feeding included the stigma associated with formula feeding and also the fact
that health workers involved in PMTCT were, apparently, not being properly trained in
infant feeding. The study further explains that antenatal follow up on PMTCT
interventions is a problem, and there was a particularly low uptake in the testing of
babies in one year.

A study conducted in the Tintsalo Hospital in South Africa revealed a shortage of
staff, particularly nursing staff trained in PMTCT. In addition, the supply and
distribution of formula was a major challenge while the stigma associated with bottle
feeding is the main difficulty facing women in the PMTCT programme and often
results in low levels of disclosure (Doherty et al., 2003).

The Health Systems Trust conducted a study of PMTCT services at 18 pilot sites
where PMTCT services were provided. The interim findings of this study suggest that
the core problems relate to a shortage of staff, poor infrastructure, unavailability of
equipment, and negative attitudes on the part of the community. The study further
found that up to as many as 15% of pregnant women do have access to PMTCT
services. In addition, it was found that 51% of the pregnant women at the national
pilot sites had agreed to be tested and, of the 51% tested, 30% had tested HIV
positive. However, Nevirapine had been administered to both mother and baby in
less than one-third of the cases of HIV-positive pregnant women identified at the
national PMTCT sites. The Health System Trust recommended that the provision of
PMTCT acts as a catalyst for the improvement of the health care system. The narrow
30

scope of the PMTCT approach has been questioned and the realities of limited
resources, inadequate infrastructure and barriers to behaviour change are all in the
process of being researched (Peltzer, Skinner, Mfecane, Shisana, Nqeketo &
Mosala, 2005).

There are also other social factors that may constitute barriers to the implementation
of PMTCT programmes, including the provision of voluntary counselling and testing
(VCT), with the latter possibly causing a major bottleneck in delivering PMTCT
services on a wide scale in countries with a high HIV prevalence (UNICEF, 2003).
Part of this bottleneck relates simply to the cost of delivering VCT on the scale
required. In addition, there are inevitable dropouts at each step of the VCT process.
Not all women will agree to be tested, while not all of those who are tested will return
for their results, nor will all those who learn of their HIV-positive status take the
necessary drugs or give birth in health facilities (Peltzer et al., 2005). The provision of
free feeding formula was also deemed to have a significant effect on PMTCT
interventions in communities where mothers experience problems with (UNICEF,
2003).

Moth, Ayayo and Kaseje (2005) conducted a study of 133 clients registered for
PMTCT services in Kenya. The study revealed that 52,4% of the clients who had
received PMTCT information at the health facility had had no prior knowledge of the
intervention. In addition, 96% had waited for more than 90 minutes to access
antenatal services while 89% had taken less than 10 minutes for post-test
counselling. The findings further revealed that knowledge of MTCT and PMTCT was
inadequate even after counselling as the participants were not able to recall the
information which had been provided during counselling. In addition, the study
revealed that 80% of the clients did not present for follow-up counselling, irrespective
of their HIV status, while 95% had not disclosed their positive HIV status to either
spouses or relatives as a result of fear of stigma, discrimination and violence.
Inadequate counselling services delivered to clients affect service utilisation in that
significant dropouts occurred at various stages, approximately 31,5% at the HIV
results stage, 53,6% during antenatal client enrolment to PMTCT and 80,7% at
delivery. The reasons for dropout include fear of a positive HIV result, chronic illness,
31

stigma and discrimination, unsupportive spouse and an inability to pay for the
services.

2.8 Barriers to the Implementation of the PMTCT Programme

According to UNICEF (2009), the following barriers were identified as inhibiting the
uptake and implementation of PMTCT services and causing lack of follow up in a
number of African countries. The numerous barriers inhibiting the uptake of PMTCT
services, especially in a resource constrained setting, are listed and described below.
Barriers to the uptake of PMTCT services include poor healthcare infrastructure,
shortages of staff, poor referral links, and a lack of communication between different
health services and within the healthcare system itself. Due to the barrier identified
above PMTCT and family-planning services are poorly integrated.

Other barriers include poor quality counselling, poor attitudes on the part of
healthcare workers and inadequate interactions with clients. Other barriers were
identified as cultural and gender-related issues, particularly the role of the male
partners in reproductive issues and their involvement in PMTCT services as well as
poverty and structural barriers, cultural factors concerning appropriate behaviours
linked to counselling and testing, PMTCT and stigma, including perceptions of poor
social support, and discriminatory perceptions of PMTCT practices. In addition, there
is a lack of awareness of and knowledge about HIV/AIDS and MTCT among
pregnant women regarding the information and services relating to PMTCT. The
reproductive and health needs of youths are also not adequately addressed, while
psychological barriers include denial, fear of death, or fear of HIV testing and
disclosure (UNICEF, 2009).

2.9 PMTCT Guideline Interventions in South Africa

The goals of PMTCT interventions are to improve the quality of the health of pregnant
women and mothers, prevent mortality; identify women who are HIV positive; ensure
HIV-positive women enter the PMTCT programme; prevent MTCT, provide AZT from
14 weeks of pregnancy or lifelong ART as soon as possible, depending on the
mothers clinical indication, provide adequate PMTCT coverage and continuity of care
32

of prophylactic and treatment antiretroviral regimens; reduce maternal Nevirapine
resistance and initiate neonates born to HIV-positive mothers with ARV prophylaxis
immediately at birth (National Department of Health & South African National AIDS
Council, 2010).

The provision of an expanded package of PMTCT services in South Africa also
includes routine offering of HIV counselling and testing for all pregnant women
attending antenatal care, as well as the involvement of both the partner and the
family in order to ensure a comprehensive approach. South African PMTCT
interventions also include the provision of appropriate regimens to prevent MTCT of
HIV according to the risk profile based on the HIV test, CD4 cell count and clinical
staging. In addition, all women of unknown HIV status should be offered HIV testing
and counselling before discharge, preferably prior to, or immediately after delivery, to
ensure that the baby is administered ARV prophylaxis if the test is HIV positive. All
abandoned infants judged to be in their first 72 hours of life should be given
Nevirapine as soon as possible and then daily for a period of six weeks. HIV exposed
breastfed infants whose mothers are not on lifelong ART should continue Nevirapine
beyond six weeks of age until all cessation of breastfeeding (National Department of
Health & South African National AIDS Council, 2010).

In 2008, all HIV-positive pregnant women with CD4 counts of below 200 were to be
placed on ART for both their own health and to reduce MTCT, while those with CD4
counts of above 200 were to be placed on AZT from 28 weeks of pregnancy and
given sd-NVP at labour. Their infants were also to be given sd-NVP at birth, followed
by AZT up until the seventh day. Then, four to six weeks after delivery, the infants
were to be given an HIV DNA PCR test in order to monitor programme performance
and to identify HIV-infected infants. These infants would then be put on ART
immediately as this would dramatically improve their chances of survival. However,
this new regimen would require far better linkage and integration between the PVT
programme, the ART programme in order to provide CD4 cell testing and ART as
well as the maternal child health services (Smart, 2011).

In April 2010, South Africa updated its guidelines as regards offering ART to all
pregnant women with CD4 cell counts below 350. The rest of pregnant women with
33

CD4 above 350 were to placed on AZT from week 14 after gestation, stopping sd-
NVP for the mother in view of possible resistance that could limit her future treatment
options. Instead, the infants were to be placed on Nevirapine for at least six weeks
after birth or for the duration of breastfeeding, while early infant diagnosis was to be
performed at the first immunisation visit. HIV DNA PCR test data from the National
Health Laboratory Service PCR test results submitted from infants of less than two
months of age was 8,2% in 2008, dropping to 5,8% in 2009. However, this data may
have been biased because those mothers who were adhering to the programme
would have been the most likely to bring their children in for HIV testing. Accordingly,
a more rigorous study was needed to monitor the PMTCT programmes effectiveness
(Smart, 2011). Reducing vertical transmission became one of the highest priorities of
the South African National HIV/AIDS Strategic Plan (20072011), with the goal being
to reduce HIV transmission in HIV-exposed infants to 5% by 2011 (Smart, 2011).

A cross-sectional survey study conducted in 2011 on the evaluation of PMTCT in
South African found that infants in South Africa are at an extremely high risk of HIV
exposure, despite the fact that the Prevention of Parent-to-Child Transmission of
HIV/AIDS (PPTCT) programme in most provinces has been more effective than was
indicated earlier. According to a weighted analysis, 31,4%, of all infants born in South
Africa are HIV exposed, with the figure ranging between 15,6% in the Northern Cape
and 20,6% in the Western Cape to a high of 43,9% in KwaZulu-Natal. HIV infection at
four to eight weeks was diagnosed in 3,5% of the HIV-exposed infants nationally,
although the programme performance varied significantly by province. If the sample
from the Northern Cape was, then the PMTCT programme in that province has a low
transmission rate of 1,9%, while Gauteng also fared well with 2,3%. However, the
Free State and Mpumalanga fared substantially worse with 5,7% and 6,2% of the
exposed infants testing positive respectively (Smart, 2011).

Despite its extremely high maternal HIV prevalence, 2,8% only of the many HIV-
exposed infants in KwaZulu-Natal tested positive, slightly better than the national
average and far removed from the 20 to 21% transmission rate. Overall, a weighted
national HIV prevalence at four to eight weeks of 1%. Significantly, Enzyme-linked
immunosorbent assay (ELISA) testing revealed that 4,1% of those infants whose
mothers reported being HIV negative had actually been exposed to HIV, possibly
34

because the mothers had become infected subsequent to the antenatal tests. This
highlights the need to provide repeat testing services during pregnancy and to offer
testing for couples in order to encourage the womens partners to be tested (Smart,
2011).

It emerged from other studies that up to 40% of vertical transmission had been
reported to occur during the late perinatal period as a result of exposure to HIV in the
breast milk. It would appear that transmission occurs primarily when mixed feeding is
practised, as opposed to exclusive breastfeeding which poses far less of a risk.
Unfortunately, 18% of the caregivers of HIV-exposed infants had reported practising
mixed feeding of their HIV-exposed infants in the last eight days before their
interviews (Smart, 2011).

In a cross-sectional survey study conducted in 2011 on the evaluation of PMTCT in
South African found that infants in South Africa approximately two-thirds of the HIV
positive women had agreed to their infants being tested for HIV at six weeks by PCR
and there has been a marked reduction in early transmission since the first quarter of
2009, when 9,7% of the HIV-exposed infants had tested positive as compared to the
most recent quarter when 2,4% had tested positive. However, at the 18 months
follow up, further findings reveal a massive under testing of infants. Nevertheless, the
study also suggested a substantial decline in HIV prevalence, with 10,7% of 18-
month-old infants testing antibody positive in the first quarter and 3,8% testing
positive in the quarter ending in March 2011 (Smart, 2011).

The study findings in Smart report 2011 shows that the problems experienced in
obtaining timeous CD4 and PCR results constitute a challenge in terms of improving
outcomes. They also note that point-of-care tests are required that may be performed
by a staff member on site and who is also able to counsel patients. In addition, the
study findings also point out that yet another challenge facing the PPTCT programme
is the lack of adequate data management tools with which to monitor the key
indicators and interventions of the programme. In the meantime, staff burnout and the
difficulty of providing infant follow up to 18 months are also perennial problems
(Smart, 2011).

35

The study conducted among sub-districts in South Africa shows that strategies
designed to improve Prevention of Parent to Child Transmission (PPCT) had
indicated that proper data recording is associated with an improved programme. In
addition, significant predictors of successful infant prophylaxis delivery included
ensuring that there was ANC cards in the delivery file and that the mothers HIV
status had been properly reported in the maternity register. It is also essential that
more effective referral systems to ART and community-based support services of
those children testing HIV positive be put in place (Smart, 2011).

Moreover, an increasing proportion of women are agreeing to be tested again at
approximately 32 weeks of gestation an increase from 15,7% in the first quarter
2010 to 27,9% in the fourth quarter 2010. This measure is extremely important
because it aims to detect HIV infections that occur during pregnancy. There has been
a slight increase in the number of women already aware of their status when first
visiting the ANC. Clinics succeeded in ensuring that almost all of the women not
already known to be HIV positive tested at booking for their antenatal consultation
(Smart, 2011).

2.10 Situation of PMTCT of HIV and AIDS in the North West Province

The North West Province had implemented PMTCT at two pilot sites in 2002,
namely, the Zeerust and Rustenburg hospitals. Since 2002, clinic staff that referred
their clients to these two pilot sites had been trained on PMTCT interventions. In
2003, the PMTCT was expanded to include six other health establishments, that is,
three hospitals the Klerksdorp Hospital, Potchefstroom Hospital and Lehurutshe
District Hospital, and three community health centres (CHC) the Tigane,
Botshabeco and Tobobane CHCs. Currently, the PMTCT programme is being
implemented in all four districts of the North West province (Tint, Doherty, Nkonki,
Witten &Chopra, 2003).

In 2008, the North West provincial HIV prevalence among antenatal women aged 15
to 49 was 31%. The HIV prevalence in this province had increased from 29% in
2006, 30,6% in 2007 to 31% in 2008 and then decrease by 1% to 30% in 2009.
However, three of the four districts in the North West province have shown an
36

increase in the past three years, with the exception of Bojanala where the prevalence
appears to be stabilising. In 2008 the highest HIV prevalence of 35,2% was recorded
in the Dr Kenneth Kaunda district, although this declined to 29,2% in 2009, while the
lowest prevalence of 28,1% was seen in the Dr Ruth S Mompati district in 2009
(Department of Health, 2010).

In the three sub-districts of the Ngaka Modiri Molema District of North West province,
namely, Mafikeng, Ratlou and Ditsobotla, it was reported that, between April and
June 2011, general PMTCT performance had not been satisfactory as most the
indicators had been below the targets set. However, antenatal clients first test
performance was seen to remain good throughout 2011 at above 100%, while PCR
testing at six weeks improved from 84% in 2
nd
quarter 2011 to 108% in quarter 3 of
2011. Cotrimoxazole performance also improved to 92% in the third quarter 2011,
although it is noted that the target is set at 100% for this indicator (South Africa North
West Department of Health, 2008-2011).

The PCR positivity rate at six weeks in the Mafikeng sub-district is 4% in 2011, which
is below the target of at least < 5%. It is, thus, essential that the sub-district effect
improvements in its implementation of the PMTCT project. The sub-district data also
show that Cotrimoxazole improved from 48 to 95 % in 2011, although the sub-district
has not yet attained the target. There was an improvement in the PCR testing at six
weeks in the third quarter of 2011. However, despite the fact that the sub-district is
doing well regarding HIV testing during at the first visit, there was poor performance
at 32 weeks in both quarters of 2011. In addition, generally speaking, the sub-district
is not faring well as regards maternal and child health services (South Africa North
West Department of Health, 2008-2011).

In 2008 there were nearly half a million HIV-positive people in the North West
province which was the fourth highest positivity amongst other South African
provinces with approximately 13% of the population in the province and one in every
five adults estimated to be HIV positive. Nevertheless, the epidemic in the North
West has not yet reached the mature phase and is still growing with the number of
new infections being higher than the number of AIDS-related deaths. An estimated
37

92 000 people were in need of antiretroviral treatment in 2008, while approximately
47% having taken up treatment (South Africa Department of Health, 2010).

2.12 Conceptual Framework

2.12.1 Johns Hopkins University (JHU) Social Ecology Model

The Johns Hopkins University Programme in South Africa noted that change at one
level may be facilitated or obstructed by another level. For example, a woman may
choose to make use of PMTCT services such as formula feeding. This behaviour
may, in turn, be impacted upon if her partner is aware and supportive of her status
and, thus, promotes the use of formula feed. However, if formula feeding is regarded
culturally as not being appropriate, this may impede the practice. In addition, the
ability to access PMTCT services may be further influenced by the relevant societal
policy and legislative levels in terms of which the availability or lack of PMTCT
services or the cost of accessing these resources may impede usage. In such cases,
poverty may place these services beyond the realm of those most in need. The social
ecology model describes four levels for addressing social and behavioural change,
namely, societal, community, social networks and individual. These levels are used to
categorise the findings of the literature as regards the following areas, namely,
barriers to PMTCT implementation, key participants to be addressed, key
communication themes and messages and effective practices in planning and
implementing successful PMTCT communication campaigns (UNICEF, 2009).

2.13.2 Public Health Approach to Unifying HIV Monitoring and Evaluation

This framework is divided into the following eight steps (SANAC & South Africa
Department of Health, 2007):

Identifying the problem
The first step in the framework involves identifying the problem. In the case of MTCT,
this step involves seeking to identify the nature, magnitude and course of the overall
epidemic and related sub-epidemics. Situational analysis, gap analysis and response
analysis comprise the typical information gathering activities that collect information
38

about the programme status from, for example, related documents, informant
interviews and field observations.

Determining the contributing factors of the risk of infection
In the second step, the aim is to determine the contributing factors and determinants
of the risk of infection. This information is usually obtained from rapid assessments;
knowledge, attitude and behaviour surveys; epidemiological risk factor studies; and
determinants research. The results from this step are then used in the design of
appropriate interventions.


Determining which interventions may work in ideal circumstances
The third step focuses on determining which interventions may work under ideal
circumstances by reviewing the available evidence from either research-driven
protocols (efficacy trials) or evaluations of interventions conducted under specific field
conditions (effectiveness studies).

Determining which interventions and resources are needed
The fourth step should be linked closely with the findings from the third step and
involves determining which interventions and resources are needed. This question is
usually addressed through a needs, resource and response analysis, and will include
an assessment of current programmes and estimated coverage of these
programmes.

Assessing the quality of interventions
The fifth step seeks to assess the quality of PMTCT interventions by inquiring into
their implementation. Process monitoring, evaluations and other forms of quality
assessments are typically performed during this step and especially as new
programmes get underway.

Examining the extent of programme outputs
This step seeks to examine the extent of programme outputs and whether the
programme is being implemented as planned and reaching its intended target
39

population. Typically this information should be routinely collected in terms of a
project recordkeeping system.

Examining programme outcomes
The seventh step examines programme outcomes and answers questions about
intervention effectiveness. Typical evaluation methods include intervention outcome
studies with control or comparison groups, operations research, health services
research, formative research, and other special studies.

Determining overall programme effects
The final step focuses on determining overall programme effects and collective
effectiveness. The systematic collection of programme related qualitative data assists
in interpreting programme outcomes and impact and contributes to the understanding
of what is or is not working.

2.14. Summary

The review of the relevant literature confirms that there are a number of barriers
which are currently preventing the successful implementation of the PMTCT
programme and which, in turn, have critical implications for the design of effective
PMTCT communication strategies. It may be concluded that access to HIV treatment,
PMTCT, and other essential HIV services have expanded significantly in recent
years, although little progress has been made in delivering essential care and
support to those children who have either been orphaned or rendered vulnerable by
the epidemic.

The following summary include somewhat broader strategies for preventing HIV
among children, namely, preventing HIV infection among prospective parents by
ensuring that HIV testing and other prevention interventions are made available as
regards the services related to sexual health, such as antenatal and postpartum care,
and which focus on preventing HIV in women of childbearing age; avoiding unwanted
pregnancies among HIV-positive women providing appropriate counselling and
support to those women living with HIV to enable them to make informed decisions
about their reproductive lives; ensuring that contraception is available to those
40

women who want it; preventing the transmission of HIV from HIV-positive mothers to
their infants during pregnancy, labour, delivery and breastfeeding and the integration
of HIV care, treatment and support for women found to be positive and their families.
Nevertheless, there is ample evidence to show that it is possible to provide PMTCT
services through the existing public health systems, even in less resourced parts of
the world. Botswana, Namibia, Swaziland, South Africa, Argentina, Belarus, Brazil,
Ecuador, Guyana, Jamaica, Malaysia, Romania, Russia, Thailand and Ukraine have
all reached the 80% coverage target of ARVs for PMTCT.


























41

CHAPTER THREE: RESEARCH METHODOLOGY

3.1. Introduction
This chapter outlines the research methods that were used in this study with the
researcher discussing the nature of the study as well as the research methods and
research designs selected. Sampling method and the sampling procedure to be
followed, including the study population, are also discussed. In addition, the chapter
focuses on the data collection instrument employed as well as the sampling
procedure adopted. The plan for the data collection and the data analysis are also
discussed.

3.2. Study Design
A quantitative, cross-sectional, descriptive study design was undertaken in 28 clinics
in the Mafikeng sub-district. The study was conducted between November 2011 and
March 2012. Quantitative research is a research method that emphasises precise,
objective and generalisable findings (Rubin & Babbie, 2010). On the other hand, the
cross-sectional design is a well-known study design in terms of which the entire
population or a subset is selected and data collected from this population or subset in
order to assist in answering the research questions of interest (Biemer & Lyberg
2003). Coughian, Cronin and Ryan (2006) describe the research methodology used
in research as the nuts and bolts of the way in which the research is undertaken.
On the other hand, descriptive studies are designed to acquire more information
about a phenomenon as it occurs naturally (Burns & Grove, 2003).

In this study the researcher used quantitative research in order to conduct research
that represents a larger population of Mafikeng clinics and to produce objective
results. In this study the cross sectional study design is used typically to find out
whether PMTCT interventions are effective in preventing mother to child
transmission.

3.3. Study Setting
Mafikeng sub-district is situated in the Ngaka Modiri Molema District Municipality in
the North West Province is 20 kilometres south of the Botswana border and 260
kilometres west of Johannesburg. Mafikeng is the capital city of North West province
42

and used to be known as the City Council of Mafikeng. The municipality is a large
local municipality in the North West province.

There are four other local municipalities surrounding Mafikeng Local Municipality,
namely, Ramotsere Moiloa, Tswaing, Ditsobotla and Ratlou sub-districts. The
Mafikeng Local Municipality comprises a total area of approximately 3 703km. It is
divided into 28 wards consisting of 102 villages and suburbs. According to Census
2005, released in July 2008, the province is estimated to have a total population of
3 669 349 million, and is served by the North West Provincial Department of Health.
The population of Mafikeng municipality is estimated to be 290 228 people with
approximately 102 987 people of the total population falling within the age category
of 15 to 34 years. Approximately 75% of the area is rural with the rural areas falling in
the southern and western parts of the municipality. These rural areas are under tribal
control (Mafikeng Municipal Integrated Development Plan (IDP), 2010 to 2011).

The challenges facing the community within the boundaries of the municipality
include the following: people are forced to travel long distances in order to access
health care facilities; the mobile clinics that service the rural areas do not visit these
areas on a consistent basis and some of the clinics are not open 24 hours a day
(Mafikeng Municipal Integrated Development Plan (IDP), 2011). The Mafikeng
Municipality is served by twenty eight clinics and community health centres, as well
as five mobile clinics that service the rural wards where there are no clinics. There
are three hospitals, namely, the Mafikeng Provincial Hospital, Bophelong Psychiatric
Hospital and Victoria Private Hospital. All these hospitals are open to the community
24 hours a day (Mafikeng Municipal Integrated Development Plan (IDP), 2011).

There are approximately 436 PHC facilities in the North West Province of which 87
are in Ngaka Modiri Molema, These include 13 CHC, 53 clinics, and 21 mobile
clinics. North West has a total PHC head count of 8 751 479 with 2 338 338 in Ngaka
Modiri Molema. According to the 2008/9 annual report for North West Department of
Health, the HIV-testing rate (excluding antenatal) was 72% in 2009 with a HIV
prevalence rate of 32% among the clients tested (excluding antenatal) in Ngaka
Modiri Molema District (Community Survey, 2007).

43

3.4 Study Population and Sampling
3.4.1 Population
Rubin and Babbie (2010) define the study population as the aggregation of elements
from which the sample is actually selected, while, according to Polit and Beck (2006),
a population may be referred to as the total number of people fitting the specific set
of specifications in a study. The study population may also be referred to as the
target population.

According to De Vos, Strydom, Fouche and Delport (2002) the population refers
either to those individuals in the universe who possess specific characteristics or to a
set of entities that represent all the measurements of the practitioner or researcher.

In this study, the study population comprised nurses from each of the 28 clinics
selected in the sample and who were both readily available during the period of data
collection and were informed about the implementation of PMTCT interventions

3.4.2 Sampling
According to Polit and Beck (2006), quantitative research designs should utilise large
samples in order both to increase the degree of representativeness and to reduce the
possibilities of sampling errors. Sampling may be described as the process of taking
a portion of a population or universe and considering it to be representative of that
population or universe (De Vos et al., 2002).

In this study probability sampling in the form of simple random sampling was used. In
probability sampling each person or other sampling unit in the population has the
same, known probability of being selected (De Vos et al., 2000).

In order to evaluate the implementation of PMTCT interventions in each clinic visited,
a questionnaire was personally administered to 28 nurses who were readily available
from each primary health care clinic in the Mafikeng sub-district which was
implementing PMTCT interventions. Nurses from each of the 28 clinics selected were
included in the sample in order to ensure the representation of each clinic. Mobile
clinics and hospitals were excluded from the study.

44

3.4.3 Sampling criteria
The following qualification criteria were applied to the participants in the study:
Professional Nurses who were implementing PMTCT interventions in
government healthcare facilities in the Mafikeng local sub-district.
Knowledge of the day to day running of the PMTCT programme in the clinics.
Registered professional nurses rendering services to antenatal clients (ANC),
including PMTCT services
Had not participated in the pretesting of the data collection instrument

3.4.4. Sampling frame
The Mafikeng Local Municipality Integrated Plan (IDP) document 2010 was used to
develop the sample frame for all the clinics.

Table 2.1: The sample frame
CLINICS IN MAFIKENG No. of health care facilities in the Mafikeng
Local Municipality
Community Health Centres (CHC) 5
Fixed and Satellite Clinics 23
Total 28 clinics

The sample frame of all 28 clinics includes 23 fixed primary health care clinics and
the five community health care centres. The four mobile clinics and three hospitals
were excluded from the sample frame.

3.5. Data Collection Instruments
According to Coughian, Cronin and Ryan (2006), there are a number of strategies
available as regards collecting data, including interviews, questionnaires, and attitude
scaled or observational tools.

3.5.1 Questionnaire

In this study the researcher utilised a questionnaire with which to collect the data.
According to Rubin and Babbie (2010), a questionnaire is a document that contains
45

questions and other types of items that are designed to solicit information appropriate
to analysis. According to De Vos et al. (2002), a checklist is a certain type of a
questionnaire consisting of certain items. The respondent is requested to indicate
which of the items are the most applicable to him/her or which describe the situation
concerned best.

A questionnaire consisting of 55 questions and 7 sections was developed after
reviewing a number of PMTCT questionnaires from previous studies which had been
conducted both in South Africa and internationally. There were about 3 Questions in
Section A, 2 Questions in Section B, 15 Questions in section C, 14 Questions in Sub-
Section C, 18 Questions in Section D, and 23 questions in section E, 9 questions in
section F. The questionnaire was labelled Evaluation on the implementation of
PMTCT interventions. The researcher administered this questionnaire containing a
list of questions to nurses in order to evaluate the implementation of PMTCT
interventions and to determine whether the clinics were implementing PMTCT
services in compliance with the PMTCT protocols and guidelines. The questions in
the questionnaire were developed based on the following instruments and core
standards manuals;
South Africa National Department of Health: Quality Assurance, October 2010.
Primary Health Care Supervision Manual: a Guide to Primary Health Care
Facility Supervision,
Reproductive Health and HIV Research Units (RHRU) HIV Standard four tool
for self-assessment to improve HIV service,
Family Health International (FHI) PMTCT baseline assessment checklist tools.
International Centre for AIDS Care and Treatment Programs (ICAP) PMTCT
baseline assessment checklist tools.
South African Department of Health Tool to Assess Site Readiness for
Initiating Antiretroviral Therapy in Public Health Facilities 2009.
The researcher also took into account the South African PMTCT 2010
guidelines and policies in order to follow the procedure of developing a
questionnaire.


46

3.5.2. Retrospective data from District Health Information System (DHIS)

The researcher reviewed a few selected PMTCT data elements and indicators from
the District Health Information System (DHIS) while routine PMTCT data from the
Mafikeng sub-district was evaluated by examining the data collated monthly in the
DHIS. Data was extracted from the DHIS from July 2008 to December 2011 by using
DHIS extract coding sheet. Routine PMTCT data elements and indicators were
calculated and summarised for six month intervals from July 2008 to December 2011.

3.6. Reliability of the Research Instrument

Rubin and Babbie (2010) define reliability as that quality of a measurement method
that suggests that the same data would be collected each time in repeated
observations of the same phenomenon, while Polit and Beck (2006) maintain that
reliability means to test the accuracy of a measuring instrument.

Reliability may, thus, be defined as the accuracy or precision of an instrument;
degree of consistency or agreement between two independently derived sets of
scores and the extent to which independent administrations of the same instrument
would yield the same or similar results under reliable conditions (De Vos et al., 2000)

The researcher conducted a pre-test of the questionnaire among five individuals from
the other clinics not included in the sample in order to determine the validity and
reliability of the instrument. The researcher aimed to assess whether the respondents
would have similar understanding of the questions when the questionnaire was
administered, whether the format of the questions was such that the respondents
were able to understand the questions, whether the format of the questions was
suitable for the population and whether the questions were relevant. In this study the
focus was on internal consistency, namely, the extent to which items on the
instrument measured the same thing.

3.7. Validity
Polit and Beck (2006) define validity in terms of whether the measuring instrument
measures what it is supposed to measure while, according to White (2003), validity
47

ensures that the instrument is measuring what it is supposed to measure. In this
study the following strategy was adopted to ensure validity: The instrument was
assessed by experts from various fields and from the staff of the University of Venda
as well as members of the University of Venda Department Public Health and the
University of Venda Higher Degree Committee (HDC) of the School of Health
Sciences.

3.7.1. Face Validity
Face validity refers to the likelihood that an instrument will appear to any person to be
a test of what it is supposed to test (Kumar, 2005). Thus, in this study the researcher
aligned the flow of questions with the objectives of the study. The instrument was
also scrutinised by experts experienced in the field of PMTCT as well as being
distributed to 5 respondents who were from a local municipality clinic other than the
Mafikeng Local Municipality for their opinion as to whether the instrument was
capable of evaluating the implementation of PMTCT interventions and measuring
whether the questionnaire did actually measure a the implantation of PMTCT
interventions among Nurses. Changes were then made to the structure of the
questionnaire while the phrasing of those questions identified was modified
accordingly.

3.7.2. Content Validity
The questionnaire was submitted to experts at the Department of Public Health at the
University of Venda and also to fellow MPH students for their evaluation of its content
validity. An extensive review of both relevant literature as well as instruments from
similar studies conducted locally and internationally provided some assurance of the
content validity of the questionnaire. According to White (2003) the assessment of
the content validity was conducted in order to determine the following;
Whether the instrument encompasses a representative sample of the
behavioural domain to be measured;
Measure whether the questionnaire included items covering all areas as
discussed in the literature.


48

3.8. Pretesting
Pretesting of the research instrument was conducted in order to improve the
questions, if necessary, and, thus, to ensure that the instrument was relevant to the
study and also to determine whether the instrument and the data analysis would be
both adequate and appropriate.

Thus, the pre-test was conducted to measure the suitability of the interview schedule
and to check the possibility of errors. The researcher also asked for comments on the
wording of the questions, the sequence of the questions, possible redundant
questions and either missing and/or confusing questions. In addition, the researcher
pre-tested the questionnaire to ascertain whether the participants understood the
questions and whether all the respondents interpreted the questions in the same
way. Those respondents who participated in the pretesting of the questionnaire were
not eligible to participate in the main study.

3.9. Method of Data Collection
Data collection refers to the precise and systematic collection of information that is
relevant to the purpose, objectives, questions or hypotheses of a study (Burns &
Grove, 2003).

The researcher administered the questionnaire personally to the nurses in order to
correct any mistakes which the respondents may have experienced when answering
the questions and to avoid bias in the answering of the questions.

The researcher reviewed a few selected PMTCT data elements from the District
Health Information System (DHIS) data. The routine sub-district PMTCT data was
evaluated by examining extracted DHIS data which had been captured monthly in the
District Health Information System (DHIS) at the sub-district level. This data was then
analysed using Excel. Routine PMTCT indicators and data elements were calculated
for the 12-month period from January 2011 to December 2011. In addition, in order to
measure PMTCT over six-month intervals the research selected data from the period
July 2008 to December 2011.


49

3.10. Method of data analysis
Data analysis refers to the process of bringing order, structure and meaning to the
mass of collected data. (De Vos et al., 2002). In view of the fact that the variables
were quantitative in nature, two statistical methods were used to analyse the data,
namely, descriptive and inferential statistics.
According to White (2003), descriptive statistics are concerned with the description
and summary of the data obtained for a group of individual units of analysis. Data is
described and summarised by tabulating and graphically depicting the data. The
purpose of descriptive statistics is to reduce large amounts of data physically in order
to facilitate the drawing of conclusions about the data. On the other hand, inferential
statistics are concerned with populations and use sample data to draw conclusions
about the population concerned. Inferential statistics also help the researcher to test
the research hypothesis (Wood, Ross-Kerr & Brink, 2006).
In this study the data was captured in a coded Microsoft Excel worksheet in order to
measure the reliability and consistency of the data and then imported to SPSS V14.0
for analysis. In this study frequency was reported in terms of numbers and
percentages and was presented in the form of tables and graphs. The DHIS data was
analysed using a Microsoft Excel spread sheet.

3.11. Ethical considerations
According to White (2003), ethics refer to a set of moral principles which are
suggested by either an individual or a group, is subsequently widely accepted, and
which offers rules and behavioural expectations about the most correct conduct
towards experimental subjects and respondents, employers, sponsors, or other
researchers, assistants and students.

This study proposal was presented to the Higher Degree Committee (HDC) of the
School of Health Sciences at the University of Venda and recommended for ethical
approval from the University Senex and Ethics Committee. Ethical clearance for the
study was granted by the Research Ethics Committee of the University of Venda
while permission to conduct the study was obtained from the North West Provincial
Department of Health and Social Development.
50


Informed consent: The respondents were interviewed after their informed consent
had been obtained. Accordingly, the researcher informed the respondents about the
objectives of the study, the ethics to which the researcher would adhere, what was
expected of the participants and the amount of time that participation in the study
would involve. The respondents all completed the consent form. The researcher
made it clear to the respondents that the research was being conducted for academic
purposes. The respondents were also fully informed about the research process. In
addition, the researcher respected the rights of the respondents to withdraw from the
study if they felt unwilling to respond as no one was to be forced to participate in the
study.

Respect the privacy of subjects and others: The researcher promised the
respondents that their privacy would be respected at all times. The researcher also
ensured that the rights and welfare of the participants were protected.

Anonymity and confidentiality: The researcher also guaranteed confidentiality and
anonymity. Accordingly, access to the completed questionnaires was restricted the
researcher only. The respondents were also told that they had the right not to reveal
their names and residential addresses. In addition, the researcher was honest as
regards the disclosure of the study findings and in the data analysis. The researcher
also explained the purpose of the study to the respondents as well as his role in the
study.

3.12. Summary
This chapter outlined the research methods that the researcher applied in conducting
the study. The chapter also described the structure or method which the researcher
used to conduct research. This chapter also indicated the way in which these
methods were applied. The chapter also discuss the research design, population and
location of the study, sampling procedures, data collection, instrument, ethical
considerations in the research, data analysis method, framework and limitations of
the study.

51

CHAPTER FOUR: RESULTS
4.1. Introduction
This chapter presents the findings of the study and the interpretation of the results
pertaining to the implementation of the PMTCT programme interventions. In the
study, 28 questionnaires were administered in the all 28 clinics selected for the study.
The response rate was 100% as all 28 respondents agreed to take part in the
interviews.
The results of this study are presented as follows:
Section A: Biographical information of the respondents
Section B: Availability of resources, infrastructure and equipment providing
PMTCT services
Subsection B: Assesses the availability PMTCT related services
Section C: Trainings received by and knowledge of health care workers
Section D: Challenges faced by health care workers
Section E: Availability of mechanisms and systems to monitor PMTCT
programme
Section F: Evaluation of the implementation of PMTCT interventions during
pregnancy and post delivery

SECTION A: BIOGRAPHICAL INFORMATION OF THE RESPONDENTS
Section A of the questionnaire required information from the respondents pertaining
to their years of experience and their job titles.

Respondents length of experience in the PMTCT services
Table 4.3: Mean and standard deviation of respondents work experience (N = 29)
Experience Observations Mode Mean Standard
Deviation
Min Max
Male 4 3 6 2 3 8
Female 24 3 8 3 3 11

According to Table 4.1 above, the four male respondents years of working
experience in PMTCT ranged between three and eight years, while that of the 24
female respondents ranged between three and 11 years. Table 4.1 depicts that the
four male respondents (14%) ages range between three and eight years, whereas
52

the female respondents (26 or 86%) ages vary between three and 11 years. The
mode of both the male and female respondents is three. The variation around the
mean age for females is higher (8) when compared to that of males (6). In addition, it
is also evident that the spread of age for the males and females was two and three
respectively.
Table 4.4: Demographic information of the respondents


Table 4.4 above presents the demographic characteristics of the respondents per
clinic. The table also reveals that 24 (83%) of the respondents who participated in the
study were females while four (14%) were males.
Characteristics Total (%) N
Gender n % 28
Male 4 14% 28
Female 24 86% 28
Job Titles


Professional Nurse 16 57% 28
Enrolled Nursing Assistant 2 7% 28
Operational Manager 10 36% 28
Chief Professional Nurse 2 7% 28
Years of Experience


1 to 3 years 6 21% 28
4 to 6 years 7 25% 28
7 to 9 years 4 14% 28
10+ years 11 39% 28
Types of clinic


Clinic 9 32% 28
Satellite Clinic 15 54% 28
Community Health Care Centre 4 14% 28
53


Figure 4.1: Respondents job titles

All 28 (100%) of the respondents were full time and permanently employed. The
majority of the respondents 16 (57%) were professional nurses while 10 (36%)
were operational managers and two (7%) were chief professional nurses.


Figure 4.2: Participants years of experience in the PMTCT services.
A total of 28 respondents took part in the study. Of the respondents, six (21%) had
one to three years experience, seven (25%) had four to six years, four (14%) had
seven to nine years while 11 (39%) had more than 10 years of experience.
54



Figure 4.3: Types of clinic in Mafikeng sub-district

Excluding mobile clinic and hospitals there are 28 clinics in the Mafikeng sub-district
of which four (14%) are community health care centres (CHS), 15 (54%) are satellite
clinics and nine are (32%) fixed clinics. Of the 28 clinics 23 are open for eight hours
while five are 24-hour clinics.

SECTION B: AVAILABILITY OF RESOURCES, INFRASTRUCTURE AND
EQUIPMENT

Table 4.5: Availability of Human resources and capacity in the clinics to provide
PMTCT services (N=28)
Characteristics Total (%) N
Nurses on duty per clinic daily n % 28
One nurse on duty 9 32% 28
Two nurses on duty 12 43% 28
Three nurses on duty 5 18% 28
Four nurses on duty 1 4% 28
Nine nurses on duty 1 4% 28
Clinic working days


Five days per week 23 82% 28
Seven days per week 5 18% 28
55

Clinic working hours


Open 8 hours 23 82% 28
Open 24 hours 5 18% 28
Number of antenatal consultations per week
Provide ANC services 1 day per week only 11 39% 28
Provide ANC services 2 days per week 1 4% 28
Provide ANC services 5 days per week 16 57% 28

Antenatal deliveries per clinic and referrals Yes % No % N
Hospital deliveries 4 (14%) 24 (86%) 28
Delivery onsite 5 (18%) 23 (82%) 28
Deliver at other clinics 18(64%) 10 (36%) 28
Home deliveries 1 (4%) 99 (96%) 28

Table 4.5 presents the data on the availability of services in the clinics. Of the 28
clinics, 16 (57%) provided antenatal care (ANC) services for five days per week, one
clinic (4%) provided ANC for two days per week while 11 (39%) clinics provided ANC
services for one day per week only. The study also revealed that, of the 28 clinics,
four (14%) indicated that deliveries happened at the hospitals, five (18%) indicated
deliveries happening onsite, 18 (64%) indicate deliveries happening at other clinics
such as CHC and delivery clinics, while one (4%) only indicated that most patients
preferred home deliveries.
The table above also showed that nine clinics (32%) allocated one nurse on duty to
handle the PMTCT programme; 12 (43%) allocated two nurses on duty daily, five
(18%) allocated three nurses per day, one (4%) clinic allocated four nurses on duty
per day, while one clinic (4%) allocated nine nurses on duty per day. Table 4.3 above
also shows that, of the 28 clinics, 23 (82%) operate for eight hours a day while and
five operate for 24 hours a day. In addition, the table shows that, of these 28 clinics,
23 (82%) operate for five (5) days in the week and three (18%) operate for seven
days of the week.



56

Table 4.6: Availability of infrastructure and equipment to Implement of PMTCT
Services (N=28)


n= %
a) Infrastructures b) Counselling room offer privacy 89% (25)
c)
d) Adequate space available for ANC which can maintain
confidentiality 71% (21)
e) Provide free infant formula to infants up to 6 months 75% (21)
f) Designated VCT rooms available in the facility 46% (13)
g) Adequate consultation rooms for ANC 43% (12)
h) Maternity services available on site 18% (5)
i) Equipment j) Antenatal card given to antenatal clients to take home. 100% (28)
k) Facility provide free infant formula to infants 82% (23)
l) Provide PMTCT information such as booklets during
ANC consultation 61% (17)
m) Provide nutritional support to HIV positive women who
are breast feeding 57% (16)
n) Human resource o) Enough staff that performs the HIV test 79% (22)


Table 4.6 above reveals that five (18%) clinics only carry out deliveries on site, 23
(82%) provide infant feeding formula to infants, all 28 clinics (100%) provide their
antenatal clients with antenatal cards to take home, 21 (75%) clinics indicated that
they have adequate space available for ANC to help ensure confidentiality, 12 (43%)
have adequate consultation rooms for ANC, 21 (75%) clinics provide free infant
formula to infants up to the age of six months,16 (57%) clinics provide nutritional
support to HIV-positive women who are breastfeeding, 25 (89%) clinics have a
counselling room which offers, 22 (79%) clinics have sufficient staff to perform HIV
testing, 17 (61%) clinics provide PMTCT information, such as booklets, during ANC
consultations while 13 (46%) clinics have designated VCT rooms available in the
facility.







57

Table 4.7: Availability of clinical Guidelines and policies within the clinic
Guidelines and policies available on site
Yes % No%
Dont
Know% N
a) Management of opportunistic infections 28 (100%) 0 (0%) 0 (0%) 28
b) TB infection clinical guidelines 28 (100%) 0 (0%) 0 (0%) 28
c) Integrated Management of Childhood Illness 28 (100%) 0 (0%) 0 (0%) 28
d) Post Exposure Prophylaxis Guidelines 28 (100%) 0 (0%) 0 (0%) 28
e) Essential Medicines List (EML) guideline 27 (96%) 1 (4%) 0 (0%) 28
f) Revised ART guidelines 27 (96%) 1 (4%) 0 (0%) 28
g) STI guidelines 27 (96%) 1 (4%) 0 (0%) 28
h) VCT and HCT( PICT) guideline 27 (96%) 0 (0%) 1 (4%) 28
i) Antenatal care guideline 27 (96%) 1 (4%) 0 (0%) 28
j) Laboratory procedures guideline 25 (89%) 1 (4%) 2 (7%) 28
k) Up and down referral of patients guideline 24 (86%) 3 (11%) 2 (7%) 28
l) Management of drug Adverse effects 23 (82%) 3 (11%) 3 (11%) 28
m) The most recent national PMTCT guideline 24 (86%) 1 (4%) 2 (7%) 28
n) Nutrition for People Living With HIV/AIDS 23 (82%) 3 (11%) 3 (11%) 28
o) Written confidentiality policy 22 (79%) 3 (11%) 4 (14%) 28
p) National Strategic Plan (HIV and AIDS) 18 (64%) 6 (21%) 3 (11%) 28
q) Staff members are able both to use and
implement the relevant PMTCT guidelines 27 (96%) 1 (4%) 0 (0%) 28
r) All document are kept in a place which is
known and easily accessible 26 (93%) 2 (7%) 0 (0%) 28

Of the total number of participants, 96% (27) were aware of the availability of the
national ART guideline in their clinics, approximately 86% (24 out of 28) were aware
of the latest National PMTCT guidelines, while guidelines on the management, of
PMTCT, VCT, HCT, sexually transmitted infections (STI) antenatal care, nutrition for
people living with HIV and laboratory procedures were available at 80% of the clinics.
On the other hand, guidelines for infant feeding counselling, the integrated
management of childhood illnesses (adapted to HIV), post exposure prophylaxis,
management of opportunistic infections and a TB infection clinical guideline were
available at all 28 (100%) clinics. However, guidelines such as the National Strategic
Plan (HIV and AIDS) and a written confidentiality policy from the sub-district were not
available at 79% of the clinics. Nevertheless, the respondents from 26 clinics (93%)
58

indicated that all the guidelines and policies are kept in a place which is easily
accessible them while respondents from 27 (96%) clinics indicated that staff
members are able to use and implement all the available guidelines.

Table 4.8: Availability of related PMTCT supplies within the clinic


Table 4.9: Time required to obtaining PMTCT-related supplies available in the clinic
How often do you run out of the
following PMTCT critical supplies
items? Month Week Sometime Rarely/never n%
a) Infant formula 9(32%) 0 (0%) 4 (14%) 15 (54%) 28
b) Lancets for finger pricking 2 (7%) 1 (4%) 3 (11%) 22 (79%) 28
c) ARV prophylaxis 1 (4%) 0 (0%) 1 (4%) 26 (93%) 28
d) HIV rapid test kits 1 (4%) 0 (0%) 2 (7%) 25 (89%) 28
e) Condoms 0 (0%) 0 (0%) 2 (7%) 26 (93%) 28

Tables 4.8 and 4.9 shows the availability of PMTCT related supplies in the Mafikeng
clinics. The respondents reported that they had the supplies of the following critical
items on stock, namely, 27 of the 28 clinics (96%) had NVP tablets, 26 (93%) had
NVP syrup, 24 (86%) had dried blood spot test kits, 18 (64%) had infant formula
while all 28 (100%) of the clinics reported that they never ran out of condoms for both
males and females. In addition, more than 80% of the clinics reported never running
out of ARV prophylaxis and HIV rapid test kits. On the other hand, approximately nine
(32%) clinics indicated that it takes a month before they receive infant formula while
15 (54%) reported never, or rarely, running out of infant formula feeding.
PMTCT related supplies available in facility Yes No N
a) Condoms 28 (100%) 0 (0%) 28
b) NVP tablets 27 (96%) 1 (4%) 28
c) NVP syrup for HIV exposed babies 26 (93%) 2 (7%) 28
d) Dried blood spot (DBS) test kits 24 (86%) 4 (14%) 28
e) Infant formula 18 (64%) 10 (36%) 28
59

Figure 4.4: Turnaround time for the HIV test and CD4 test results
The figure (4.3) above shows that seven (25%) of the clinics indicated that they
receive PCR test results in less than one week, eight (29%) indicated that it takes
one to two weeks to receive PCR results, while 12 (43%) indicated that it takes them
between four and six weeks to receive their PCR test results. However, all the clinics,
28 (100%), indicated that they receive their rapid HIV test results in less than one
week or on the same day. Most of the clinics were no longer conducting the ELISA
test unless the result of the confirmatory test was not satisfactory. However, 20 (71%)
clinics indicated that it takes less than one week to receive their results while eight
(29%) indicated that it takes one to two weeks. In addition, 26 of the clinics (93%) in
Mafikeng indicated that they receive their CD4 results in less than one week; one
(4%) indicated that it takes one to two weeks, while another one (4%) indicated that
the CD4 results take between four to six weeks.






60

SUB-SECTION B: ASSESS THE AVAILABILITY OF PMTCT RELATED SERVICES
Table 4.10: Availability of PMTCT-related services (N=28)
Which of the following PMTCT related services are offered at your site? n %
a) Antenatal consultation 100% (28)
b) PMTCT services 100% (28)
c) Family planning for pregnant women 100% (28)
e) VCT (Voluntary Counselling and Testing Services)
100% (28)
f) TB treatment and screening for pregnant women.
100% (28)
g) Immunisations for infants 100% (28)
h) Exposed infant follow up 100% (28)
i) Infant feeding counselling 100% (28)
j) PCR testing for infants 100% (28)
k) Postnatal follow up of mother and infant 100% (28)
d) HIV care and treatment (ART clinic) 89% (25)

Table 4.10 presents the availability of PMCTC services as regards meeting national
PMTCT criteria. Of the 28 clinics assessed, most met the national PMTCT criteria
while, of the 28 clinics, 25 (85%) were accredited to provide ART to HIV-positive
patents, including pregnant women, with three only not being accredited.
In general, the five delivery facilities complied with the PMTCT delivery site criteria,
including the provision of antenatal consultations, PMTCT services, family planning
for pregnant women, VCT, TB treatment and screening for pregnant women,
immunisations for infants, exposed infant follow ups, PCR testing for infants,
postnatal follow ups of mother and infant, as well as HIV counselling before and after
delivery.

The NSP 2007 to 2011 calls for an increase in the proportion of public sector
antenatal services providing PMTCT of 85% in 2007, 95% in 2008, and 100% from
2009 to 2011, an increase in the proportion of the estimated population of HIV-
infected pregnant women in need receiving PMTCT services of 70% in 2007, 85% in
2008, 90% in 2009 and 95 % in 2009 to 2011, as well as an increase in the
proportion of the estimated population of HIV-infected pregnant women in need of
61

receiving PMTCT services of 60% in 2007, 70% in 2008, 80% in 2009, 90% in 2010
and 95% in 2011.

Table 4.11: Availability of services providing PMTCT interventions to ANC (N=28)
Items n %
a) The facility provides guidance regarding the volume and frequency of
feeding at each age 100% (28)
b) The facility provides infant feeding counselling 96% (27)
c) Civil society and home base care are involved in the PMTCT
programme 89% (25)
d) NGOs or partners working to support the implementation of PMTCT
services in the clinic 89% (25)
e) Clinic had received at least one visit by the district PHC supervisor in
the previous four months 86% (24)
f) Clinic conducts PMTCT health promotion through community outreach
programmes 82% (23)
g) Clinic had received at least one visit by the sub-district PMTCT
coordinator in the previous four months 54% 15
h) Clinic had received at least one visit by the sub-district MCH
coordinator in the previous four months 32% (9)
i) Clinic provides ANC delivery services 29% (8)

The table (4.11) above illustrates that nine clinics (32%) only had indicated that they
had received support visits from the maternal health and child coordinator at least
once in the previous four month, 24 (86%) had received visits from the sub-district
supervisors, while 15 (54%) had received one support visit from the PMTCT/HIV
coordinator in the previous four months. In addition, eight of the 28 clinics (29%) were
conducting antenatal deliveries, 23 (82%) were able to provide PMTCT health
promotion through community outreach programmes, approximately 25 (89%)
indicated they had supporting partners (NGOs) as regards the implementation of the
PMTCT programme, approximately 27 (96%) clinics were providing infant feeding
counselling, while all 28 clinics were providing guidance to antenatal patients as
regards the volume and frequency of infant feeding.


62

SECTION C: TRAINING RECEIVED BY AND KNOWLEDGE OF HEALTH CARE
WORKERS

Table 4.12: Knowledge, Training and skills transfer among Nurses (N=28)

n%
a) Training b) Have knowledge in providing PMTCT interventions 96% (27)
c) Trained on HIV testing and Counselling for PMTCT 93% (26)
d) Confidant in testing and counselling for PMTCT 93% (26)
e) Clinical staff trained on ART guidelines 93% (26)
f) Clinical staff trained on PMTCT guidelines 93% (26)
g) Staffs trained on relevance PMTCT Interventions 86% (24)
h) Trained infant feeding in the context of HIV infection 86% (24)
Trained on stigma and discrimination related to MTCT 75% (21)
i) Training(s) received adequate to provide PMTCT services 64%(18)
j) PMTCT training received in the last 6 month 57%(16)
k) Able to apply learned skills and knowledge through training 100%(28)
l) Knowledge m) Have knowledge on PMTCT intervention 96% (27)
Clinical staff able to apply the transferred knowledge and
skills learned during in-service training and orientations 93% (26)
Able to apply the acquired knowledge and skills received in
PMTCT training 89% (25)
Skill transfer Able to transferee skills and knowledge learned through
training 96% (27)
Guidelines used for in-service training 89% (25)
All staff members are given opportunity to transfer skills 89% (26)

The table (4.12) above illustrates that 24 (86%) respondents had been trained on
PMTCT interventions and that the training received had also included infant feeding
in the context of HIV infection. In addition, 26 (93%) had been trained on HIV testing
and counselling for PMTCT, 26 (93%) indicated they were confident in the testing
and counselling of PMTCT while 21 (75%) had been trained on stigma and
discrimination related to MTCT. It also emerged from the table above that 18 (64%)
were of the opinion that the training they had received was adequate while one
respondent (4%) only did not appear to have the knowledge to provide PMTCT
interventions for both mother and child.
The study shows that staff members in 16 (57%) clinics had received PMTCT related
training in the previous 6 months while 25 (89%) indicated that they had been given
the opportunity to transfer the skills and knowledge they had acquired through
63

training. Of the 28 respondents, 26 (93%) were trained on ART guidelines and 26
(93%) trained on PMTCT guidelines. The study also shows that 27 (96%) of the
respondents were informed about PMTCT interventions, 27 (96%) had been able to
transfer the skills and knowledge they had acquired through training while all 28
(100%) had been able to apply the skills and knowledge they had acquired through
training.
Of the 28 respondents, 25 (89%) were able to use ART and PMTCT guidelines
during in service training while 26 (93%) respondents indicated that other staff
members were able to apply the knowledge and skills they had acquired during in
service training and orientation.

Figure 4.5: Knowledge to provide PMTCT Interventions (N=28)

The above Figure (4.4) provided staff members with the opportunity to rate their
facility as Good Fair Poor or Excellent. According to table 4.12 above, 16 (57%)
respondents rated themselves as good on the implementation of PMTCT guidelines
in their clinics, 8 (29%) rated themselves as excellent and 4 (14%) only rated their
clinics as fair. As regards the PMTCT training which they had received 18 (64%)
rated it as good, five (18%) as fair, two (7%) as poor and three (11%) as excellent.
On the other hand, 15 (54%) indicated that the PMTCT services which they were
rendering were good, two (7%) rated them fair and 11 (39%) rated them as excellent.


64

The figure 4.5 indicates that 10 (36%) of the respondents indicated that the VCT
services for antenatal clients at their clinics were good and 18 (64%) rated their
clinics as excellent. In addition, 10 (36%) rated the PCR testing for infants at six
weeks as good, two (7%) rated it as fair while 16 (57%) rated it as excellent. Of the
28 respondents 9 (32%) rated the antibody testing at 18 months as fair, two (7%) as
poor and 11 (39%) as good, while six (21%) rated the baby antibody testing at 18
months as excellent. The majority of the respondents 15 (54%) indicated that the
monitoring efforts of the PMTCT programme were good, 8 (29%) as fair, one (4%) as
poor and three (11%) as excellent.

SECTION D: CHALLENGES FACED BY HEALTH CARE WORKERS

Table 4.13: Challenges and barriers that contribute to the failure of the PMTCT
programme (N=28)
Challenges and barriers that contribute to the failure of the PMTCT
programme n %
a) Under staffed personnel/Inadequate human and physical resources 71% (20)
b) Traditional beliefs 64% (18)
c) Too many registers 54% (15)
d) Long waiting time in queues for consultations 54% (15)
e) Lack of support and supervision 50% (14)
f) Lack of proper programme monitoring 46% (13)
g) Poor data quality and management of data 43% (12)
h) Lack of community involvement and support 39% (11)
i) Fear and stigma attached to patient 29% (8)
j) Lack of team work 25% (7)
k) Shortage of equipment, and resources to deliver PMTCT services 25% (7)
l) Lack of commitment and motivation to carry out the work 21% (6)
m) Lack of coordination and integration of PMTCT with other programmes 21% (6)
n) Poor management of programmes 21% (6)
o) Lack of training and skills transfer 18% (5)
p) ANC patient are not turning up for appointments 18% (5)
q) Lack of enthusiasm and confidence in PMTCT 14% (4)
r) Lack of knowledge on the part of health care workers 14% (4)
s) Lack of knowledge of the PMTCT programme on the part of patients 14% (4)
65

t) Poor training of health care workers 14% (4)
u) Lack of understanding of PMTCT guidelines and protocols 7% (2)
v) Negative attitude on the part of some nurses 7% (2)
w) Poor quality counselling 7% (2)

Table 4.13 above indicates the challenges and barriers that contribute to the failure
of the PMTCT programme. The table shows that 13 (46%) respondents had cited that
the failure of the PMTCT programme was as a result of a lack of proper programme
monitoring, fifteen (54%) indicated too many registers, seven (25%) a lack of team
work, four (14%) a lack of knowledge on the part of health care workers, four (14%) a
lack of enthusiasm and confidence in the PMTCT programme, six (21%) a lack of
commitment and motivation to carry out the work ,fourteen (50%) a lack of support
and supervision and under staffed personnel, 20 (71%) inadequate human and
physical resources while five (18%) had cited the fact that that antenatal clients did
not turn up for their appointments.

This study further indicated that 11 (39%) of the respondents felt that the failure of
the PMTCT programme was as a result of a lack of community involvement and
support, four (14%) a lack of knowledge of the PMTCT programme on the part of
patients, five (18%) a lack of training and skills transfer, four (14%) the poor training
of health care workers, two (7%) a lack of understanding of PMTCT guidelines and
protocols, eight (29%) cited fear and stigma attached to patient while seven (25%)
indicated that the failure of the programme may be as a result of a shortage of the
equipment and resources required to deliver PMTCT services.

In addition, six (21%) indicated that the lack of coordination and integration of
PMTCT with other programmes was a challenge that may also contribute to the
failure of the PMTCT programme, 12 (43%) respondents cited poor data quality and
management, six (21%) respondents indicated poor management of programmes, 18
(64%) cited traditional beliefs, 15 (54%) indicated long waiting times in queues for
consultations, two (7%) mentioned negative attitudes on the part of some of the
nurses while two (7%) only indicated that poor quality counselling may contribute to
the failure of the PMTCT programme.
66

SECTION E: AVAILABILITY OF MECHANISMS WITH WHICH TO MONITOR
PATIENTS

Table 4.14: Availability of systems to monitor PMTCT programme (N=28)

The above table (4.14) depicts the availability of mechanisms and systems in terms
of which to monitor and evaluate the PMTCT programme. The table shows that 23
(82%) respondents had reported that PMTCT records, such as E-tool, PMTCT, ANC
registers and patient files, were completed correctly and kept up to date, 23 (82%)
indicated that the PMTCT patient records were stored safely in such a way as to
guarantee confidentiality, 26 (93%) indicated that PMTCT DHIS routine
report/monthly statistics forms were correctly completed, nine (32%) clinics displayed
PMTCT data or information graphically, 27 clinics (96%) had unstandardised
registers to monitor HIV exposed infants and to ensure follow ups with HIV-positive,
antenatal clients which were developed in conjunction with the development partner.

The table also indicates that 25 (89%) respondents had indicated that the registers
for infant follow ups was up to date, 16 (57%) of the clinics received written referrals
from hospital for infants born to HIV positive mothers, 16 of the 28 clinics (57%)
indicated that ANC cards were provided with comprehensive information from the
referring clinics, and 16 (57%) of the clinics indicated that road to health cards were
provided with comprehensive information from the referring clinics.

Items n %
a) PMTCT DHIS routine report/ monthly statistics forms correctly completed 93% (26)
b) Register for HIV exposed Infant follow-up available 96% (27)
c) Register for infant follow-up is up-to-date 89% (25)
d) PMTCT patient records stored in a safe and confidential manner 82% (23)
e) PMTCT records (E-tool, PMTCT, ANC registers) are correctly completed and
kept up-to-date 82% (23)
f) PHC facility receive written referrals from hospital for infants born to HIV
positive mothers 57% (16)
g) ANC card provided with comprehensive information from referring clinics 57% (16)
h) Road to health card provided with comprehensive information from referring
clinics 57% (16)
i) PMTCT data or information displayed graphically 32% (9)
67

SECTION F: EVALUATE THE IMPLEMENTATION OF PMTCT INTERVENTIONS
DURING PREGNANCY AND AT POST DELIVERY
Table 4.15 below illustrates the implementation of PMTCT interventions during
pregnancy and delivery, as well as reflecting the frequency of missed opportunities
for PMTCT as estimated from the DHIS information on the 28 clinics for the period
January 2011 to December 2011.
Evaluating PMTCT interventions using 12 month DHIS data from January to
December 2011

Figure 4.6: PMTCT performance as against 2012 targets

The above figure 4.6 indicates that the rate of ANC clients booked less than 20
weeks at gestational age is 46% below the expected target of 60%. The rate of
antenatal clients CD4 first test was at 70% as against a target of 85%, while 55% of
antenatal clients are initiated onto AZT during ANC as opposed to a target of 90%.
The table also shows that 67% of antenatal clients were initiated onto HAART as
against an expected target of 95%, while the rate of antenatal client retest at 32
weeks was 43% with an expected target of 70%. The data show that the rate of baby
PCR testing positive at six weeks was 4% of which the expected target is less than
2% for the years 2012 to 2015.


68

Table 4.15: PMTCT stage one: antenatal clients bookings and testing
PMTCT interventions based on DHIS data for January to December 2011
Data elements
Estimated proportion (%) of
interventions for PMTCT that
were missed
% of
received
PMTCT
interventions
Number of
missed
PMTCT
interventions
% of missed
PMTCT
interventions
Antenatal 1st
visit before 20
weeks
2862/5348 (54%) of ANC eligible
for HIV 1
st
test were not tested
during their 1
st
visit before 20
weeks
46% 2 862 54%
Antenatal client
HIV 1st test
337/5349 (6%) of those ANC 1
st

visits were not tested for HIV
94% 337 6%
Antenatal client
CD4 1st test
556/1693 (33%) missed their 1st
CD4 test from those eligible at
SUM=ANC 1st test positive,
SUM= ANC retest at 32 weeks
positive, SUM=Antenatal client
known HIV positive but NOT on
HAART at 1st visit.
67% 556 33%
Antenatal client
HIV 1st test
positive
3896/4131(78%) of those tested
received HIV negative result
22% 3896 78%

The table above depicts a rate of approximately 46% antenatal first visits to Mafikeng
clinics before 20 weeks, of which 2862/5348 (54%) of ANC eligible for HIV first
testing were not tested during their first visit before 20 weeks. However, about 94%
antenatal clients did undergo their first HIV test while 337/5349 (6%) were not tested
for HIV at their first antenatal visit. The table also reveals that approximately 67%
antenatal clients were tested for their CD4 first, while 556/1693 (33%) of those
eligible total number of ANC first test positive missed their first CD4 test. The
data reveal that about 22% antenatal clients were tested HIV first test positive which,
in turn, implies that 3896/4131(78%) of those tested had tested HIV negative. The
69

performance target rate for antenatal visits before 20 weeks is 70% and the
antenatal client HIV first test rate is 95%. The sub-district antenatal client CD4 first
test rate performance was 80% at the time of review in June to December 2011.

Table 4.16: PMTCT phase two: antenatal clients retesting
Missed PMTCT interventions based on DHIS data for January to December 2011
Data elements
Estimated proportion (%)
of interventions for
PMTCT that were missed
% of
received
PMTCT
interventions
Number of
missed
PMTCT
interventions
% of missed
PMTCT
interventions
Antenatal client HIV
retest at 32 weeks or
later
2452/4131 (59%) missed
their HIV retest at 32
weeks
41% 2452 59%
Antenatal client HIV
retest positive at 32
weeks or later
1571 / 1678(94%) of
those retested at 32
weeks were HIV negative.
6% 1571 94%

Table 4.16 above shows that 41% only of antenatal client HIV were retested at 32
weeks or later which means that approximately 2452 of 4131 (59%) missed their HIV
retest at 32 weeks or later. Of those tested for HIV at 32 weeks or later,
approximately 6% of antenatal client HIV retested positive at 32 weeks or later while
about 1571/1678 (94%) of those retested at 32 weeks were HIV negative. The
performance target rate for the antenatal client HIV retest at 32 weeks is 100%.





Table 4.17: PMTCT phase three: antenatal clients initiated on dual therapy and
HAART
70

Missed PMTCT interventions based on DHIS data for January to December 2011
Data elements
Estimated proportion
(%) of interventions for
PMTCT that were
missed
% of received
PMTCT
interventions
Number of
missed PMTCT
interventions
% of missed
PMTCT
interventions
Antenatal clients
initiated on AZT
216/1116 (19%) missed
their AZT dose.
81% 216 19%
Antenatal client on
AZT before labour
632/1529 (41%) missed
their AZT before labour
59% 173 41%
Antenatal client on
HAART at delivery

76% 121 24%
121/499 (24%) of ANC
eligible for ART were
not initiated on HAART
at delivery


Antenatal client
eligible for HAART
617/1116 (55%) of
those tested had an
HIV-positive result and
were not eligible for
HAART
45% 617 55%
Antenatal client
initiated on HAART
137/499 (27%) of
those eligible for
HAART were not
initiated on HAART
73% 137 27%
Antenatal client
Nevirapine taken
during labour
459/1529 (30%) live
births to HIV positive
women and not given
Nevirapine during
labour
70% 459 30%

Table 4.17 above illustrates that 81% of antenatal clients was initiated on AZT while
approximately 216 of 1116 (19%) missed their AZT dose. The sub-district
performance for antenatal client on AZT before labour is 59% which means that
approximately 632 of 1529 (41%) missed their AZT before labour. On the other hand,
antenatal client on HAART at delivery was 76% which means that about 121 of 499
(24%) of ANC who were eligible for ART were not initiated on HAART at delivery.
71

Approximately 45% antenatal clients were eligible for HAART while about 617/1116
(55%) of those tested HIV positive were not eligible for HAART.

Table 4.17 further illustrates that 73% of antenatal clients were initiated on HAART,
although approximately 137/499 (27%) of those eligible for HAART were not initiated
on HAART. The performance for the antenatal client Nevirapine taken during labour
was 70% although the data also shows that about 459 of 1529 (30%) live births to
HIV positive women were not given Nevirapine during labour.

Table 4.18: PMTCT Phase four: Postnatal care
Missed PMTCT interventions based on DHIS data for January to December 2011
Data elements
Estimated proportion (%) of
interventions for PMTCT that
were missed
% of received
PMTCT
interventions
Number of
missed
PMTCT
interventions
% of missed
PMTCT
interventions
Baby given
Nevirapine within
72 hours after
birth
33/1529 (2%) Live birth to
HIV positive women not given
Nevirapine within 74 hours
after birth
98% 33 2%
Baby PCR test at
about 6 weeks
An estimated 412/1529 (27%)
of eligible infants were not
tested for PCR
73% 412 27%
Baby initiated on
Co-Trimoxazole
at about 6 weeks
660/1529 (43%) of infants
born to HIV positive women
were not initiated on
Cotrimoxazole at about 6
weeks
57% 660 43%
Baby PCR test
positive at about
6 weeks
1071/1117(96%) of infants
born to HIV positive women
and tested for PCR at 6
weeks were HIV negative.
4% 1071 96%
Baby HIV
antibody test at
18 months
An estimated 881/1116 (79%)
of eligible infants were not
tested for HIV
21% 881 79%
72

Baby HIV
antibody test
positive at 18
months
229/235(97%) of babies born
to HIV-positive women and
tested for antibody test at 18
month were HIV negative
3% 229 97%

The above table (4.18) illustrates the performance of the sub-district as regards
babies receiving PMTCT interventions. The sub-district is clearly performing
extremely well as approximately 98% of babies were given Nevirapine within 72
hours after birth. However, 33 of 1529 (2%) live births to HIV-positive women were
not given Nevirapine within 74 hours after birth. Approximately 73% of babies were
tested for PCR at about six weeks, while the data show that about 412/1529 (27%) of
eligible infants were not tested for PCR at about six weeks. However, approximately
57% of babies were initiated on Co-Trimoxazole at about six weeks while the data
from the above table shows, in turn, that 660/1529 (43%) of infants born to HIV-
positive women were not initiated on Co-Trimoxazole at about six weeks.
Approximately 4% babies PCRs tested positive at about six weeks, while 96%
(1071/1117) of the infants had been born to HIV-positive women and tested for PCR
at six weeks were HIV negative. Approximately 21% of babies underwent an HIV
antibody test at 18 months which means that an estimated 881/1116 (79%) of eligible
infants were not tested for HIV. Of the 21% of babies who were tested for HIV
approximately 3% were reported to be HIV positive. The table above also shows that
229/235 (97%) of the babies tested for antibody test at 18 months tested HIV
negative.

73


Figure 4.7: PMTCT Interventions at 6 month intervals Source: DHIS


Figure 4.8: PMTCT Interventions at 6 month intervals Source: DHIS

Figure 4.7 and 4.8 Mafikeng Sub-District PMTCT implementation process at 3 to 6
month intervals

Figure 4.7 and 4.8 above illustrates the performance of the sub-district at 6 months
intervals. The baseline depicts the PMTCT during the introduction of dual therapy,
that included AZT, and which was implemented in accordance with the August 2008
PMTCT guideline. The figure above also shows the monitoring of the PMTCT
guideline from January to June 2009. The figure also shows when the Department of
Health phased out triple therapy from July to December 2009 while, from January to
June 2010, it shows the implementation of truvada in the guideline. From January to
74

June 2011 it shows the continuous monitoring of PMTCT to check whether truvada is
effective while, from July to December 2011, the figure shows the review of PMTC to
check the progress and to ascertain the impact after the NSP 2007 to 2011 which
had come to an end by 2011.

During the baseline period in 2008, the figure shows an 80% performance for NVP
given to pregnant women during labour. This increased to 82% between January and
June 2009 and remained at 75% from July 2009 to December 2010. In 2011, during
the review period, the NVP given to ANC was at a level of 85%.

AZT was first implemented in 2009 during the phasing out of triple therapy. The data
shows that, during this period, AZT was at 60%. However, the data shows that AZT
then went up to 125%, although this may be the result of poor reporting. From
January to June 2010 AZT was at 69% and, from January to June 2011, it was at
67% while, from July to December 2011, AZT was performing at 50%.

The figure shows that, at baseline from June to December 2008, the NVP issued to
babies was 101%, from January 2009 to June 2009 it was 91%, from July to
December 2009 101%, from January to June 2010 100%, from January to June
2011, it was 93% and, from July to December 2011, it was 103%.

In addition, the figure shows that baby PCR at six weeks was at 65% at baseline from
June to December 2008 while baby PCR testing at six weeks was still at 65%
between January and June 2009.From July to December 2009 baby PCR at six
weeks was at 51% and from January to June 2010 it was 69%. The performance rate
for PCR testing was 75% from January to June 2011 while the RCR testing rate
dropped to 66% between January and June 2011. However, from July to December
2011 the performance rate for PCR testing was 81%.

The baby PCR positivity rate at six weeks was 9% at baseline June to December
2008 while from January to June 2009 the PCR positivity rate was at 26% and from
July to December 2009 it was at 6%. From January to June 2010 the PCR positivity
rate was at 5%, from January to June 2011 it was at 3%, from January to June 2011
75

it was at 7% while from July to December 2011, during the review, the PCR positivity
rate dropped to 1%.


Figure 4.9: Performance of PMTCT maternal health indicators

Figure 4.9 above shows the performance of the sub-district as regards PMTCT
maternal health indicators, comparing all quarters. The figure shows that, when
comparing both quarters, ANC retested at 32 weeks was still below 50% while
antenatal clients first visit before 20 weeks was also performing at less than 50%. As
observed with ANC first test rate, which was performing at more than 100%, data
quality remains a challenge. The ANC client initiated on AZT rate was at 43% during
the fourth quarter 2011 while the ANC client initiated on HAART rate was 54% during
the fourth quarter 2011. The antenatal CD4 first test rate was at 57% during the first
quarter in 2010 and 64% during the fourth

quarter in 2011. Antenatal issued
Nevirapine was at performing at 75% during the first quarter 2010, 80% during the
third quarter 2011 while it was at 87% during the fourth quarter 2011.
76



Figure 4.10: Baby PCR positivity rate for Mafikeng Sub-District

Figure 4.10 shows the performance of the sub-district as regards testing HIV
exposed babies for PCR. The figure shows PCR testing above the expected need,
which is the annual 12 month average ANC HIV positive. The sub-district was
performing at a PCR positivity rate of 1% in September 2011.An outstanding
performance in terms of PCR testing is noted in August and September 2011 when
comparing exposed babies by using average ANC positive. There was a steady
increase of 15% in the PCR positivity rate between March and May 2011 while, it has
dropped to 1% a significant improvement.


77


Figure 4.11: PMTCT Child Health Indicators

The sub-district performed well when all the quarters are compared. The PCR
positivity rate was 2%, which meant that the NSP 2007 to 2011expected target of 5%
was being met. This, in turn, is indicative of good performance. The PCR uptake of
101% and the Nevirapine uptake of 103% appear to be good, although there were
challenges as regards data quality, especially during the third quarter of 2011. In
addition, in terms of issuing Cotrimoxazole, the sub-district performed well at 81%
during the fourth quarter, although performance as regards the issuing of
Cotrimoxazole was still not satisfactory when compared with that of the previous
quarters. The above graph indicates that the PCR positivity rate was at 2% during the
fourth

quarter 2011 although it had been 8% during the third

quarter.



Figure 4.12: PCR Positivity rate Source: DHIS and NHLS data

Figure 4.12: Mafikeng Sub-District Baby PCR positivity rate using NHLS data

Figure 4.12 above illustrates the PCR testing positivity rate for the 14-month period
from April 2010 until May 2011. The NHLS data for babies below two months is
compared with the NSP 2007 to 2011 target of 5%. This result is then measured
against all PCR testing carried out during the same period. From October 2010 to
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May 2011 the PCR positivity rate in the sub-district was below the expected NSP
target performing at 2% in March and had increased to 4% by May 2011. Both the
DHIS and the NHLS data show that the PCR positivity rate was at 4% over the 14
month period. The DHIS data shows that baby antibody testing at 18 months for the
12-month period from October 2010 to May 2011 for the sub-district was at 2%.

Figure 4.13: Number of HIV positive antenatals who received the dual therapy

Figure 4.13 above depicts the performance of HIV-positive ANCs receiving dual
therapy at 28 weeks. The figure shows that the sub-district was, indeed, faring very
well in terms of issuing NVP. The figure also shows that most of the HIV-positive
women were initiated on NVP. Nevertheless, more work is still needed in terms of
issuing AZT as the graph shows that not all women are receiving AZT. This
performance drops further between the months of April and December 2011.

79



Figure 4.14: Number of babies tested for HIV antibody at 18 months

Figure 4.14 above depicts the gap in terms of identifying children for antibody testing.
This, in turn, shows that not all children who tested negative for PCR at six weeks
returned for their antibody testing at 18 months.


Figure 4.15: Antenatal clients initiated on HAART

The figure above (Fig. 4.15) depicts the performance of the sub-district in terms of
fast tracking pregnant women on HAART. On average, from January to December
2011, the sub-district performed at 74%. However, in January 2011 the performance
was at 57%, although there was a significant improvement up to 100% in February
80

2011. However, in mid June 2011 the performance experienced a significant drop to
49% but went up by 77% in August 2011. Since October 2011 there has been a
significance improvement in terms of ANCs initiated on HAART as the rate went up to
81%, although it had dropped by 1% in November to remain at 80%. In December
2011 the performance for antenatals initiated on HAART had dropped to 1% and
then remained at 79%.

Figure 4.16: Antenatal clients initiated on AZT and NVP dual therapy

Figure 4.16 above illustrates the performance of HIV positive ANCs receiving dual
therapy at 28 weeks. The figure shows that the sub-district is, indeed, doing
extremely well in terms of NVP issuing with most of the women being given NVP.
However, more work does still need to be done in terms of issuing AZT as the graph
shows that not all the women were receiving AZT. The performance dropped further
from April up until December 2011.

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Figure 4.17: Number of babies in Mafikeng receiving PMTCT interventions at six
weeks

The graph above illustrates that, despite the fact that the sub-district is showing an
improvement in that it is managing to carry out PCR tests for the majority of exposed
babies, a minority of the babies who have been exposed to live births to HIV positive
mothers are still being missed out. According to the graph above 57% of babies who
are HIV exposed received Cotrimoxazole at six weeks from the period January 2011
to December 2011. However, the main challenge involves poor record keeping and
poor recording after issuing of Cotrimoxazole at facility level, as some of the clinics
do not appear to have the register where they record the uptake of Cotrimoxazole.
According to the graph above, 99% of babies who are HIV exposed received
Nevirapine at six weeks from the period January 2011 to December 2011.

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Figure 4.18: ANC first visit v/s first test

The figure above (Fig. 4.18) also illustrates that, in terms of HIV first testing, the sub-
district is faring extremely well. Despite the fact that the testing rate did fluctuate in
most months 100% of the women who booked were tested for HIV. Figure 4.18
illustrates the sub-districts performance as regards ANC first bookings before 20
weeks of gestation and HIV testing from January to December 2011. It is important
that ANC clients book early for ANC so that they may be tested for HIV early so as to
make a decision as whether the woman qualifies either for dual therapy or for HAART
early in her pregnancy in order to reduce the possibility of MTCT.



Figure 4.19: Number ANC retesting at 32 weeks
83


Figure 4.19 also illustrates that, in terms of HIV testing at 32 weeks, the sub-district is
not performing well as there is a significant gap between those who tested negative
at their first tests and those retested at 32 weeks. It is important that ANC clients be
retested at 32 weeks so that, if necessary, they may be issued with NVP before
labour and fast tracked onto HAART. This is also depicted in Figure 4.20 below in the
percentage performance at 32 weeks.



Figure 4.20: ANC retest rate at 32 weeks

The figure above also illustrates that, as regards HIV testing at 32 weeks, the sub-
district is not performing well as there is a significant gap between those who tested
negative at their first tests and those retested at 32 weeks. The sub-district
performance was still poor between January and December 2011 as the performance
remained below the 44% annual average. However, the 62% in December signified a
steady improvement. This improvement may be as a result of the ANC register which
was introduced earlier that year with health care workers endeavouring to fill the
register in correctly and keep it up to date.




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CHAPTER FIVE: DISCUSSION OF FINDINGS
5.1 INTRODUCTION
The main objective of this study was to evaluate the implementation of the prevention
of mother to child transmission (PMTCT) interventions during pregnancy and post-
delivery in Mafikeng clinics in the Mafikeng Sub-District in the North West Province,
South Africa. The study showed consistent findings from the questionnaires
administered to health workers from 28 clinics in the Mafikeng Sub-District. The study
also reflected data from the DHIS and NHLS from July 2008 to December 2011 with
the aim of presenting and reviewing the performance of the PMTCT programme in
the Mafikeng Sub-District.
The specific objectives of the study were to assess the availability of the resources,
infrastructure and equipment required to implement PMTCT services; to assess the
availability of PMTCT related services; to evaluate the implementation of PMTCT
interventions during pregnancy and post-delivery ; to assess the training received
and the knowledge of health care workers regarding the implementation of PMTCT
services; to describe the challenges faced by health care workers with regard to the
implementation of the PMTCT programme and to evaluate the PMTCT programme
intervention data elements in order to ascertain which patients had missed the
PMTCT interventions both during pregnancy and at post-delivery.
5.1.1 Biographical information of respondents.
The demographic patterns of the respondents in this study are typical of Department
of Health employees. In this study the majority of the respondents were women.

5.1.2 Resources, infrastructure and equipment available to implement PMTCT
services

There are 28 clinics which are implementing PMTCT services in the Mafikeng Sub-
District. However, of these 28 clinics, four (14%) only are community health centres
(CHC). There are five (18%) clinics only in the sub-district which offer deliveries to
antenatal clients (ANC) although other clinics do carry out deliveries in emergencies.
The fact that, of the 28 clinics, five (18%) only operate for 24 hours a day may result
85

in ANCs either delivering at home or on the way to the clinic. This, in turn, may mean
that HIV is transmitted from mother to child if NVP is not taken. The study also
revealed that there are still antenatal patients who still prefer home deliveries as 1
(4%) respondent indicated that most antenatal patients prefer to deliver at home as a
result of cultural beliefs. However, it is essential that women who are HIV positive be
encouraged to give birth at a clinic to avoid the transmission of HIV from mother to
child.

Karcher (2006) indicated that, if PMTCT programmes are to attain high coverage, the
programmes must also reach those women who deliver at home. This may be
achieved by giving a Nevirapine pill to each HIV positive woman in advance, perhaps
even at the time of the HIV diagnosis. This pill may then be kept at home and taken
at the onset of labour.

Despite the fact that the sub-district has managed to scale up access to the PMTCT
programme by ensuring that all clinics provide PMTCT services, there is still a
shortage of the infrastructure required to provide these services as only a few clinics
carry out antenatal deliveries. However, all the clinics have been able to allocate one
to three nurses per day to manage the PMTCT programme. One of the strategic
directions of the World Health Organisation 2010 to 2015 as regards scaling up the
quality and effectiveness of PMTCT services is the promotion and support of health
system interventions in order to improve the delivery of HIV prevention, care and
treatment services to both women and children.

A similar study to this conducted by Rispel, Peltzer, Phaswana-Mafuya, Metcalf, and
Treger (2009) in the Eastern Cape in South Africa indicated a higher number of
clinics providing antenatal care (ANC) services five days per week with a few clinics
only providing ANC for one day per week. This study further revealed high levels of
awareness of HIV policies on the part of staff members, while most staff members
had received at least some relevant training.

Although this study revealed that are several challenges as regards the
implementation of the PMTCT programme, there are, nevertheless, several
programme strengths, including the existing health care clinic infrastructures in
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villages, trained nurses with high levels of awareness of national policies, and a large
number of lay health counsellors. Mandal, Purdin & McGinn (2006) reported that poor
infrastructure has meant that specialised projects, such as HIV/AIDS programmes,
have not achieved their targets.

The findings from this study revealed that, of the 28 of Mafikeng clinics, 23 (82%)
only were providing infant formula feeding; this is after when the sub-district manager
indicated that infant formula should no longer be ordered. The intention was to
provide ANCs with infant formula feeding up to certain period until such a time that
the mothers were able to provide for their children or until when children seize
feeding in accordance to the 2010 PMTCT guidelines. However the infant formula
feeding choice was discontinued by the sub-district although a few clinics continued
to providing the infant formula feeding as they had still had remaining stocks.
However, there was very little information provided as to what would happen to those
mothers who were already using bottle feeding in order to avoid mixed feeding.

The study also revealed that, at the time of the study, all ANC patients were being
advised to use breast feeding although this may have complicated matters for those
who were already using formula feeding. A study undertaken by Stephen, Bamford,
Patrick, and Wittenberg (2009) indicated that there is a strong association between
severe malnutrition and HIV infection. The study further revealed that almost half
(40.2%) of the children under 5 years who had died had been severely malnourished
and had been co-infected with HIV. The major concern from the respondents was
that Department of Health should continue to provide nutritional supplements only to
those mothers who are experiencing problems with breast feeding as well as to those
mothers who have already started breast feeding in order to avoid complication
during post natal care.

According to the findings of this study all 28 of the clinics in Mafikeng provide
antenatal cards to their antenatal clients to take home. These cards, in turn, help
when the women go into labour as they inform other health care workers of the
patients histories before delivery. This, in turn, enables the health care workers to
issue prescriptions to prevent the transmission of HIV from mother to child if the
87

patient is HIV positive. In addition, the antenatal clients are able to use the cards
when they visit the clinics of their choice during pregnancy.

The findings of this study also revealed that seven (25%) of the clinics had indicated
that they did not have adequate space available for ANC consultations which would
guarantee privacy while 12 (43%) clinics did have had adequate sufficient for
antenatal consultations. It is, thus, evident that more needs to be done to provide
sufficient rooms for antenatal clients as this would offer privacy and confidentiality
during the process of testing and counselling antenatal patients. This study did reveal
a significant number of clinics in Mafikeng do have counselling rooms which offer
privacy but much needs to be done to ensure that all clinics are able to offer privacy
during consultations. In addition, there is still a shortage of separate, designated VCT
rooms for counsellors in the facilities with the study revealing that some clinics are
using storage rooms and small kitchens as counselling rooms.

According to Phaswana-Mafuya and Kayongo (2008), one of the barriers to the
effective implementation of the PMTCT programme is the lack of space for consulting
and counselling while research conducted by Doherty, Besser, Donohue, Kamoga,
Stoops, Williamson and Visser, (2003) into the PMTCT pilot sites found that barriers
to the implementation of the PMTCT programme included a lack of space for the
counselling of patients. Other studies have also shown that inadequate space for
confidential counselling and private disclosure inhibits the uptake of PMTCT services
(Skinner, Mfecane, Henda, Dorkenoo, Davids, Gumede, and Shisana, 2003; World
Health Organisation, 2007a).

Doherty, McCoy and Donahue (2005) found that a lack of privacy in delivery rooms
may prevent women from disclosing their HIV status when so asked by a health care
worker. In addition, a lack of space will impact on both the privacy of a counselling
session and the quality of counselling offered in terms of the PMTCT programme
(Skinner et al., 2003). A study undertaken by Moth, Ayayo, and Kaseje (2005)
reported that privacy and confidentiality were inadequate in counselling rooms. It was
further reported that there is interruptions by other care providers during counselling
sessions. These findings are similar to those of the study conducted by Raburu
(2004) where 92% of respondents had reported a lack of privacy in counselling
88

rooms, as evidenced by the presence of more than 2 people in the room. This
violates the clients right to confidentiality during counselling in that counselling
information should remain between the counsellors and patients only.

This study reveals that few clinics of the clinics are providing nutritional support to
HIV positive women who are breast feeding. However, most of the clinics in Mafikeng
do have sufficient staff to carry out the HIV testing and counselling. Nevertheless, the
study reveals that few clinics are providing PMTCT information, such as booklets,
during ANC consultations.

A study undertaken by Moth et al (2005) indicated that approximately half of the ANC
clients (52.4%) had received their first PMTCT information at a health facility. This, in
turn, indicates that community mobilisation is still inadequate as regards the
communication of PMTCT information. Similarly, one of the recommendations of a
study conducted in Durban, South Africa, was that there be community involvement
to ensure that the community and households accept the fact when a woman
chooses not to breastfeed her child (Chopra, Piwoz, Sengwana, Schaay, Dunnett, &
Saders, 2002).

A study undertaken by Doherty, Besser and Donohue (2003) indicates that, in
addition to human resource support for counselling, the physical infrastructure of
facilities also impacts on the ability to provide individual, confidential counselling. In
addition, the study also found significant differences between facilities with regard to
the physical space available in which to perform counselling. In some instances
rooms were found to have a dual purpose, serving as both storerooms and
counselling rooms. However, this resulted in frequent interruptions during counselling
sessions.

5.1.3. Guidelines and policies available within the clinic
It emerged from this study that 96% of the nurses who had participated were aware
of the National ART guidelines although most of the nurses (86%) not aware whether
the National PMTCT guidelines were available in their clinics. Nevertheless, most of
the PMTCT relevant guidelines were available in most of the clinics. However,
policies such as the National Strategic Plan of HIV and AIDS 2007 to 2011 and
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confidentiality policy were not available in most of the clinics. Most of the clinics
(93%) did indicate that all the guidelines and policies were kept in a place that was
easily accessible while 96% of the clinics indicated that staff members were able to
use and implement all the available guidelines. It must be further emphasised that
health care workers should familiarise themselves with such guidelines and policies
in order to acquire the knowledge necessary to provide PMTCT interventions.
The results of this study are similar to the results of a study undertaken by Rispel et
al (2009) which indicated that the respondents were aware of the guidelines and that
the guidelines on PMTCT, VCT, sexually transmitted infections (STI), management
and family planning for HIV-positive women were available at more than 80% of
clinics. In addition, guidelines for infant feeding counselling, the integrated
management of childhood illnesses and baby-friendly facilities were available at most
clinics although half of the clinics only had a written policy in place on confidentiality.
This is to confirm that access to policy and guidelines is provided at facility level.

5.1.4. Availability of related PMTCT supplies in the clinics
In this study most of the clinics had sufficient supplies of critical items, including NVP
tablets, NVP syrup (93%), and dried blood spot test kits (86%) while condoms for
both males and females were always available at all clinics. The study also showed
that more than 80% of the clinics never ran out of ARV prophylaxis and HIV rapid test
kits although there were clinics where it took a month for them to receive supplies.

A study conducted by Doherty, Chopra, Duduzile, Nsibande and Mngoma (2009) at
Amajuba in KwaZulu-Natal, South Africa showed good management of drugs and
supplies with one clinic only being found to be out of stock of rapid HIV test kits while
one facility did not have any Nevirapine tablets. The study conducted by Nuwagaba-
Biribonwoha, Mayon-White, Okong and Carpenter (2007) reveals it would appear
that, generally, antiretroviral drugs for PMTCT were readily available although there
was an incident reported when the drugs had expired. Their study also revealed
similar findings to this study as regards a shortage of space for counselling with
privacy and confidentiality sometimes being compromised.

90

The findings of this study differed from those of a study conducted by Tayla and
Colton (2005) in Kenya which showed that several facilities were running out of
stocks of HIV testing kits and Nevirapine tablets and syrup. However, there were
similarities in the findings of the two studies as regards the lack of physical space for
PMTCT counselling and testing in several facilities, thus delaying initiation of PMTCT
services as the necessary renovations were carried out.

This study revealed that the most of the respondents 12 (43%) had indicated that it
took between four to six weeks for their clinics to receive their PCR test results. This,
in turn, may mean that it would take them too long to identify HIV positive babies.
However, all 28 (100%) clinics reported receiving their Rapid HIV test results on the
same day. A study conducted by Janse van Rensburg-Bonthuyzen, Engelbrecht,
Steyn, Jacobs, Schneider, and Van Rensburg (2008) in South Africa revealed that
there had been an improvement in drug supplies and the availability of equipment
and laboratory systems which, although good at the baseline, had improved further
over the period of observation. This indicates that pregnant women may be identified
early to be initiated on PMTCT or fast-tracked on HAART.

Most of the clinics in this study were no longer carrying out the ELISA test although
they did test if the results for the confirmatory test were not satisfactory. However, the
majority of the respondents (71%) indicated that it used to take less than one week to
receive the ELISA test results which shows that it is possible for pregnant women to
receive their results immediately after their HIV first test. This study shows that 93%
of the clinics received their CD4 results in less than 1 week. Accordingly, there needs
to be further efforts made to improve the turnaround time of the CD4 and polymerase
chain reaction (PCR) test results. In addition, in order to fast track those patients who
are HIV positive as regards treatment there is a need to fast track the delivery of
NHLS HIV test results.

The South African PMTCT policy states that a CD4 cell count should be taken on the
same day that the HIV positive status is established and, preferably, at the first ANC
visit. Accordingly, all clinics should be drawing blood for the CD4 test. The median
91

turnaround time for CD4 results was one week, ranging from one to five weeks. This
is better than the nationally recommended turnaround time of two weeks. All of the
clinics in the study, except one, provided infant PCR testing while the median
turnaround time for PCR results was six weeks, and ranging between one and 24
weeks (Doherty, Chopra, Duduzile, Nsibande & Mngoma, 2009).

The National PMTCT Guidelines for 2010 state that all facilities should have the
capacity to collect dried blood spots for the PCR testing of infants. There is no South
African norm for the turnaround time of these results although WHO recommends a
turnaround time from collection of sample to return of results of no more than four
weeks (Doherty.,et al 2009). A study conducted by Rispel et al. (2009) in the Eastern
Cape, South Africa, indicated that HIV test results were available on the day of
testing at all clinics, except where discordant rapid test results required laboratory
confirmation.

The World Health Organisation (2010) indicated that a lack of essential supplies was
continuing to hinder PMTCT service delivery in several countries. For example, in
2008 there were no CD4 machines in the grantsupported sites in Zimbabwe, thus
making it extremely difficult to assess women for ART eligibility.

A study conducted by Rispel et al. (2009) found that HIV test results were available
on the day of testing at all clinics, except where discordant rapid test results required
laboratory confirmation. In accordance with what was reported through the process
evaluation of the CCMT in 2007 (South Africa Department of Health, 2009) it would
appear that drug procurement and distribution had improved dramatically through the
awarding of the national tender for the supply of ARVs. This study revealed that a
significant number of the respondents had indicated that they were provided with
their medication at all times with no stock-outs.

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5.1.5. Availability of PMTCT-related services
This study found that most of the clinics met the national PMTCT criteria as they
were offering comprehensive services to their antenatal clients. The study also
showed that the majority of the clinics (85%) were accredited to provide antiretroviral
treatment to HIV positive patents, including pregnant women. while 3 of the clinics
only were not accredited. These 3 clinics included two clinics which were hospital
gateways which were not qualified to be accredited to initiate patients on HAART as
they were next to hospitals. In general, the 5 delivery facilities complied with the
PMTCT delivery site criteria, including the provision of antenatal consultations,
PMTCT services, family planning for pregnant women, Voluntary Counselling and
Testing Services (VCT), TB treatment and screening for pregnant women,
immunisations for infants, exposed infant follow up, PCR testing for infants, postnatal
follow up of mother and infant as well as HIV counselling both before and after
delivery.

Universal access to PMTCT services depends on the capacity of both national and
local health systems to deliver these services while weaknesses in human resource
capacity, supply chain, programme management, health financing and information
systems have hampered the scale up of these services (World Health Organisation,
2010). This is further confirmed by the NSP 2007 to 2011 which aims to increase the
proportion of public sector antenatal services providing PMTCT by 85% in 2007, 95%
in 2008, and 100% from 2009 to 2011 and to increase the proportion of the estimated
population of HIV infected pregnant women receiving PMTCT services to 70% in
2007, 85% in 2008, 90% in 2009 and 95% in 2009 to 2011.

5.1.6. Availability of support services to provide PMTCT interventions

The results of this study show that the PMTCT/ maternal health and child coordinator
(MCWH) and also programme coordinators from the sub-district, district and province
had carried out few visits in the four months preceding the study. However, if more
support were provided by programme coordinators they would be able to provide
support and mentorship to nurses regarding PMTCT interventions. Programme
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coordinators should, thus, be able to conduct clinic visits at least once a month.
However, it would appear that more support is provided by the sub-district
supervisors. The study also revealed that a few (29%) clinics only were conducting
antenatal deliveries. In addition, there needs to be greater effort made to provide
PMTCT promotion through community outreach programmes as 82% of the clinics
only were able to provide PMTCT health promotion though community outreach.
However, the study showed that there was more support from the development
partners as almost all of the clinics (89%) had indicated they were receiving support
from development partners (NGOs) through mentorship aimed at improving the
PMTCT programme.

According to the World Health Organisation (2010) grant funds were being used in a
number of countries to support community mobilisation activities designed to
increase the awareness of the availability and benefits of PMTCT services. According
to Tayla and Colton (2005), community leaders were providing invaluable guidance
on social, political, and cultural matters that affected the acceptance of the PMTCT
services. It is, thus, crucial that these leaders have a basic working knowledge of
PMTCT to enable them to promote the services effectively. Tayla and Colton (2005)
further indicated that it is essential that the PMTCT services be extended to the
community level in order to decrease stigma, increase demand, involve families and
partners in decision-making and ensure the follow up of facility services. Support
groups are key elements of the PMTCT services while on-going care and support
and community involvement increase HIV prevention.

A study conducted by Doherty et al. (2009) in the Amajuba District in KwaZulu-Natal
province in South Africa revealed that the supervision systems were found to be
poor. There were similar results in this study which showed that 7% only of facilities
had been visited by the district MCH supervisor and 33% only had been visited by the
district PMTCT supervisor in a period of six months. In the same study supervision on
the part of the PHC clinic supervisors was reported to be better with a median of
three visits per clinic within six months. However, these statistics fall far short of the
national norm of one visit per month to each facility.

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Torpey, Kabaso, Kasonde, Dirks, Bweupe, Thompson and Mukadi (2010) indicate
that the uptake of PMTCT services in resource limited settings may be improved by
utilising innovative alternatives to mitigate the effects of human resource shortage, for
example, by providing technical assistance and mentorship beyond regular training
courses, integrating PMTCT services into existing maternal and child health
structures, addressing information gaps, mobilising traditional and opinion leaders
and building strong relationships with the government. These health system based
approaches would provide a sustainable improvement in the capacity and uptake of
the PMTCT services.

5.1.7. Knowledge and training of health care workers as regards the
implementation of PMTCT interventions.

The results from this study reveal that almost 86% of the respondents had received
training on PMTCT interventions while 93% had received training on HIV testing and
PMTCT counselling. The training received had also included infant feeding in the
context of HIV infection. This indicates that health care workers are clearly sufficiently
informed to provide PMTCT interventions for both mothers and children. In addition,
the results of this study indicated that 96% of the respondents were able to provide
infant feeding counselling while all the respondents were providing guidance to
antenatal patients regarding the volume and frequency of infants feeding.

The fact that most of the staff members were confident in terms of PMTCT testing
and counselling may be due to the training they had received. However, additional
training is needed to cover the stigma and discrimination related to MTCT as 75% of
the respondents only had received training on this aspect. However, this would help
health care workers to improve the uptake of HIV testing among antenatal clients.
The study also revealed that there is a need for ongoing training and mentorships as
64% only of the respondents had indicated that the training they had received had
been adequate. In addition, skills transfer should be encouraged at all clinics as 89%
only of the respondents had indicated that they had been given the opportunity to
transfer the skills and knowledge they had acquired through other training they had
attended.

95

The majority of the respondents (93%) were trained on ART while 93% were trained
on PMTCT guidelines. This, in turn, indicates that health care workers are informed
about the implementation of PMTCT interventions. The study also revealed that
health care workers (96%) were able to transfer their skills and knowledge through
training. The study further revealed that all the respondents (100%) were able to
apply the skills and knowledge they had acquired through training. This, in turn,
indicates that health care workers are able to able to mentor other nurses in their
clinics after training. The study also confirmed that most clinics (89%) were able to
use guidelines during in service training. In addition, the study revealed some
improvement as 26 (93%) of the respondents were able to apply the transferred
knowledge and skills learned during in service training and orientation. However,
further mentorship is required to ensure that all health care workers are able to apply
the skills learned during in service training and through mentorship.
The World Health Organisation (2010) indicated that, in most African countries,
human resource capacity is a major challenge affecting health service delivery,
including PMTCT services. A study conducted by Rispel et al. (2009) indicated that
formal training records were not available and that it was not possible to verify the
extent of health worker training in PMTCT service provision.
Research conducted by Tint, Doherty, Nkonki, Witten & Chopra (2003) in South
Africa shows that staff shortages also impacted on the ability of the participants to
attend training courses. The study further indicated that post training knowledge of
the PMTCT protocol and Nevirapine administration was generally good amongst both
trainers and participants. However, the study indicated that knowledge of infant
feeding risks was poor. The study also showed a low level of knowledge assessment
(Tint, Doherty, Nkonki, Witten & Chopra, 2003). The study confirmed that levels of
confidence in counselling HIV infected women were generally high while it further
revealed that levels of confidence were lower with regard to counselling on the
cessation of breastfeeding and breastfeeding difficulties. A key finding of the study
indicated that very few of the participants and trainers had received post training
support/ follow up while 81% of the trainers and 67% of the participants had
expressed the need for ongoing supervision and mentorship (Tint,. et al 2003).

96

Similar results reveal that the respondents felt comfortable counselling HIV-infected
women on infant feeding while the interviewees also indicated that they felt that they
possessed the skills required to assist mothers. However, the results from this study
differ as this study shows that there were no sessions held that were intended
specifically for infant feeding counselling (Tint et al 2003).

This study showed that the majority of the respondents had rated their clinics as good
with regard to the implementation of PMTCT guidelines within the clinics. The
majority of the clinics also showed improved knowledge on PMTCT related trainings
as the majority of the respondents had rated the PMTCT training which they had
received as good. The results of this study further indicated that the majority of the
respondents had rated the PMTCT services which they were rendering as either
good or excellent. The results from this study also indicated that the Voluntary
Counselling and Testing (VCT) service for antenatal clients was excellent as was the
PCR testing for children at six weeks. However, the majority of the respondents rated
the antibody testing at 18 month as fair while the study also revealed that there was
not sufficient monitoring of the PMTCT programme. This result has, however, not
previously been published by other researchers.

5.1.8. Challenges faced by health care workers when implementing PMTCT
intervention

This study reveals the challenges and barriers that contribute to the possible failure
of the PMTCT programme. It is clear that considerable effort is needed as regards
monitoring the PMTCT programme as almost half of the respondents had indicated
that they believed that a lack of proper monitoring may be regarded as contributing to
the failure of the PMTCT programme. In addition, much effort should also be made to
standardise and minimise large number of unstandardised registers which are used
to record and monitor the PMTCT programme. The study also identified a lack of
team work as one of the challenges involved in the failure of the PMTCT programme.
It emerged that a few health care workers (14%) only lack knowledge of the PMTCT
programme and, thus, the the majority of health care professional have been trained
on PMTCT. The study results also highlighted a lack of enthusiasm and confidence
and a lack of commitment and motivation to carry out the work involved as a
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challenge as regards the implementation of the PMTCT programme. It also emerged
that half of the respondents (50%) felt that lack of support and supervision, including
under staffed personnel, may contribute to failure of the PMTCT programme
implementation.

The results of this study showed that most the human resources and physical
infrastructures in the clinics (71%) were inadequate with this issue being identified as
a major factor in the failure of the PMTCT programme. The study results further
confirms that ANC patients were not turning up for their antenatal booking
appointments and follow up. The study also revealed that there is still a need to
encourage community involvement and support with 39% of respondents highlighting
this as a challenge in terms of the PMTCT programme. Some of the respondents
(14%) expressed the view that a lack of knowledge of PMTCT on the part of patients
also contributed to the failure of the PMTCT implementation. The study also
highlighted challenges and barriers such as a lack of training and skills transfer, poor
training of health care workers, a lack of understating of PMTCT guidelines and
protocols, fear and stigma attached to the patient, a shortage of the equipment, and
resources required to deliver the PMTCT services, a lack of coordination and
integration of the PMTCT programme with other programmes, poor data quality and
data management, poor management of programmes, traditional beliefs and lengthy
waiting times in queues for consultations as some of the major challenges that
contributed to the failure of the PMTCT programme.

The study also highlighted other challenges and barriers that contributed to the
failure of the PMTCT programme, including negative attitudes on the part of some of
the nurses and poor quality counselling. It is, thus, clear that much needs to be done
regarding the major challenges identified including improving programme monitoring,
minimising registers, providing human and physical resources, improving data
management and addressing traditional beliefs and the long time spent waiting in
queues for consultations.

A similar study conducted by Nguyen, Oosterhoff, Pham, Hardon and Wright (2009)
revealed that the factors that may result to health workers failing to render good
quality services in terms of the prevention of mother to child transmission include the
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health workers own fear of HIV infection; a lack of knowledge of HIV and inadequate
counselling skills; high workloads and a shortage of staff; the unavailability of HIV
testing at community level; a shortage of antiretroviral drugs and a lack of operational
guidelines. In addition, a negative attitude during counselling and the provision of
care, treatment being rendered in a separate area and a refusal to provide services
at all were perceived by health workers as being the result of both fear of infection as
well as distrust towards almost all HIV-infected patients because of the prevailing
association of the disease with antisocial behaviours.


Tayla and Colton (2005) indicated that more sensitisation and stigma reduction
activities are needed as most community members are still not being tested for HIV,
which is the entry point to care and support. In addition, some Health care providers
and Community Health Workers are still promoting replacement feeding despite the
fact that it is widely acknowledged that women may not be able to meet the hidden
costs associated with replacement feeding, including stigma, wood, fuel, clean water,
clean cups and spoons and the time required to prepare feeds

The following barriers were identified by UNICEF (2009) as inhibiting the uptake and
implementation of PMTCT services and causing loss as regards follow up in a
number of African countries. UNICEF (2009) lists and describes the numerous
factors inhibiting the uptake of PMTCT services, especially in a resource constrained
setting. Barriers to the uptake of PMTCT services include poor healthcare
infrastructure, shortages of staff, poor referral links and a lack of communication
between the various health services and within the healthcare system itself (UNICEF,
2009).

As a result, PMTCT and family planning services are poorly integrated. Other factors
include poor quality counselling, negative attitudes on the part of healthcare workers
and deficient interactions with clients. Other barriers were identified as cultural and
gender related issues, particularly the role of the male partners in reproductive issues
and their involvement in PMTCT services. Poverty and structural barriers as well as
cultural factors concerning appropriate behaviours linked to counselling and testing,
PMTCT and stigma, including perceptions of poor social support and discriminatory
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perceptions of the PMTCT practices were also cited (UNICEF, 2009). In addition,
there is lack of awareness and knowledge about HIV/AIDS and MTCT among
pregnant women as regards PMTCT information and services. The reproductive and
health needs of youths are also not adequately addressed. Psychological barriers
include denial, fear of death, or fear of HIV testing and disclosure (UNICEF, 2009).

A similar study conducted by Rispel et al. (2009) indicated that, despite the fact that
the study had revealed several challenges regarding the implementation of the
PMTCT programme, there were, nevertheless, several programme strengths
including an existing health care infrastructure, PHC service availability and trained
nurses with high levels of awareness of national policies

The findings of a similar study conducted by the Health Systems Trust on PMTCT
services at 18 pilot sites suggest that the core problems relate to lack of staff, poor
infrastructure, unavailability of equipment, and negative community attitudes. On the
other hand, other studies revealed that, in the case of less than one third of the
number of HIV positive pregnant women identified at the national PMTCT sites,
Nevirapine had been administered to both mother and baby (Peltzer et al., 2005).

A study conducted by Doherty (2003) shows similar challenges, including the fact
that space appears to be an issue at many sites and this, in turn impacts on the
uptake of VCT. Nevertheless, this study results did indicate that the Mafikeng sub-
district was faring well in term of HIV testing and counselling. However, the findings
of Dohertys study differed from the findings of this study as Dohertys findings
indicated a lack of the proper supply and distribution of consumables, such as
Nevirapine (NVP) and test kits, although the study did offer the same results as this
study to the effect that formula milk appears to be a persistent and universal
challenge to the success of the implementation of the PMTCT programme.

The findings from Doherty et al (2003) study which explain that there was the
unreliable supply of formula, in particular, exacerbates one of the greatest challenges
to the successful implementation of the PMTCT programme, namely, infant feeding,
corroborated the findings of this study. The study also confirmed that disruption in
supplies results in mixed feeding while further findings highlighted other challenges to
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infant feeding, including the stigma associated with formula feeding as well as the
fact that health workers involved in PMTCT are often not properly trained in infant
feeding. Nevertheless, the findings in this study showed that nurses are being trained
properly. The study finding from Doherty et al (2003) also revealed that follow up is a
problem with a particularly low uptake in the testing of babies in one year coming to
the fore. A study conducted in the Tintsalo Hospital in South Africa revealed a
shortage of staff, particularly nursing staff trained in PMTCT. This study showed
similar results found which were also found in this study, in that the supply and
distribution of formula was identified as a major challenge. In addition, the stigma
associated with bottle feeding is the main difficulty facing women in the PMTCT
programme and this result in low levels of disclosure (Doherty, 2003).

The literature also revealed that not all women will agree to be tested and, of those
who are tested, not all will return for their results, nor will all who learn of a HIV
positive status take the necessary drugs or give birth in health facilities (Peltzer et al.,
2005). The UNICEF report of 2003 highlighted that it appeared that the provision of
free feeding formula had also had a significant effect on PMTCT interventions in
communities (UNICEF, 2003).

A study conducted by Moth et al. (2005) in Kenya showed that few antenatal clients
received PMTCT information at the health facility without prior knowledge of the
intervention while large numbers of ANC often waited for more than 90 minutes for
post-test counselling. The same study also revealed that knowledge of PMTCT was
inadequate, even after counselling, as the participants were not able to recall the
information which had been provided during counselling. The study also revealed
that 80% of antenatal clients did not present for follow up counselling, irrespective of
their HIV status. The study further revealed that 95% of antenatal clients had not
disclosed their positive HIV status to either spouses or relatives as a result of the fear
of stigma, discrimination and violence. Further results from the same study
conducted by Moth et al. (2005) indicated that inadequate counselling services
delivered to clients affected service utilisation in that significant levels of dropout
occurred after the stages of HIV result, during enrolment and at delivery. The study
also revealed that the reasons for dropout included fear of a positive HIV result,
stigma and discrimination, unsupportive spouses and an inability to pay for the
101

services. This is confirmed by the results in this study which indicated that stigma and
discrimination were also regarded as a challenge to access PMTCT services.

A study undertaken by Rispel et al. (2009) cited a lack of supplies, inadequate patient
transport, staff shortages and high patient loads, demoralised, overworked staff, and
insufficient training or supervision as obstacles to provision of PMTCT services. The
study also revealed that all the delivery facilities had reported sufficient supplies and
equipment, including sterilising equipment, protective clothing, delivery packs, cord
ligatures, disposable needles and syringes, sharps containers, sterile gauze,
disinfectants and gloves. This finding was confirmed by observation during site visits.
The process evaluation of CCMT conducted by the Department of Health during
2007 (South Africa Department of Health, 2009) cited that the most common
challenge impeding the attainment of targets set out in the operational plan is the
lack of adequate, experienced and skilled human resources.

5.1.10. Availability of mechanisms and systems to monitor the PMTCT
programme

The majority of the respondents In this study indicated that records were correctly
completed and kept up to date. If records are up to date this should result in an
improvement in programme performance and this may, in turn, help in programme
monitoring. The study results also showed that PMTCT patient records were stored in
a safe and confidential manner. However, the results also indicated that there was
room of improvement as most of the respondents had confirmed that the PMTCT
DHIS routine report/ monthly statistics forms were not always correctly completed.
The study also revealed some bottlenecks with regard to a lack of PMTCT data being
displayed graphically on walls although this may be as a result of a shortage of data
capturers as well as insufficient skills to perform such activities. Much should be done
to mentor health care workers as regards designing and plotting graphs manually if
there are no data capturers or if they lack the necessary computer related skills.

This study shows that clinics have no standardised registers that are used to record
and monitor PMTCT programme interventions and to follow up HIV exposed Infants
102

although most of the clinics had compiled registers for their own clinics. However, this
may result in poor recording and poor data quality as it is possible that health care
workers may fail to record the most important information. Nevertheless, the registers
which were available had been compiled with the assistance of development
partners.

The results from this study (89%) indicated that the registers for infant follow up were
up to date. However, the major challenge still remains as half of the clinics receive
written referrals from hospital and local clinics for infants born to HIV positive mothers
and these referrals often include a lack of comprehensive information on the ANC
card from the referring local clinics and Hospital. The study also showed that there is
a gap in the provision of comprehensive information on the road to health cards from
referring clinics. This may, in turn, cause problems in the follow up information as
there is no baseline information provided. In addition, this study revealed that there
are poor referral systems and a lack of mechanisms, including a lack of standardised
systems, to monitor the PMTCT programme. A study conducted by Doherty et al.
(2009) in the Amajuba District in KwaZulu-Natal in South Africa showed that
documentation and record keeping were, generally, found to be good with all clinics
having an HIV testing register and a Nevirapine drug register which were up to date.
However, there were no specific results which indicate comprehensive information on
the road to health cards.

A study undertaken by Singh (2010) confirms that findings of this study to the effect
that not all of the facilities (77,7%) had transfer forms for the referral of patients from
a hospital or clinic to another facility. The results from study conducted by Singh
(2010) further confirmed that a few only of the facilities (33,3%) filled out the referral
forms correctly. The results from the same study further indicated that less than half
of the facilities (44,4%) used a tracking system for patients. The study also revealed
that less than half of the facilities (44,4%) had a procedure in place in terms of which
to contact patients who had missed their appointments.

The World Health Organisation (2010) indicated that monitoring and evaluation
remain a major challenge in all countries. The literature reveals that PMTCT data
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collection and reporting in many countries remains weak, affecting both project
implementation and the ability to report accurately on key indicators (WHO, 2010).

A study conducted by Doherty, Besser, Donohue, Kamoga, Stoops, Williamson &
Visser, (2003) in the Free State and Mpumalanga provinces reveals that the numbers
of data collection tools had been reduced by consolidating recording efforts into a
single register for antenatal and child health services. The study also indicated that
the delivery register had been adapted to record HIV tests carried out and NVP
dispensed to both mother and baby. Existing tally sheets used in PHC facilities had
been adapted to collect aggregated PMTCT data. This, in turn, indicates that the
standardisation of routine health data collection registers may improve PMTCT
services and produce more reliable data.

5.1.11. Evaluation of the implementation of PMTCT interventions during
pregnancy and at post-delivery, using DHIS data from six (6) month periods.

When PMTCT interventions were evaluated using District Health Information System
(DHIS) data for six (6) month periods it emerged that there was a low level of PMTCT
programme efficiency and effectiveness in the clinic in the Mafikeng Sub-district.
However, the performance of the sub-district over the 6 month intervals showed that
the programme is faring well in terms of some of the programme indicators and data
elements. The baseline data shows the PMTCT during the introduction of dual
therapy that included AZT for both mother and the baby as implemented in August
2008 in terms of the PMTCT guideline. However, the programme is not meeting
certain of the Department of Healths national targets as regards PMTCT indicators.
The data shows an increase and improvement in the percentage of NVP given to
pregnant women during labour from 80% in the June to December 2008 period to
85% in the June to December 2011 period. However, this was below the expected
target of 100%.

The World Health Organization (2010) reported that an over 90% of children had
been newly infected with HIV through mother to child transmission (MTCT) in 2008.
The results from the literature indicated that, without treatment, approximately half of
these infected children will die before their second birthdays. The literature further
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indicated that, without intervention, the risk of MTCT ranges from 20% to 45%.
However, the literature confirmed that, with specific interventions in non-
breastfeeding populations, the risk of MTCT may be reduced to less than 2%, and to
5% or less in breastfeeding populations. This emphasises the effort that is needed to
provide antenatal clients with treatment in order to prevent the transmission of HIV
from mother to child.

In order to prevent the transmission of HIV from mother to baby, the World Health
Organization (WHO) promotes a comprehensive approach, which includes the
following four components, namely, primary prevention of HIV infection among
women of childbearing age; prevention of unintended pregnancies among women
living with HIV; prevention of HIV transmission from a woman living with HIV to her
infant; and the provision of appropriate treatment, care and support to mothers living
with HIV and to their children and families (WHO, 2010).

The results of this study show that there were few antenatal clients who were being
initiated on AZT as the sub-district was performing at 50% in June to December 2011
a steady decline from 67% between January to June 2011. The results show that
the sub-district was performing below the expected targets and, thus, that there are
several patients who are missing PMTCT interventions.

The sub-district data shows good performance on NVP to baby at 6 month intervals
from 101% at baseline in June to December 2008. This was still stable during the 6
month interval from July to December 2011 at 103%. However, the performance
shows that 100% babies were issued with NVP, although data shows some
discrepancies of over reporting at more than 100% this may as a result of data quality
challenges and poor recording.

The sub-district showed as increase in baby PCR testing at six weeks with 65% in
June to December 2008 and, recently, 81% from July to December 2011.However, it
is evident that not all babies are being tested for PCR at six weeks and this, in turn,
means that there are a number of children who are missing PMTCT intervention
opportunities. All children should be tested for PCR as early as possible in order to
identify those who are HIV positive and fast track them on HAART.
105


The sub-district showed good performance on baby PCR positivity rate at six weeks
with 9% between June and December 2008 and between July to December 2011.
However, the data shows a sudden drop in the PCR positivity rate of 1% in the sub-
district during the July to December 2011 review of NSP targets at the six-month
interval from July to December 2011. This shows that interventions aimed at
preventing the transmission of HIV from mother to child are being implemented
successfully, including the issuing of NVP and AZT to antenatal clients and the
issuing of NVP and Cotrimoxazole syrup to HIV exposed babies.

The sub-district was performing well in terms of identifying babies who were HIV
exposed with 81% from July to December 2011. However, the study also shows the
performance of initiating pregnant women on NVP was below the South African
target at 85% in December 2011. In other words, there is still room for improvement
in this area as the target was not met. In terms of dual therapy to HIV exposed babies
the sub-district was also managing to issue both NVP and AZT to the majority of the
babies. The South African National Strategic Plan (NSP) on HIV & AIDS and STIs of
2007 to 2011 aimed to reduce MTCT to less than 5% of infants born to HIV-positive
women by 2011. With a performance of below 5% the sub-district had manage to
achieve this target. Reducing vertical transmission was one of the highest priorities of
the NSP of 2007 to 2011. The goal was to reduce HIV transmission to 5% in HIV
exposed infants by 2011.

The fact that the PMTCT programme intervention was working was confirmed by the
results of the study conducted by the Medical Research Counsel to the effect that the
performance of the programme to prevent mother to child HIV transmission (MTCT)
had been reduced the a rate of transmission of 3.5% at approximately six weeks of
age a profound improvement compared to the reports of a few years ago (Smart,
2011).




106

5.1.12. Evaluation of the implementation of PMTCT interventions during
pregnancy and at post-delivery using DHIS quarterly data.

When evaluating PMTCT interventions the DHIS quarterly data shows that there has
been a significant improvement in the performance of the sub-district when
comparing all quarters. However, the sub-district was not faring well in terms of ANC
retesting at 32 weeks and is still below 50%. There was also a delay in ANC first
visits before 20 weeks as this was still below 50%. Nevertheless, the sub-district did
perform well in terms of certain indicators although there is room for improvement on
others. Data quality remains a challenge as it was observed that ANC first test rate
was above 100%. Generally, however, the sub-district was still not performing well as
regards the PMTCT programme although there is an improvement on some of the
indicators as compared to the second

quarter and the third quarter 2011. The results
from this study show that there remains the challenge on ANC clients initiated on
AZT as the uptake was low. The study also identified that the CD4 first test rate
needs to improve although it may be confirmed that the gap identified on low uptake
of CD4 testing was due to poor recording of the tests.

A study conducted by Doherty et al. (2009) in the Amajuba District in KwaZulu-Natal
in South Africa showed that the district was clearly performing well in terms of HIV
testing as regards antenatal care and that this had been achieved through both the
provision of adequate human resources in the form of lay counsellors and a
philosophy of making HIV testing a routine component of antenatal care. The same
study further identified areas of weakness. However, the findings of this study by
Doherty et al. (2009) did differ somewhat from the results of this study, for example,
the findings relating to the inadequate training amongst clinical staff. However, the
similar results finding in this study of Doherty et al. (2009) also revealed inadequate
infrastructure in terms of counselling rooms, infrequent supervision by district
supervisors and a low coverage of CD4 tests.

The study conducted by Doherty et al. (2009) further confirmed a low coverage of
Nevirapine uptake by antenatal clients, including NVP uptake as regards infants and
PCR testing of infants. These findings differ from the findings of this study as the
results in this study showed good performance in terms of issuing NVP to children. .
107

In addition, the study results from Doherty et al. (2009) show that the weaknesses
which were identified were as a result of a lack of information and fear of disclosing
HIV status as well as a lack of ownership of the PMTCT programme on the part of
nurses, unclear roles and responsibilities, lack of knowledge of the protocol, poor
recording systems and inadequate continuity of care (Doherty et al., 2009).

The sub-district had performed well in terms of preventing HIV transmission from
mother to child when comparing both quarters as the PCR positivity rate had met the
expected NSP target an indication of good performance. In addition, both the PCR
uptake and the Nevirapine uptake appeared to be good though there were
challenges as regards data quality, especially during the third quarter which showed
a performance of more than 100%. The sub-district performed well in the fourth
quarter in terms of issuing Cotrimoxazole although performance had not been
satisfactory in the previous quarters.

The most striking finding of this study is the fact that, despite all the babies who
tested negative for PCR at six weeks, the study results show that there was a gap in
terms of identifying children for antibody testing at 18 months. This, in turn, shows
that not all children who tested negative for PCR at six weeks are returning for their
antibody testing at 18 monthd.

A study conducted by Van Lettow, Bedell, Landes, Gawa, Gatto, Mayuni, Chan,
Tenthani and Schouten (2011) further confirms poor follow up HIV testing for HIV
exposed infants with the results showing that 28% of exposed infants only had been
followed up and tested at least once by 18 to 20 months of age.

5.1.13. Evaluation of the Implementation of PMTCT Interventions during
pregnancy and at post-delivery at 12 month periods.

When evaluating PMTCT using the 12 month period data, the results still show that,
according to the 12 month periods, the sub-district was doing well in identifying HIV
exposed babies and ensuring that they received PCR testing. The sub-district was at
a 1% PCR positivity rate which shows good performance in terms of the MTCT
programme with outstanding performance in terms of PCR testing being noted in
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August and September 2011. There was a steady increase of 15% in the PCR
positivity rate between March and May 2011 which dropped to 1% which is showing
significant improvement as the sub-district is still performing well within the expected
NSP target. This good performance may be the result of the knowledge and training
on the part of staff members.

When the PMTCT programme interventions were evaluated using the DHIS and
NHLS data for the period of 14 month from October 2010 to May 2011, the study
results show good performance in terms of MTCT programme from both sources,
which also confirm a PCR testing positivity rate of 4%. This shows that the sub-
district PCR positivity rate had met the expected NSP target of scaling up coverage
and improving the quality of PMTCT by reducing MTCT to less than 5%.

When evaluating the PMTCT programme using the DHIS 12 month period data from
October 2010 to May 2011 it emerges that the baby antibody testing at 18 month
positivity rate indicates that the sub-district antibody test positivity rate had met the
expected NSP target of scale up coverage and improving the quality of PMTCT by
reduce MTCT. This is evident from the 2% performance which in indicative of good
performance in the PMTCT programme. However, it is evident that not all the
children were returning for their antibody testing at 18 months.

Nuwagaba-Biribonwoha et al. (2007) also confirm that a significant number of babies
had been lost to follow up by 18 months with an unknown number of deaths.
Accordingly, infant HIV status and the effectiveness of the programme in reducing
MTCT were largely unknown. However, if this is to be improved there it is essential
that PMTCT be linked with community health care workers while health promotion
would enhance the PMTCT programme. It is possible that those poor results of lost to
follow up by 18 months are the result of a lack of community engagement and health
promotion while it may also that most women choose to go to their preferred facilities
and this may lead to loss as regards the follow up of infants.

According to Smart, (2011) a study conducted by Medical Research Council (MRC)
in 2011, which was presented at the 5th South African AIDS Conference in June
2011, in Durban, revealed that the percentage of children who, ultimately, become
109

infected will increase, particularly in view of the fact a significant proportion of the
children are not being fed safely with either exclusive breastfeeding or exclusive
formula feeding by their caregivers (Smart, 2011).

The results from this study the results show that the sub-district was performing
extremely well in terms of initiating HIV positive ANC on dual therapy at 28 weeks.
The study results also show that the Mafikeng clinics were doing extremely well in
terms of issuing NVP as most of the women were given NVP during labour. However,
more work still needs to be done in terms of AZT issuing as the study shows that not
all the women receive AZT with the performance dropping still further in the period
between April and December 2011.

It may be confirmed that, although the sub-district did not meet the expected target of
initiating antenatal clients on HAART, the sub-district is, nevertheless, doing well in
terms of fast tracking pregnant women who are eligible on HAART as the clinics were
performing at 75% on annual average from January to December 2011. In addition,
the sub-district was clearly performing well as the clinics had been able to meet the
NSP targets in some months. The goal of the NSP 2007 to 2011 was to reduce the
impact of HIV on individuals, families, communities and society by expanding the
access to appropriate treatment, care and support to 80% of all people diagnosed
with HIV while the target for ANC to be initiated on ART rate was 95% monthly.
However, it should be borne in mind that those HIV-infected mothers who were not
yet on HAART were provided with sd-NVP.

The study findings indicate that, although the sub-district is managing to carry out
PCR tests for the majority of exposed babies, which is an improvement, a minority of
the babies who are exposed live birth to HIV positive mothers still missed out.
According to the results of this study 57% only of babies who were HIV exposed
received Cotrimoxazole at six weeks in the period January to December 2011.
However, this low uptake of Cotrimoxazole may be as a result of poor record keeping
as some of the clinics do not have a standardised source in which they record the
uptake of Cotrimoxazole. The data in this study shows that 95% of babies who were
HIV exposed had received Nevirapine at six weeks in the annual period from January
to December 2011. This, in turn, implies that the sub-district is performing well as
110

most of the HIV exposed babies are covered, although there is a small annual
percentage (5%) of babies who missed NVP. Nevertheless, the data shows that
clinics are able to issue Nevirapine to all babies monthly (100%).

The study findings also show that the sub-district was doing well in terms of ANC HIV
first testing as the testing rate in most of the months showed that 100% of the
pregnant women were tested for HIV. However, the sub-district performance on ANC
first bookings rate below 20 weeks of gestation from January to December 2011 was
46% which is below the expected target of 60%. It is important that Antenatal clients
book early for Antenatal care so that they may be tested for HIV early and, thus,
enable the decision to be made as to whether the woman qualifies for dual therapy or
HAART early in pregnancy in order to reduce the chance of MTCT.

This study also illustrates that, in terms of HIV testing at 32 weeks, the sub-district
was not doing well. There was a significant gap between those who tested negative
at their first test and those retested at 32 weeks. It is important that ANC clients be
retested at 32 weeks in so that they may be issued with NVP before labour and fast-
tracked onto HAART. The sub-district performance performed poorly for the period
January to December 2011 as the performance was always below the 44% on
annual average, although there was a steady improvement in performance of 64% in
December 2011.The improvement may be the result of the availability of ANC
register which was piloted and introduced to clinics early in 2011 and it may, thus, be
confirmed that health care workers were apparently able to complete the register
correctly and keep it up to date.

5.1.14. Evaluation PMTCT intervention missed using 12 month DHIS data

The study results reveal that antenatal clients are missing opportunities to be tested
during their first visits as 54% of the antenatals eligible for first HIV test had not been
tested before 20 weeks. This, in turn, shows that there are still large numbers of ANC
who are not booking early for their Antenatal subsequent follow up visits.
Approximately 94% of the women who had attended antenatal consultation had been
tested for HIV which means that 6% only had not been tested for HIV. Although the
study had identified lack of a space for counselling there was still a significantly high
111

number of antenatal clients who had been counselled and tested for HIV. However,
the study reveals that low numbers (67%) of antenatal client who were tested for
firstCD4 which means that approximately 33% of those eligible had missed their first
CD4 test. The CD4 testing rate is below the expected target of 80% of the NSP 2007
to 2011. This, in turn, is evident of poor performance and this has a negative impact
on identifying ANCs who are eligible for HAART.

The study reveals that, of the 94% of antenatal clients tested for HIV, approximately
22% were confirmed to be HIV positive. This, in turn, implies that 78% of those
tested were HIV negative. The NSP 2007 to 2011 performance target rate for
antenatal visits before 20 weeks was 70% while the antenatal client HIV first test rate
was expected to be 95%. Clearly the sub-district is performing well as the clinics are
meeting the target.

The National Department of Health and the South African National AIDS Council
(2010) have indicated that all women with unknown HIV status should be offered HIV
testing and counselling before discharge, preferably prior to, or immediately after,
delivery to ensure that the baby receives antiretroviral prophylaxis should the test be
HIV positive. In addition, all abandoned infants judged to be in their first 72 hours of
life should be given NVP as soon as possible and then daily for six weeks. On the
other hand, HIV exposed, breastfed infants whose mothers are not on lifelong ART
should continue NVP beyond six weeks of age until all cessation of breastfeeding
The results of this study indicate low uptake (41%) of antenatal clients who were
retested for HIV at 32 weeks and this, in turn, means that approximately 59% missed
their HIV retest at 32 weeks. The study results further show that of the 41% of those
antenatals retested for HIV at 32 weeks 6% were confirmed to be HIV positive. Thus,
this study confirms that not all women are returning for their retest at 32 weeks. This
be as a result of a lack of support from the families. It is, however, important that all
antenatal clients be retested at 32 weeks so that they may be fast tracked onto
treatment if they are HIV positive. This, in turn, will prevent the transmission of HIV
from mother to child. Thus, antenatal clients should be continuously reminded to be
retested as there may be HIV infection during pregnancy. However, although not all
women are being retested the result shows a low number of antenatals testing HIV
112

positive as 94% of those retested at 32 weeks were HIV negative. Nevertheless, the
study results show that the sub-district performance was poor as the NSP target for
the antenatal client HIV retest rate at 32 weeks was 50%.
A study conducted by Nuwagaba-Biribonwoha et al. (2007), in Uganda also confirms
that the follow-up of HIV positive women is a major challenge with the study revealing
that some women attended the antenatal clinic once and then disappeared without a
trace. Others did not deliver in the PMTCT hospitals and, thus missed antiviral
prophylaxis and modified intrapartum obstetric care. The study further indicated that
these problems were more common in the rural areas than the urban areas and also
when women depended on their spouses for transport to hospital. The follow up of
women and their babies after delivery was even more difficult.
This study shows that approximately 81% of antenatal clients initiated on AZT which,
in turn, that approximately 19% missed their AZT dose. The sub-distict performance
for antenatal clients on AZT before labour was 59%. This, in turn, means that
approximately 41% missed their AZT before labour. The NSP target for the antenatal
client initiated on AZT rate during antenatal care was 85%. Antenatal clients on
HAART at delivery was 76%, which means that approximately 24% of the ANC
eligible for ART were not initiated on HAART at delivery. The NSP target for
antenatal clients initiated on HAART rate was 90%. The performance for the
antenatal clients who were administered Nevirapine during labour was 70% over a
period of one year while the national target for antenatal client Nevirapine uptake rate
was 100%. This target was not met. Thus, the findings of this study indicate that the
Mafikeng sub-district has not met most of the national targets set. However, despite
that fact that the sub-district is not meeting targets, the study does show that the
Mafikeng clinics are doing well in comparison with the findings of other studies which
show low uptake on NVP, AZT and HAART among antenatal clients.

A similar study conducted by Rispel et al. (2009) indicated that, since 2002, the
implementation of single-dose Nevirapine-based PMTCT programmes in South Africa
has progressed although these programmes rely on efficiently functioning health
systems.

113

The results of this study show that the sub district is performing extremely well in
terms of issuing NVP to babies as the results show that 98% of babies were given
Nevirapine within 72 hours after birth. The expected target is 95%. However, much
still needs to be done to ensure that all (100%) children exposed to HIV mothers are
given Nevirapine within 72 hours of birth. The NSP target for babies to be initiated on
NVP before 72 hours was 100%. The study results also show that the sub-district is
doing well as regards the large number of babies (73%) being PCR tested at six
weeks. However, it is necessary to point out that much still needs to be done to link
immunisation with PCR testing at the 4 to 12 weeks visits. In addition, all HIV positive
children should be identified earlier in order to fast track them on HAART.

An evaluation of PMTCT pilot sites found that 85% of tested pregnant women
received their HIV test result but 55% of HIV-positive women only received
Nevirapine prophylaxis (Doherty et al., 2003).

In this study the data shows that there high numbers of children (43%) were not
issued with Co-Trimoxazole at six weeks which means, in turn, that there are large
numbers of children who are missing out on their PMTCT opportunity. In addition, this
is evident of the fact that the sub-district did not meet the target of 100%. However,
the low uptake may also be as a result of poor recording of Co-Trimoxazole at six
weeks. Nevertheless, this study revealed a significant breakthrough as regards the
PCR positivity rate of 4% over the 12-month period when using both NHLS and DHIS
data as 96% of infants born to HIV-positive women were tested HIV negative while
the expected target for baby PCR test positivity rate at six weeks was 5%.

A study conducted by Rispel et al. (2009) showed that the number of infants tested
for HIV by PCR at six weeks and at nine months was low in relation to the number of
women who tested HIV-positive at an ANC visit. The findings in this study confirmed
that several babies born to HIV positive women were lost to follow up by the PMTCT
programme.

The results of this study are confirmed by the results of the North West Provincial
Strategic Plan (PSP) end term review (2011) which further show that the PMTCT
programme has improved steadily from 2005 to 2011, despite the fact that some of
114

the 2007 to 2011 targets were not met. According to the PSP 2011 review document,
the indicators for HIV positive pregnant women receiving ART in the province was
67% against a target of the >70% who were expected to be initiated on HAART, 59%
initiated on AZT against a target of 95% and a 64% Nevirapine (NVP) uptake rate
against a target of >95%. The PSP document further highlighted the fact that the
province had performed extremely well in terms of the proportion of the infants
receiving PCR, namely, 95%. The document also revealed a decreasing number of
infants born HIV positive an important outcome of the PMTCT programme. Further
PSP literature revealed that the proportion of HIV positive pregnant woman initiated
on ART had increased dramatically from 15% in 2008 to 65% in 2010/11 (The North
West Provincial Council on AIDS & North West Department of Health, 2011).






















115

CHAPTER 6: SUMMARY, CONCLUSION AND RECOMMENDATIONS

6.1 Summary
The objectives of the study were:
To assess the availability of the resources, infrastructure and equipment
available to implement PMTCT services.
To assess the availability of PMTCT related services.
To assess the training and knowledge of health care workers regarding the
implementation of PMTCT services.
To describe the challenges faced by health care workers with regard to the
implementation of the PMTCT programme
To assess the availability of mechanisms and systems with which to monitor
and evaluate the PMTCT programme.
To evaluate the implementation of PMTCT interventions during pregnancy and
post delivery

Chapter four presented the findings of the study while chapter five discussed these
findings in detail. This chapter summarises the study and the findings presented. The
chapter also discusses the conclusions drawn from the study and offers
recommendations based on these conclusions. The main objective of the study was
to evaluate the implementation of prevention of mother to child transmission
(PMTCT) interventions during pregnancy and post-delivery at clinics on the Mafikeng
Sub-District in the North West Province in South Africa.

The PMTCT programme is implemented in all the clinics in the Mafikeng Sub-district.
However, the study has shown that 5 of the 28 clinics only carry out ANC deliveries in
the Mafikeng sub-district. It would appear that all the health care workers are aware
of the PMTCT relevant clinical guidelines and that most of the clinics have all the
guidelines available on site. The majority of health care workers are trained and
informed about the PMTC programme interventions. Supplies of critical items are
always available at the clinics. However, much needs to be done to ensure that the
PCR test results are available immediately at the clinics. There is a gap in the
116

retesting antenatal at 32 week rate (43%) and as regards the baby antibody testing at
21%, ANC CD4 testing at 70% and ANC initiated on HAART at 73%. Almost all
babies are issued with NVP performance of 98%. However, by performing at 4%
over the period of 12 month the sub-district has met the NSP national Department of
Health target by ensuring that less than 5% babies are positive.
Improving the access to PMTCT interventions would require the strengthening of the
formal health sector as well as improving liaison with stakeholders, and community
support. However, much still needs to be done to encourage ANCs to book for their
visits early before 20 weeks while it is essential that HIV testing and counselling be
carried out. There should also be enhanced integration of the family planning and
PMTCT services. In addition, there is a need for more accredited public health
facilities offering comprehensive PMTCT services, including antenatal deliveries and
HAART interventions. The ongoing training and mentoring of health care workers
would ensure that health care workers possess PMTCT relevant knowledge and
skills to administer ART. There should be more done to improve the NHLS in order to
facilitate the immediate delivery of laboratory results, including PCR and Elisa test
results. There should also be ongoing support to and monitoring of ANCs after
delivery though home based care services.

The study findings show that the resources, infrastructure and equipment needed to
implement PMTCT services are available in the Mafikeng clinics. The study also
shows that nurses receiving PMTCT related training and that they are informed about
on the implementation of the PMTCT services. However, there are still some
challenges facing health care systems and it is essential that these challenges be
addressed in order ensure the successful implementation of the PMTCT programme.
The study also revealed that there are mechanisms in place to monitor the PMTCT
programme although there are still some weaknesses which need to be addressed,
including the introduction of systems to monitor and evaluate the PMTCT
programme. It would, however, appear that the PMTCT interventions are effective
during pregnancy and at post-delivery. However, the results do show that there are
certain indicators which need to be improved.

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6.2 Conclusions

The conclusions will be discussed under the different sections contained in the
questionnaire and will acknowledge the responses of the respondents.
6.2.1 The availability of resources, infrastructure and equipment to implement
PMTCT services.
It may be concluded that a significant number of clinics are still non-delivery sites as
regards antenatal care although most of the clinics do provide deliveries in cases of
emergency. There are 5 clinics only in the Mafikeng sub-district which operate on a
24 hours basis. As a result of staff shortages the majority of the clinics are able to
allocate one nurse per day who is able to handle PMTCT. Some of the clinics no
longer provide infant feeding formula as its supply was discontinued by the sub-
district. All antenatal clients are given ANC cards to take home. However, there are
still clinics in the sub-district where there is a shortage of consultation rooms in order
to maintain confidentiality as well as inadequate space available for ANC. Not all
Mafikeng clinics are providing free infant formula to infants up to six months and not
all are providing nutritional support to HIV-positive women who are breastfeeding
while some of them were out of stock of formula for long periods. Some clinics do not
provide PMTCT information, such as booklets, during ANC consultations while some
clinics do not have designated VCT rooms with some using kitchen as a result of the
shortage of rooms for counsellors. However, the majority of clinics have relevant
PMTCT guidelines available on sites and the guidelines are used by staff. It is also
evident that policies and guidelines are also kept in a place where everyone is able to
access them.
The majority of clinics having PMTCT related supplies of critical items in stock and
one only was out of stock of NVP syrup for babies. In addition, none of the clinics
ever run out of condoms. However, infant feeding formula was out of stock at the
majority of the clinics and it often takes a month for the majority of clinics to receive
infant formula. It takes the majority of the clinics four to six weeks to receive PCR
results. Most of the clinics are no longer conducting the ELISA test unless the results
of the confirmatory test are not satisfactory. However, it takes them less than one
118

week if it is done immediately. Most of the clinics in Mafikeng indicated that they
receive their CD4 results in less than 1 week. Of the 28 clinics assessed, most met
the national PMTCT criteria.
Most of the clinics (85%) were accredited to provide antiretroviral treatment for HIV-
positive patents, including pregnant women, and three only were not accredited.
However, the three which are not accredited included two clinics which did not qualify
as they are next to hospitals. There is little support from programme coordinators at
facility level from higher level although support is available from the clinic
supervisors.

6.2.2. Training and knowledge of health care workers as regards the
implementation of PMTCT services.

The study confirmed that the majority of staff had been trained on PMTCT relevant
interventions although most of them indicated that they felt they needed ongoing
mentorship as guidelines are continuously changing. In addition, the majority
indicated that the training they had received had not been adequate. Most of them
had also been trained on PMTCT and ART guidelines. The majority of the health care
workers appear to have a good understanding and knowledge regarding the
implementation of the PMTCT programme, including PCR testing at six weeks. Most
of the training and mentorships were conducted by the development partners
supporting the Mafikeng sub-district on ART and PMTCT.

6.2.3. Describe the challenges faced by health care workers with regard to the
implementation of the PMTCT programme

It may be concluded that the main barriers and challenges as regards the successful
implementation of the PMTCT programme include understaffing, inadequate human
and physical resources, traditional beliefs, long waiting times in queues for
119

consultations as well as poor data quality and data management. The availability of
too many registers for the programme was also viewed as a major challenge
although this did not apply to the PMTCT register. Most of the clinics had two
registers in which to monitor PMTCT for both babies and mothers, including the
standardised ANC register which was used mostly by the majority of the clinics. The
lack of proper programme monitoring was regarded as a challenge by the majority of
the respondents. Other challenges which were highlighted included a lack of support
and supervision and a lack of community involvement and its support.
6.2.4. Assess the availability of mechanisms and systems with which to
monitor and evaluate the PMTCT programme.

It is evident that there are no proper mechanisms and systems in place to monitor
and evaluate the PMTCT programme as the majority of clinics had no PMTCT data
nor did they have information displayed graphically on their walls and information
boards. The study also showed poor referral systems as some PHC facilities do not
receive written referrals from hospital for infants born to HIV positive mothers. The
findings also highlighted the fact that most referring clinics do not provide
comprehensive information on the ANC card which may be used to diagnose patient.
Most of the clinics indicated that the referring clinics also do not provide the road to
health card with comprehensive information. It may, thus, be concluded that there are
both poor referral systems and a lack of mechanisms and standardised systems in
place to monitor the PMTCT programme. However, the data in most of the clinics
was reported to be accurate.

6.2.5. Evaluate the implementation of PMTCT interventions during pregnancy
and post delivery

In conclusion the PMTCT indicators and data elements further show that, in general,
the implementation of the PMTCT programme in the Mafikeng clinics is sufficiently
effective to prevent mother to child transmission (MTCT) as the PCR positivity rate
120

has proved to be less than the 5% target of the National Strategic Plan of 2007 to
2011. However, much still needs to be done to encourage retesting at 32 weeks as
too few ANC are being retested at 32 weeks. In addition, it is evident that not all
children are returning for their antibody retest at 18 months. The majority of babies
are being tested for PCR and issued with NVP at six weeks, but a few exposed
infants only are being issued or initiated on Cotrimoxazole at six weeks. There is a
significant achievement in terms of issuing NVP to mothers during labour although
not all women are being given AZT during that period. The sub-district is also doing
fairly well as regards of initiating women on HAART as the majority of HIV positive
women are being initiated on HAART, including those who were initiated before
delivery. In addition, the programme is doing well in terms of testing antenatal clients
during their first test for HIV although the antenatal first visit before 20 weeks rate is
not good. The sub-district is also not doing well in terms of antenatal client CD4 first
test. However, the sub-district is performing well as regards issuing NVP to exposed
babies during or after birth.

6.3. Recommendations
In order to address the gaps identified in the study, the following recommendations
are proposed in the hope of bringing about the required improvements at policy,
programme and health systems levels and, thus, to strengthen, as well as to scale
up, access to the continuum of care within the public health sectors. Accordingly,
based on the findings of this study, the following recommendations are proposed to
improve and promote the PMTCT services within the public health sector further:

6.3.1 The availability of resources, infrastructure and equipment to implement
PMTCT services.

A need for more support to public health facilities to enable them to offer
comprehensive PMTCT services such as antenatal deliveries and HAART
interventions.
More effort should be made to strengthen the NHLS so as to speed up the
delivery of laboratory results, including PCR and Elisa test results.
121

There is a need to increase the number of clinics which operate on a 24 hour
basis, especially in the rural settings of Mafikeng.
Infant feeding formula options should, at least, be made available to those
mothers who are experiencing problems with breastfeeding and also for those
who have already chosen bottle feeding so as to avoid mixed feeding of
infants up to six months. In addition, HIV-positive ANC patients who are on
the PMTCT programme should be provided with nutritional support so as to
avoid complications during medication uptake.

6.3.2. Training and knowledge of health care workers regarding the
implementation of PMTCT services.

There should be continuous training and mentorship of staff to help them
acquire the skills necessary to ensure that health care workers have PMTCT
relevant knowledge and skills in the administration of ART.
HIV specific information or material must be made available to antenatal
clients in order to help educate those patients accessing health care facilities,
particularly patients on the PMTCT programme.
A greater investment in the effective training and continuing support of PHC
health workers and lay counsellors is required so that high quality infant
feeding counselling and support may be provided.
The higher department of health level should provided more support to
programme coordinators at facility level in order to mentor health care
workers.
There should be continuous mentoring of health care workers as the majority
of participants indicated that training received is not adequate as guidelines
are constantly changing. In addition, there should be education provided to
help address the traditional beliefs among antenatal clients and to ensure the
ongoing development of the quality interventions.

122

6.3.3. Describe the challenges faced by health care workers with regard to the
implementation of the PMTCT Programme
Relationships with the community should be strengthened as this will enhance
community involvement and support. In addition, the PMTCT programme
should be linked with a home community based care programme.

There is a need to recruit more health care workers as there is a shortage of
human resources. More midwives should also be recruited and adequate
space provided for ANC to help ensure confidentiality.

PMTCT registers for both mother and child should be improved and
standardised by the National Department of Health in order to improve
PMTCT programme performance and the data quality. This would also help
reduce the number of registers.

6.3.4. Assess the availability of mechanisms and systems to monitor and
evaluate the PMTCT programme.

Continuous monitoring of patients should be carried out using standardised
registers to ensure that patients adhere to the treatments prescribed.
There is a need to monitor and evaluate the PMTCT service frequently so as
to enhance good service delivery though the display of information at facility
level and through reviews.
There should much more done to educate or train health care workers to
enable them to display PMTCT information graphically on the walls for
themselves.
Referral mechanisms should be put in place to improve the writing of referrals
from hospital for infants born to HIV positive mothers. This would involve
including comprehensive and adequate information on the referral forms and
on the ANC card and the road to health card from referring clinics as the
coding systems is no longer used in the health care system.
123

6.3.5. Implementation of PMTCT interventions during pregnancy and post
delivery

It is essential that the PCR test positivity rate improve to be less than 2% as
envisaged in the new National Strategic Plan of HIV and AIDS 2012-2016.
Much work should be done to encourage retesting at 32 weeks as too few
patients are being retested at 32 weeks.
Mothers who have tested HIV positive as well as those who have tested
negative should be encouraged to return after 18 months to retest their
babies antibodies. This should include improving the issuing or initiating of
HIV exposed babies on Cotrimoxazole at six weeks as well as improving the
issuing of AZT to HIV positive mothers at the same time as NVP. More
women should be fast tracked on HAART, as per the guidelines. In addition,
more women should be informed of the importance of early bookings for
antenatal first visit before 20 weeks. The sub-district should also expend more
effort on improving antenatal CD4 first testing.
HIV-infected mothers who choose to breastfeed should receive proficient and
on-going support from health workers to support them in terms of exclusive
breastfeeding.
There is a need to ensure the on-going support of both mothers and babies
after delivery.
6.4. Recommendation and suggestions for further research
Further research is needed to investigate the reason for the low HIV retest
at 32 weeks rate as part of ascertaining the root cause of uptake failure.
This researcher would like to recommend that research be conducted into
assessing why babies are not brought for their antibody testing at 18
months.
Models for community involvement in the PMTCT programme should be
evaluated.
124

Public private partnerships as a strategy to strengthen the PMTCT
programme should be assessed
The impact of traditional beliefs amongst antenatals regarding
antiretroviral treatment should be assessed
In-depth research need to be conducted to assess the experiences of
patients regarding the prevention of mother to child transmission
programme in the rural settings in the Mafikeng sub-district.
Further research should to be conducted to ascertain whether
breastfeeding is the best option for HIV exposed children in rural settings
and also to investigate the need for alternative nutritional support;
Research is needed to explore the effective use of communication
strategies to promote the PMTCT programme.

6.5. Limitations of the Study
According to De Vos, Strydom, Fouch and Delport (2000), generally, when
identifying the limitations of a study, the researcher must consider the validity and
reliability of all data collection instruments, the generalisability of the sample to the
population from which it is drawn, access to data, ethical problems, as well as the
ability to control for extraneous factors within the environment and as regards the
respondents.
As a result of the small number of samples, it is not possible to generalise the study
to the entire population of North West Province, so therefore this study is applicable
to Mafikeng Sub-district clinics only. Time constraints also constituted a limitation of
the study as the researcher had intended to include facility managers only but, as a
result of the unavailability of the facility managers during the data collection period,
the researcher was obliged to interview any senior Nurse who was available and
acting as a facility manager while some of the respondents were busy managing
patients. The use of routine DHIS data for the evaluation process in the study also
posed problems as there were several discrepancies as regards the quality of the
data as the researchers had had little control over the data collection tools, data entry
or data flow. However, the study was descriptive in nature and assisted in identifying
those problem areas requiring further study.
125


REFERENCES

Ahoua, L., Ayikoru, H., Gnauck, K., Odaru, G., Odar, E., Ondoa-Onama, C., Pinoges,
L., Balkan, S., Olson, D. & Pujades-Rodrguez, M. (2009). Evaluation of a 5-year
Programme to Prevent Mother-to-child Transmission of HIV Infection in Northern
Uganda. J Trop Pediatr., 56(1), 4352. Epub 2009 Jul 13. PMID: 19602489

All Africa. (2010). "Mothers' protest at withdrawal of free formula milk". Preventing
Mother-to-child Transmission (PMTCT) in Practice. Accessed on
www.avert.org/pmtct-hiv.htm:

Babbie, E. (1992). The practice of social research (6th ed.). California: Wordsworth.

Bailey, K. D. (1987). Method of social research (3rd ed.). New York: The Free Press.

Biemer, P. P., & Lyberg, L E. (2003). Introduction to survey quality. Hoboken, NJ:
John Wiley & Sons.

Bless, H. (1995). Fundamentals of social research methods: An African perspective.
Pretoria: Juta.

Boston Globe (2007). "Saving the babies: A victory for Africa" .UNICEF (August
2003), "Evaluation of United Nations-supported pilot projects for the prevention of
mother-to-child transmission of HIV": www.avert.org/pmtct-hiv.htm: Preventing
Mother-to-child Transmission (PMTCT) in Practice

Botswana Ministry of Health. (2010) .UNGASS Country Report: Progress report of
the national response to the 2001 declaration of commitment on HIV and AIDS
Reporting Period: 20082009.

Burns, N., & Grove, S. K. (2003). Understanding nursing research (3rd ed.).
Philadelphia: W.B. Saunders.
126



Chopra, M., Doherty, T., Jackson, D., & Ashworth, A. (2005). Preventing HIV
transmission to children: An evaluation of the quality of counselling provided to
mothers in three PMTCT pilot sites in South Africa. Acta Paediatrica, 5(94), 357363.

Chopra, M., Piwoz, E., Sengwana, J., Schaay, N., Dunnett, L., & Saders, D. (2002).
Effect of a mother-to-child HIV prevention programme on infant feeding and caring
practices in South Africa. SAfr Med J, 92(4), 298302.

Chopra, M., & Rollins, N. (2008). Infant feeding in the time of HIV: Rapid assessment
of infant feeding policy and programmes in four African countries scaling up
prevention of mother to child transmission programmes. Arch Dis Child, 93(4), 288
291.

Collins, K. J. (2000). Only study guide for RSC. Pretoria: University of South Africa.

Community Survey. (2007). Statistical Release Basic Results Municipalities.
Published by Statistics South Africa, Pretoria.

Community Survey. (2007). Statistical release: Basic results municipalities, 2008.
Published by Statistics South Africa, accessed October 2010, Pretoria. Available
online at: http://www.statssa.gov.za/publications/P03011/P030112007.pdf

Coughian, M., Cronin, P., & Ryan, F. (2006). Cross-sectional study design and data
analysis. Chicago, Illinois (IL).

Creswell, J. W. (1998). Qualitative inquiry and research design: Choosing among five
traditions. Thousand Oaks: Sage Publishers.

Day, C., Barron, P., Monticelli, F., & Sello E. (2009). The District Health Barometer
2007/08. Durban: Health Systems Trust; June 2009. ISBN: 1-919839-63-1. Available
online at: www.hst.org.za/uploads/files/DHB0708.pdf

127



De Vos, A. S. (1998). Research at grass roots: For the social sciences and human
service professions. Pretoria: Van Schaik.

De Vos, A. S., Fouche, C. B., Poggenpoel, M., Schurink, E., & Schurink, W. (1998).
Research at grass roots: A primer guideline for caring professions. Pretoria: Van
Schaik.

De Vos, A. S., & Strydom, H. (2000). Research at grass roots: For the social
sciences and human service professions (1st ed.). Pretoria: Van Schaik.

De Vos, A. S., Strydom, H., Fouch, C. B., & Delport, C. L. S. (2000). Research at
grassroots: For the social sciences and human service professions (1st ed.). Pretoria:
Van Schaik.

De Vos, A.S., Strydom, H., Fouche, C.B. & Delport, C.S.L. (2002). Research at Grass
Roots: For the Social Sciences and Human Service Professions (2nd ed.). Pretoria:
Van Schaik.

De Vos, A. S., Strydom, H., Fouche, C. B., & Deport, C. S. L. (2005). Research at
grass roots: For the social sciences and human service professions (3rd ed.).
Pretoria: Van Schaik.

Doherty, T. (2003). Baby steps: Reporting on the Prevention of Mother-to-Child
Transmission of HIV (PMTCT). 8 April 2005. Available online at:
www.nelsonmandela.org/images/uploads/Baby_Steps.pdf

Doherty, T., & Besser, M. (2003). An evaluation of the Prevention of Mother to Child
Transmission (PMTCT) of HIV Initiative in South Africa: Outcomes and key
recommendations. Available online at: www.hst.org.za. [Retrieved 13 June 2006].

Doherty, T., Besser, M., & Donohue, S. (2003). An evaluation of the prevention of
Mother to Child Transmission (PMTCT) of HIV Initiative in South Africa: Outcomes
128

and key recommendations. Durban: Health Systems Trust. Accessed 2006 13 June;
Available online at: www.hst.org.za.

Doherty, T., Besser, M., Donohue, S, Kamoga, N., Stoops, N., Williamson, L., &
Visser, R. (2003). An evaluation of the Prevention of Mother-to-child Transmission
(PMTCT) of HIV Initiative in South Africa: Lessons and key recommendations.
Durban: Health Systems Trust.

Doherty, T.M., McCoy, D & Donahue, S. (2005). Health system constraints to optimal
coverage of the PMTCT HIV transmission programme in South Africa. African Health
Sciences, vol. 5, no. 3, 213-218.

Doherty, T., Chopra, M., Nsibande., D., & Mngoma, D. (2009). Improving the
coverage of the PMTCT programme through a participatory quality improvement
intervention in South Africa. BMC Public Health, 9, 406. Available online at:
10.1186/1471-2458-9-406www.ncbi.nlm.nih.gov/pmc/articles/PMC2777166
Accessed 5 November 2009.

Family Health International Institute for HIV/AIDS & Elizabeth Glaser Pediatric AIDS
Foundation. (2003). Baseline assessment tools for preventing mother-to-child
transmission (PMTCT) of HIV. Available online at:
http://www.fhi.org/NR/rdonlyres/ejkelmgqgkbumgmsmuzbeaiys3rjpgbnzed5jtygb26iny
2vhlk4naexoprcwoy6u6e5vnsfcd4yga/PMTCTreportcorrectedFINAL.pdf

Frizelle, K., Solomon, V., & Rau, A. (2009). Strengthening PMTCT through
communication and social mobilisation: A review of the literature. Johannesburg:
CADRE. Available online at:
http://www.cadre.org.za/files/Strengthening%20PMTCT%20through%20communicati
on.pdf

Grinnel, R. M. (1998). Social work research and evaluation (3rd ed.). Itasca, IL: FE
Peacock.

HIV and AIDS in South Africa: Available online at: www.avert.org/aidssouthafrica.htm
129


Holloway, I. (1997). Basic concepts for qualitative research. New York: Blackwell
Science Publishers.

Human Sciences and Research Council (HSRC). (2009). Third South Africa National
HIV Prevalence, Incidence, Behaviour and Communication Survey of 2008. Pretoria:
HSRC Press.

International Centre for AIDS Care and Treatment Programs (ICAP) (2009). PMTCT
baseline assessment checklist tools. ICAP. Available online at:
http://www.columbiaicap.org/resources/pmtct/SiteAssessmentTool110107.pdf

Jackson, D. J., Chopra, M., Doherty, T. M., Colvin, M. S., Levin J. B., Willumsen,
J. F., Goga, A. E., & Moodley, P. (2007). Operational effectiveness and 36 week HIV-
free survival in the South African programme to prevent mother-to-child transmission
of HIV-1. AIDS, 21(4), 509516.

Janse van Rensburg-Bonthuyzen, E., Engelbrecht, M., Steyn, F., Jacobs, N.,
Schneider, H., & Van Rensburg, D. (2008). Resources and infrastructure for the
delivery of antiretroviral therapy at primary health care facilities in the Free State
Province, South Africa. Journal of Social Aspects of HIV/AIDS: An Open Access
Journal, 5(3), 106112. http://dx.doi.org/10.1080/17290376.2008.9724908

Karcher, H. (2006). Outcome of different nevirapine administration strategies in
Preventing Mother-to-Child Transmission (PMTCT) Programs in Tanzania and
Uganda. MedGenMed, 8(2), 12 April 2006. Availbale online at: www.avert.org/pmtct-
hiv.htm: Preventing Mother-to-child Transmission (PMTCT) in Practice.

Kumar, R. (2005). Research methodology: A step-by-step guide for beginners (2nd
ed.). London, Thousand Oaks, CA, New Delhi: Sage. ISBN 141291194X,
9781412911948.

Kvele, S., & Brinkman, S. (2008). Interviews (2nd ed.). Thousand Oaks, CA. Sage.
ISBN: 97807619255422
130


Leedy, P. D. (1997). Practical research: Planning and design (6th ed.). Columbus,
OH Mervill (Prentice Hall).

Lesotho Ministry of Health. (2009). Lesotho UNGASS Country Report status of the
national response to the 2001 declaration of commitment on HIV AND AIDS January
2008 - December 2009. Lesotho Ministry of Health and Social Welfare (MOHSW)

Limpopo Department of Health & Social Development. (2005). State of the Province
Report. Population and Development Directorate.

Linkages Project. (2004, April 14). "A review of UNICEF experience with the
distribution of free infant formula for infants of HIV-infected mothers in Africa."
Preventing Mother-to-child Transmission (PMTCT) in Practice. Available online at:
www.avert.org/pmtct-hiv.htm

Mafikeng Municipal Integrated Development Plan (IDP). (20102011). Available
online at: www.mafikeng.gov.za/index.php?option=com_docman&task.

Magoro, M. T. (2009). On assessment of the experiences of patients on the
Comprehensive HIV AND AIDS Care Management and Treatment Programme in
Tshwane, Gauteng. School of Public Health, University of Limpopo. Available online
at: http://ul.netd.ac.za/handle/10386/250

Maman, S., Cathcart, R., Burkhardt, G., Omba, S., Thompson, D., & Behets, F.
(2011). The infant feeding choices and experience of women living with HIV in
Kinshasa, Democratic Republic of Congo. Department of Health Behaviour and
Health Education, University of North Carolina, Chapel Hill. NC, USA. AIDS Care,
24(2), 259265; Epub 2011 Jul 25.

Mandal, M., Purdin, S., & McGinn, T. (2006). A study of health facilities: implications
for reproductive health and HIV/AIDS programs in southern Sudan. Int Q Community
131

Health Educ., 24(3), 175190 Unabridged (v 1.1). Random House, Inc. 20 Sep.
2007. Available online at: www.ncbi.nlm.nih.gov/pubmed/17686738

Mangale, N. (2006). Challenges faced by women who are in senior positions.
University of Venda. South Africa (Unpublished).

Mogorosi, L. D. (2005). Steps in research and thesis writing process: Choice and
project management. University of Venda. Unpublished.

Moth, I. A., Ayayo, A. B. C. O., & Kaseje, D. O. (2005). Assessment of utilisation of
PMTCT services at Nyanza Provincial Hospital in Kenya. Journal of Social Aspects of
HIV/AIDS 2(2), July, 244251. Available online at:
www.sahara.org.za/index2.php?option=com_docman.

Mouton, J. (1996). Understanding social research. Pretoria: Van Schaik.

Muko, K. N., Tchangwe, G. K., Ngwa,V. C., & Njoya, L. (2004). Preventing mother-to-
child transmission: Factors affecting mothers choice of feeding. A case study from
Cameroon. Journal of Social Aspects of HIV/AIDS, 1(3), 132138.

South Africa North West Department of Health. (2012).North West Province
Department of Health Strategic Plan for HIV AND AIDS, STIs and TB, for 20122016.
North West Department of Health. South Africa.

NASCOP. (2001). AIDS in Kenya: Background, projections, impact, interventions and
policy (6th ed.). Nairobi: Republic of Kenya, Ministry of Health.

NASCOP. (2001). Kenya National Guidelines for Voluntary Counselling and Testing
services. Nairobi: Republic of Kenya, Ministry of Health.

NASCOP. (2002). National Guidelines for Prevention of Mother-to-Child
Transmission of HIV in Kenya (2nd ed.). Republic of Kenya, Ministry of Health.

132

Neuman, W. L. (1997). Social research methods: Qualitative and quantitative
approach. Boston, MA: Allyn & Bacon.

Nguyen, T. A., Oosterhoff, P., Pham, Y. N., Hardon, A., & Wright, P. (2009). Health
workers' views on quality of prevention of mother-to-child transmission and postnatal
care for HIV-infected women and their children. Human Resources for Health, 7, 39
doi:10.1186/1478-4491-7-39. Published: 13 May 2009. licensee BioMed Central Ltd.
Available online at: http://www.human-resources-health.com/content/7/1/39

Niang, C., & Peltzer, K. (2005). Social Aspects of HIV and AIDS Research Alliance
Journal (SAHARA J). Journal of Social Aspects of HIV/AIDS/Journal des Aspects
Sociaux du VIH/SIDA. ISSN 1729-0376. Sahara July 2005. Published by SAMA
Health and Medical Publishing Group (HMPG). South Africa . SAHARA J is listed on
www.ajol.co.za and www.sabinet.co.za

North West Provincial Council on AIDS & North West Department of Health.
Implementation of the 2007-2011 HIV & AIDS AND STI Strategic Plan End Term
Review: North West Province Final: 7 October 2011

Nuwagaba-Biribonwoha, H., Mayon-White., R. T., Okong, P., & Carpenter., L. M.
(2007). Challenges faced by health workers in implementing the prevention of
mother-to-child HIV transmission (PMTCT) programme in Uganda. Journal of Public
Health, 29(3), 269274 doi:10.1093/pubmed/fdm025, Advance Access Publication 30
May 2007.

Painter, T. M. (2004, September 4). "Women's reasons for not participating in follow
up visits before starting short course antiretroviral prophylaxis for prevention of
mother to child transmission of HIV: qualitative interview study", BMJ, 329(7465):
Preventing Mother-to-child Transmission (PMTCT) in Practice. Available online at:
www.avert.org/pmtct-hiv.htm

Parab, S., & Bhalerao, S. (2010). Research methodology: Study designs.
International Journal of Ayurveda Research, 1(2), AprilJune. Department of Clinical
Pharmacology, Seth G, Medical College and KEM Hospital, Parel, Mumbai - 400 012,
133

India,
1
Department of Clinical Pharmacology, TNMC and BYL Nair Hospital, Mumbai
Central, Mumbai - 400 008, India. Int J Ayurveda Res. 2010 AprJun; 1(2): 128131.
doi: 10.4103/0974-7788.64406. Available online at:
http://www.ijaronline.com/temp/IntJAyurvedaRes12128-1405036_035410.pdf

Peltzer, K., Skinner, D., Mfecane, S., Shisana, O., Nqeketo, A., & Mosala, T. (2005).
Factors influencing the utilisation of prevention of mother-to-child-transmission
(PMTCT) services by pregnant women in the eastern Cape, South Africa. Health SA
Gesondheid, 10(1), 2640.

Phaswana-Mafuya, N., & Kayongo, D. (2008). Experiences of prevention of mother to
child transmission services by HIV positive mothers in the Eastern Cape of South
Africa. African Journal for Physical, Health Education, Recreation and Dance
(AJPHERD), 14(1), 6387.

Polit,. D., & Beck., C. (2006). Essentials of nursing care: Methods, appraisal and
utilization (6th ed.). Philadelphia: Lippincott Williams and Wilkins.

Raburu, J. A. (2004). Factors influencing quality of maternal health services: A case
study of Nyanza and Nakuru Provincial Hospitals. Kenya Nursing Journal, 32(2), 23
29.

Reid, W. J., & Smith, A. S. (1981). Research in social work. New York: Columbia
University Press.

Reproductive Health and HIV Research Units (RHRU) HIV Standard no: 4 tool, for
self-assessment to improve HIV service within Primary Health Care services.

Rispel, L. C., Peltzer, K., Phaswana-Mafuya, N., Metcalf, C. A., & Treger, L. (2009).
Assessing missed opportunities for the prevention of mother-to-child HIV
transmission in an Eastern Cape local service area. South African Medical Journal,
99(3), 174179.

134

Rubin, A., & Babbie, E. (2010). Research methods for social work (7th ed.). USA:
Chapman University, Linda Schreimber.

Republic of South Africa. (2008). Progress Report on Declaration of Commitment on
HIV and Aids. Available online from: http://data.unaids.org/pub/Report/2008/
south_africa_2008_country_progress_report_en.pdf

SANAC & South Africa Department of Health. (2007). Developing a Comprehensive
Monitoring and Evaluation framework for the HIV & AIDS and STIs National Strategic
Plan 20072011. South Africa November 2007.

Shisana, O., Rehle, T., Simbayi, L. C., Zuma, K., Jooste, S., Pillay-van-Wyk, V.,
Mbelle, N., Van Zyl, J., Parker, W., Zungu, N. P., Pezi, S., & the SABSSM III
Implementation Team. (2009). South African National HIV Prevalence, Incidence,
Behaviour and Communication Survey 2008: A turning tide among teenagers? Cape
Town: HSRC Press.

Singh, V. (2010). Implementation of the dual therapy Prevention of Mother-to-Child-
Transmission Protocol. Nelson Mandela Metropolitan University, July 2010.
http://www.nmmu.ac.za/documents/theses/mpharm%20v%20singh.pdf

Skinner, D., & Mfecane, S. (2004). Stigma, discrimination and implications for
PLWHA. Journal of Social Aspects of HIV/AIDS, 1(3), 157164.

Skinner, D., Mfecane, S., Gumede, T., Henda, N., Dorkenoo, E., Davids, A. &
Shisana, O. (2003). Situational Analysis of PMTCT Services in Region E of the
Eastern Cape. Cape Town, South Africa, HSRC Press.

Skinner, D., Mfecane, S., Gumade, T., Henda, N., & Dekenoo, E. (2004). Report on
research for Eastern Cape PMTCT project. Available online at:
http//www.sahara.org.za.

Skinner, D., Mfecane, S., Henda, N., Dorkenoo, E., Davids, A., Gumede, T &
Shisana, O. (2003). Situational analysis of PMTCT services in Region E of the Easter
135

Cape, 1-28. [Date of access: 5 January 2009]. Available online at:
http://www.sahara.org.za/index.php/Download-document/54-Situational-analysis-of-
PMTCT-services-in-Region-E-of-the-Eastern-Cape.html

Smart, T. (2011, July 1). HIV & AIDS treatment in practice. .5th South African AIDS
Conference, Durban 2011. HATiP, Issue 178, 7.

South Africa North West Department of Health. (2008-2011). District Health
Information system Quarterly report.

South Africa Department of Helath. (2010). Country Progress Report on the
Declaration of Commitment on HIV/Aids 2010. Reporting Period: January 2008
December 2009. Department of Health, South Africa.

South Africa Department of Health. (2007). HIV and AIDS statistics for South Africa:
The South African Department of Health Study, 2007. Available online at:
www.avert.org/safricastats.htm

South Africa: Gaps remain in government's PMTCT programme. (IRIN In-Depth).
Johannesburg. Available online at:
http://www.plusnews.org/InDepthMain.aspx?InDepthId=40&ReportId=70984
[Accessed 14 September 2006]

South Africa Department of Health. (2008). National Antenatal Sentinel HIV and
Syphilis Prevalence Survey, 2008. September 2009. Pretoria Available online at:
www.doh.gov.za/docs/nassps-f.html

South Africa Department of Health. (2009a). Tool to assess site readiness for
initiating antiretroviral therapy. Public Health Facilities.

South Africa Department of Health. (2009b). National Antenatal Sentinel HIV and
Syphilis Prevalence Survey in South Africa, 2009. Pretoria: Department of Health.

136

South Africa Department of Health. (2009c). Midterm Review of the National
Strategic Plan on HIV, AIDS and STIs. Summary Report. November 2009. Pretoria:
Department of Health.

South Africa Department of Health. (2009d). UNGASS Country Progress Report, on
the Declaration of Commitment on HIV/AIDS, March 2010. Reporting Period: January
2008December 2009

South Africa Department of Health. (2010). National Antenatal Sentinel HIV and
Syphilis Prevalence Survey in South Africa, 2009. Pretoria: Department of Health.

South Africa Department of Health & South African National AIDS Council (SANAC).
(2000). HIV/AIDS and STI Strategic plan for South Africa 2000-2005. Pretoria:
Department of Health

South Africa Department of Health & South African National AIDS Council (SANAC).
(2007). HIV/AIDS and STI National Strategic Plan for South Africa (NSP) 20072011.
Pretoria: Department of Health.

South Africa Department of Social Development. (1998). Population Policy for South
African, April 1998. The Minister of Welfare and Population Development, South
Africa. Pretoria.

South Africa National AIDS Council (SANAC) &. Health Development Africa
Consultant (HDA). (2010). Mid-Term Review of South Africas performance in
implementing the National Strategic Plan for HIV and AIDS and STIs, of 2007-2011
(the NSP). South Africa: SANAC Secretariat.

South Africa Department of Health & SANAC. (2010). The South African Antiretroviral
Treatment Guidelines.

South Africa Department of Health and Social Development. (2009). National
Antenatal Sentinel HIV and Syphilis Prevalence Survey report in South Africa 2008.
Department of Health and Social Development: Pretoria
137


South Africa Department of Health. (2010). National Antenatal Sentinel HIV and
Syphilis Prevalence Survey in South Africa, 2009. Department of Health: Pretoria.

South Africa Department of Health & Social Development. (2008). National HIV and
Syphilis Prevalence Survey report. Pretoria, South Africa.

South Africa Department of Health. (2008). National HIV and Syphilis Prevalence
Survey report. Pretoria: Department of Health.

South Africa Department of Health.. (2009). Primary Health Care Supervision
Manual: A guide to Primary Health Care Facility Supervision. Commissioned and
published by: The National Department of Health: Quality Assurance Directorate.

South Africa Department of Health & South African National AIDS Council (SANAC).
(2010), Clinical Guidelines on the Prevention of Mother-to-Child Transmission
(PMTCT). Pretoria, South Africa.

Stephen, C. R., Bamford, L. J, Patrick, M. E, Wittenberg, D. F., the MRC Unit for
Maternal & Infant Health Care Strategies eds. Saving Children. (2009). Five years of
data: A Sixth Survey of Child Healthcare in South Africa. Pretoria: Tshepesa Press,
MRC, CDC, 2011. Pretoria 2011, ISBN No: 978-0-620-50443-0.

Strauss, A., & Corbin, J. (1998). Basics of qualitative research: Techniques and
procedures for developing grounded theory. London: Sage.

Solomon, V., Frizelle., K, and Rau, A. (2009). Strengthening PMTCT through
communication: A review of the literature. Johannesburg: CADRE. 1-64.

Swaziland Ministry of Health,.(2010). UNGASS Country Report: Monitoring the
declaration of the commitment on HIV and AIDS (UNGASS) Swaziland Country
Report March 2010.

138

Tayla, C., & Colton, S. C. M. (2005). Preventing mother to child transmission of HIV
in Kenya: Pathfinder international`s experience: 2002-2005. Nairobi, Kenya :
Pathfinder International/Kenya ; Watertown, MA : Pathfinder
International/Headquarters, [2005]

Tint, K., Doherty, T., Nkonki, L., Witten, C., & Chopra, M. (2003). An evaluation of
PMTCT and infant feeding training in seven provinces of South Africa. October 2003.
ISBN: 1-919743-77-4

Torpey, K., Kabaso, M., Kasonde, P., Dirks, R., Bweupe, M., Thompson, C., &
Mukadi,. Y. D. (2010). Increasing the uptake of prevention of motherto- child
transmission of HIV services in a resource limited setting. BMC Health Services
Research, 10(29) http://www.biomedcentral.com/1472-6963/10/29.

United Nations Programme on HIV/AIDS (UNAIDS) (2008) Report on the Global Aids
Epidemic, available online from:
http://www.unaids.org/en/KnowledgeCentre/HIVData/GlobalReport/2008/2008_Globa
l_report.asp

UNAIDS. (2001a). Local monitoring and evaluation of the integrated prevention of
mother to child HIV transmission in low-income countries. New York: United Nations.

UNAIDS. (2001b). Declaration of Commitment on HIV/AIDS. Heads of State and
Representatives of Governments issued the Declaration of Commitment on HIV/AIDS
during the United Nations General Assembly in June 2001. Available online at:
http://www.unaids.org/en/aboutunaids/Goals/default.asp.

UNAIDS. (2003). Progress report on the Global response to the HIV/AIDS epidemic
2003. Geneva. UNAIDS

UNAIDS. (2004a). Report on Global AIDS epidemic. Geneva. UNAIDS

UNAIDS. (2007). AIDS epidemic update, Geneva. UNAIDS

139

UNAIDS, (2008a). Report on the global HIV/AIDS epidemic, Joint United Nations
Programme on HIV/AIDS (UNAIDS).WHO Library Cataloguing-in-Publication Data,
Switzerland.

UNAIDS. (2008b). Report on the Global AIDS Epidemic. Geneva. UNAIDS

UNAIDS. (2009). Report on the global HIV/AIDS epidemic, Joint United Nations
Programme on HIV/AIDS (UNAIDS).WHO Library Cataloguing-in-Publication Data,
Switzerland

UNAIDS. (2010). UNAIDS report on the global AIDS epidemic. Available at:
http://www.unaids.org/globalreport/documents/20101123_GlobalReport_full_en.pdf.
Accessed on September 13, 2011

UNAIDS. (20112015). Strategy: Getting to zero. Available at:
http://www.unaids.org/en/media/unaids/contentassets/documents/unaidspublication/2
010/JC2034_UNAIDS_Strategy_en.pdf. Accessed on September 13, 2011

UNAIDS and WHO. AIDS epidemic update. (2009). Geneva, UNAIDS, 2009
(http://www.unaids.org/en/dataanalysis/epidemiology/2009aidsepidemicupdate,
accessed 15 October 2011).

UNAIDS & World Health Organization (WHO). (2009). HIV and AIDS epidemic
update. WHO Library Cataloguing-in-Publication Data, Switzerland.

UNICEF. (2003). Annual Report Published by: UNICEF, Division of Communication,
3 United Nations Plaza, H-9F, New York, NY 10017.

UNICEF & Centre for AIDS Development, Research and Evaluation (CADRE).
(2009). Strengthening PMTCT through communication: A review of the literature.
South Africa. Johannesburg: UNICEF & Centre for AIDS Development, Research
and Evaluation (CADRE). 1-64.

140

United Nations General Assembly Special Session (UNGASS) (2010). Country
Progress Report on the Declaration of Commitment on HIV/AIDS.

UNICEF. (August 2003). "Evaluation of United Nations-supported pilot projects for
the prevention of mother-to-child transmission of HIV" Preventing Mother-to-child
Transmission (PMTCT) in Practice. Available online at: www.avert.org/pmtct-hiv.htm

UNICEF. (2008). Scaling up HIV prevention, diagnosis and treatment for mothers and
babies in Southern Africa. Accessed 30 April 2009,
http://www.unicef.org/sowc09/docs/SOWC09-CountryExample-SouthAfrica.pdf

UNICEF. (2009). The state of the world's children: Maternal and newborn health
Available online at: www.unicef.org/sowc09/report/report.php.

Van Lettow, M., Bedell, R., Landes, M., Gawa, L., Gatto, S., Mayuni, I., Chan, A. K.,
Tenthani, L., & Schouten, E. (2011). Uptake and outcomes of a prevention-of mother-
to-child transmission (PMTCT) program in Zomba district, Malawi. BMC Public
Health, 11:426 http://www.biomedcentral.com/1471-2458/11/426

Wacker, G., Guido, J. D., & Wacker, C. G. (1998). Legal issues in nursing (2nd ed.).
Connecticut: Appleton and Lange.

White, C. J. (2003). Research methods and techniques. C.J White, Mustang Road
44, Pierre Van Ryneveld, 0157

World Health Organization (WHO). (2006). "Antiretroviral drugs for treating pregnant
women and preventing HIV infection in infants in resource-limited settings: towards
universal access." Preventing Mother-to-child Transmission (PMTCT) in Practice.
Available online at: www.avert.org/pmtct-hiv.htm:

WHO, UNAIDS & UNICEF. (2010). Towards universal access: Scaling up priority
HIV/AIDS interventions in the health sector. Preventing Mother-to-child Transmission
(PMTCT) in Practice, Geneva. Available online at: www.avert.org/pmtct-hiv.htm:
141

Wood, M. J., Ross-Kerr, J. C., Pamela, J., & Brink, P. J. (2006). Basic steps in
planning nursing research: From question to proposal (6th ed.). London: Jones and
Bartlett ISBN-10: 0-7637-3478-0.
World Health Organization. (2000). Preventing mother to child transmission:
Technical experts recommended use of antiretroviral regimens beyond projects. Joint
press release. Geneva.

World Health Organization. (WHO). (2001). Prevention of mother-to-child
transmission of HIV: Use of nevirapine among women of unknown serostatus. Report
of a technical consultation, Geneva, accessed 5-6 December 2001. Available online
at: www.who.int/hiv/pub/mtct/en/isbn9241562129.pdf

World Health Organization (WHO). (2010). PMTCT strategic vision 2010 to 2015:
preventing mother-to-child transmission of HIV to reach the UNGASS and Millennium
Development Goals. WHO Library Cataloguing-in-Publication data

World Health Organization. (2007a). Task shifting rational distribution of tasks
among health workforce team: Global recommendations and guidelines. [Web:]
http://www.data.unaids.org/pub/Manual/2007/ttr_taskshifting_en.pdf [Date of access:
10 July 2009].

World Health Organization. (2007b). Guidance on global scale up of the prevention of
mother-to-child of HIV. [Date of access: 17 July 2009].
[Web:] http://www.who/int/hiv/pub/guidelines/pmtct_scaleup2007/en/

World Health Organization. (2010). PMTCT Strategic vision 2010-2015: preventing
mother-to-child transmission of HIV to reach the UNGASS and Millennium
Development Goals. World Health Organization HIV/AIDS Universal Access Plan 2nd
Performance Report Accessed on September 13, 2011 Available at:
http://www.who.int/hiv/pub/mtct/strategic_vision.pdf


142

World Health Organization, UNAIDS. & UNICEF. (2009) Towards universal access:
scaling up priority HIV/AIDS interventions in the health sector. Progress report 2009.
Geneva, World Health Organization, 2009, accessed 15 October 2011).
(http://www.who.int/hiv/2009progressreport/report/en/index.html

Zimbabwe Ministry of Health. (2010). UNGASS Country Report.: Country United
Nations General Assembly special session report (UNGASS) special session report
on HIV and AIDS on HIV & AIDS follow-up to the declaration of commitment on HIV
and AIDS, Reporting Period: January 2008 to December 2009

143

APPENDIX A:

Questionnaire:
Evaluation of the implementation of PMTCT interventions in Mafikeng Local Municipality
Clinics,
North West Province, South Africa.
INSTRUCTIONS TO THE RESPONDENT:
(The researcher will ask the participant if he/she is willing to answer a few questions. After
reading the following introduction, the participant will be presented with the consent form.)
SECTION A: DETAILS OF THE FACILITY
Questionnaire number:
Type of clinic?
Code___________ [K-Z]
Clinic contact number?
When was the clinic opened?
_______/_______/________
SECTION B: BIOGRAPHICAL INFORMATION OF THE RESPONDENT
a) Gender? Male Female

b) What is the length of your experience as regards the PMTCT programme in this
clinic?

#______
_
SECTION C: AVAILABILITY OF RESOURCES, INFRASTRUCTURE AND EQUIPMENT TO
IMPLEMENT THE PMTCT SERVICES.
Questions: Yes No Comments
1. Is there a maternity facility available on site? 01 02
2. Does the facility provide free infant formula to
infants?
01 02
3. Do the mothers receive an ANC card? 01 02
4. Is there adequate space for ANC which will ensure
confidentiality during counselling?
01 02
5. Do you have adequate consultation rooms for
ANC?
01 02
6. Does the facility provide free infant formula to
infants up to 6 months in order to avoid mixed
feeding by HIV positive mothers?
01 02
7. Does the facility provide nutritional support to HIV
positive women who are breastfeeding and to HIV
exposed infants?
01 02
8. Does the counselling room offer privacy so other
people are not able to see inside?
01 02
9. Do you have sufficient staff to perform the HIV
testing in this facility?
01 02
10. Do you provide PMTCT information, including
hand-outs and booklets, during family planning
counselling?
01 02
144

11. Are there any designated VCT rooms at this
facility?
01 02
12. Does this facility have the following guidelines and
policies available?
Yes No Comments
a) Revised ART guidelines 01 02
b) Management of drug adverse effects 01 02
c) Management of opportunistic infections 01 02
d) Essential Medicines List (EML) 01 02
e) Up and down referral of patients 01 02
f) STI guidelines 01 02
g) TB infection clinical guideline 01 02
h) VCT and HCT( PICT) 01 02
i) Nutrition for PLWHA 01 02
j) Antenatal care 01 02
k) Written confidentiality policy 01 02
l) Laboratory procedures 01 02
m) Integrated Management of Childhood Illness
(IMCI) Guidelines.
01 02
n) PEP Guidelines 01 02
o) National Strategic Plan (HIV and AIDS) 01 02
p) Is the most recent National PMTCT Guideline
available at the clinic?
01 02
q) Are the documents kept in a place known to
staff members and easily accessible?
01 02
r) Are staff members able to use and implement
the relevant PMTCT guidelines?
01 02
13. Are the following PMTCT related supplies available
in this facility?
Yes No Comments
a) ARV (NVP) tablets for ANC and during
delivery.
01 02
b) ARV syrup (NVP) for HIV exposed babies 01 02
c) Dried Blood Spot (DBS) test kits 01 02
d) Infant formula 01 02
e) Condoms 01 02
14. How often do you run out of the following Weekly Monthly Often Rarely
145

PMTCT supplies?
a) ARV prophylaxis 01 02 03 04
b) HIV rapid test kits 01 02 03 04
c) Lancets for finger pricking 01 02 03 04
d) Infant formula (Other nutritional supplements) 01 02 03 04
e) Condoms 01 02 03 04
15. What is the turnaround time for the following
HIV test results (HIV and CD4 Tests)?
07 Weeks
and
Above
04 to 06
Weeks
01 to
02
weeks
01 Week
a) PCR results 01 02 03 04
b) Rapid HIV test 01 02 03 04
c) ELISA results 01 02 03 04
d) CD4 results 01 02 03 04
SUB-SECTION C: AVAILABILITY OF PMTCT RELATED SERVICES
16. How many midwives/nurses are assigned to the PMTCT
services on a daily basis?
#____________________
_
17. How many days per week does the clinic provide PMTCT
services?
#____________________
_
18. What are the normal working hours at this clinic? #____________________
_
19. Which of the following PMTCT related services are
offered at your site?
Yes No Comments
a) Antenatal consultation (Maternity, labour and
delivery) for ANC
01 02
b) PMTCT services 01 02
c) Family planning for pregnant women 01 02
d) HIV care and treatment (ART clinic) 01 02
e) VCT (Voluntary Counselling and Testing
Services)
01 02
f) TB treatment and screening for pregnant
women
01 02
g) Immunisations for infants 01 02
h) Exposed infant follow up 01 02
i) Infant feeding counselling 01 02
j) PCR testing for infants 01 02
k) Postnatal follow up of mother and infant 01 02
20. Has your clinic been visited at least once by the 01 02
146

sub-district MCH coordinator in the last four
months?
21. Has your clinic been visited at least once by the
district PHC supervisor in the last four months?
01 02
22. Has your clinic been visited at least once by the
sub-district PMTCT coordinator in the last four
months?
01 02
23. Does the facility provide ANC delivery services? 01 02
24. Does the clinic conduct PMTCT health promotion
through community outreach programmes?
01 02
25. Are there NGOs or partners working to support the
implementation of PMTCT services in this clinic?
01 02
26. Is civil society and home base care involved in the
PMTCT programme coverage?
01 02
27. Does the facility provide infant feeding
counselling?
01 02
28. Does the facility provide guidance regarding the
volume and frequency of feeding at each age?
01 02
29. Where do the women attending antenatal services in this facility normally deliver?
a) At the hospital or other health centres 01
b) At home 02
c) Within this facility 03
d) Do not know 04
e) Not Applicable 05
f) At the hospital or other health centres 06
SECTION D: KNOWLEDGE OF HEALTH CARE WORKERS REGARDING THE
IMPLEMENTATION OF PMTCT SERVICES.
Questions: Knowledge and training on PMTCT Yes No Comments
30. Are staff members trained on relevant intervention to
prevent MTC?
01 02
31. Are clinical staff members on trained infant feeding
in the context of HIV infection?
01 02
32. Are clinical staff members trained on HIV testing and
Counselling for PMTCT?
01 02
33. Are clinical staff confident as regards testing and
counselling for PMTCT?
01 02
34. Are clinical staff trained on the stigma and
discrimination related to MTCT?
01 02
35. Do you think the training(s) received was adequate
as regards providing PMTCT services at this clinic?
01 02
36. Are you informed as regards providing PMTCT
interventions for both mothers and children?
01 02
37. Have any of the staff members received PMTCT 01 02
147

training within the last 6 months?
38. Are all clinical staff trained on PMTCT able to apply
the knowledge and skills they have acquired?
01 02
39. Are all staff members given an opportunity to
transfer the skills they have learned?
01 02
40. Has any of the clinical staff been trained on ART
guidelines?
01 02
41. Has any of the clinical staff been trained on PMTCT
guidelines?

42. Do you have knowledge of PMTCT interventions? 01 02
43. Are clinical staffs able to transfer the skills they have
acquired through training?
01 02
44. Are clinical staff able to apply the skills they have
acquired through training?
01 02
45. Are clinical staff able to apply and transfer the
knowledge and skills they have acquired through in-
service training and orientations?
01 02
46. Are the guidelines used for in-service training? 01 02
47. How would you rate the clinic on the knowledge provided as regards the following PMTCT
interventions?
Questions: Good Fair Poor Excellent
a) Implementation of PMTCT
guidelines
01 02
03 04
b) PMCTCT training received
01 02
03 04
c) PMTCT services rendered 01 02 03 04
d) VCT services for ANC 01 02 03 04
e) PCR testing for children 01 02 03 04
f) Antibody testing for children 01 02 03 04
g) Monitoring of the PMTCT
programme
01 02 03 04
SECTION E: CHALLENGES AND BARRIERS FACED BY HEALTH CARE WORKERS WITH
REGARD TO THE IMPLEMENTATION OF THE PMTCT PROGRAMME
48. What are the challenges and barriers that may contribute to the failure of the implementation of
the PMTCT programme in this facility?
a) Lack of proper programme monitoring Yes No Comments
b) Availability of too many registers 01 02
c) Lack of teamwork 01 02
d) Lack of knowledge on the part of health
care workers
01 02
e) Lack of enthusiasm and confidence as
regards PMTCT
01 02
f) Lack of commitment and motivation to carry
out the work
01 02
148

g) Lack of support and supervision 01 02
h) Understaffing/ inadequate human and
physical resources
01 02
i) ANC patients not arriving for their
appointments
01 02
j) Lack of community involvement and support
(Including NPO and community civil
structures)
01 02
k) Lack of knowledge of PMTCT on the part of
patients
01 02
l) Lack of training and skills transfer 01 02
m) Poor training of health care workers 01 02
n) Lack of understating of PMTCT guideline
and protocols on the part of health care
workers
01 02
o) Fear and stigma on the part of the patients 01 02
p) Shortage of equipment, and resources with
which to deliver PMTCT services
01 02
q) Lack of coordination and integration of
PMTCT with other programmes
01 02
r) Poor data quality and data management 01 02
s) Poor management of programmes 01 02
t) Traditional beliefs 01 02
u) Long waiting time in queue for consultations 01 02
v) Negative attitude on the part of some of the
nurses
01 02
w) Poor quality counselling 01 02

SECTION F: RECORDING OF PMTCT ACTIVITIES FOR PATIENT MONITORING
49. Are the PMTCT records (E-tool, PMTCT, ANC
registers) retained by the PHC facility
completed correctly and kept up to date?
Yes No Comments
50. Are patient (including PMTCT) records at the
PHC facility stored in a safe and confidential
manner?
01 02
51. Is the PMTCT report correctly completed in the
DHIS monthly statistics form?
01 02
52. Is the PMTCT data or information displayed
graphically?
01 02
53. Is there a register for infant follow up, especially
for those infants born to HIV positive mothers?
01 02
54. Are records for infant follow up up to date,
including treatment administered to babies born
of HIV positive mothers?
01 02
55. Does the PHC facility receive written referrals
from hospital for infants born to HIV positive
mothers?
01 02
149

j) Is the ANC card provided with comprehensive
information from referring clinics?
01 02
k) Is the road to health care provided with
comprehensive information from referring
clinics?
01 02


SECTION G: EVALUATING PMTCT PROGRAMME INTERVENTION DURING
PREGNANCY AND POST DELIVERY.

56. Raw data for the following PMTCT data elements (June 2008 to December 2011).

A. PMTCT Data Elements for Mother

PMTCT intervention data elements for
mothers
Oct
2010
Nov
2010
Dec
2010
Jan
2011
Feb
2011
Mar 2011
# of Antenatal first visits
# of Antenatal client pre-test counselling for HIV
# of Antenatal client HIV 1st test
# of Antenatal client HIV 1st test positive
# of Antenatal clients re tested for HIV at 32
weeks or later

# of Antenatal clients retested positive at 32
weeks or later

# of HIV maternal status known
#of HIV maternal status unknown
# of Antenatal client Nevirapine taken during
labour

#of ANC on ART

B. PMTCT Data Elements for Babies

PMTCT intervention data elements for
babies
Oct
2010
Nov
2010
Dec
2010
Jan
2011
Feb
2011
Mar 2011
#Deliveries in the clinic
#Baby given Nevirapine within 72 hours of
birth

#Baby initiated on Cotrimozole at 6 weeks
#Baby PCR test at 6 weeks
#Baby PCR test positive at 6 weeks
#Live births in facility
#Live births to HIV positive woman
#Baby HIV antibody test positive at 18 months
#Baby HIV antibody test at 18 months

THANK YOU FOR YOUR PARTICIPATION AND HONESTY

150


APPENDIX B:
UNIVERSITY OF VENDA (INFORMED CONSENT LETTER)

Research Project: A Cross Sectional Descriptive Study Evaluation of the
Implementation of Prevention of Mother to Child Transmission of HIV (PMTCT)
Interventions in Mafikeng Sub-District Clinics, North West Province, South Africa
My name is Ndivhuho Mangale; I am a masters student at the University of Venda
conducting research on Evaluation of the implementation of PMTCT interventions at
Mafikeng clinics. The main objective of the study is to evaluate the implementation of
prevention of mother-to-child transmission (PMTCT) interventions during pregnancy and at
post-delivery at Mafikeng clinics, in Mafikeng Sub-District, in North West province, South
Africa. The study finding will benefit the department of health to improve quality of PMTCT
services. The Questionnaire will take 30 to 45 minute of your time during the interview
process.

You are kindly invited to participate in this research project. There are researcher would like
to inform you that there wont be any risk or cost as the results of taking part in the study.
There are no direct benefits, remunerations or incentives to be given to the respondents
before and after participating in the study.

The researcher would like to ensure you confidentiality and will not write down your name,
and your answers will be treated with strict confidentiality. Your participation is voluntary,
and you are not obliged to answer any questions you do not want to answer. You are free to
withdraw from the study if you want.

I greatly appreciate your taking the time to speak with me.

Yours Faithfully

--------------------------------- --------------------------------
Mangale Ndivhuho (Mr) Date
Principal investigator
151

APPENDIX C:

PARTICIPANT CONSENT FORM

By signing this consent form, you indicate that; 1) you have read or understood the consent
form; 2) your questions about the research have been answered to your satisfaction, and 3)
you voluntarily agree to participate in this study. A copy of this signed consent form can be
provided upon request.

I, ____________________________, agree to participate in the study. The conditions are as
follows:

I have read the information on the proposed study, heard the aims and objectives of
the proposed study and was provided the opportunity to ask questions and given
adequate time to rethink the issue.
The aim and objectives of the study are sufficiently clear to me. I have not been
pressurised to participate in any way;
I understand that participation in this Study is completely voluntary and that I may
withdraw from it at any time and without supplying reasons;
There will be no direct benefits or incentives to be given respondents for participating
in the study or answering Questions;
All interview data will be handled in confidentiality and stored in a safe place for the
period of data collection and data analysis. No identifying names will be associated
with the questionnaire;
All questionnaire data will be destroyed at the conclusion of the study. The researcher
will not use any audio or tapes to record the interview process. The researcher would
like to promise you that informed form will be placed in a separate place away from
the Questionnaire answered to promote anonymity and confidentiality.
I am aware that this Study has been approved by the University of Venda Research and
Ethics committee. I am fully aware that the results of this Study will be used for scientific
purposes and may be published. I agree to this, provided my privacy is guaranteed. I hereby
give consent to participate in this Study.
__________________________________________ __________
Participant Signature Date

__________________________________________ __________
Interviewer Signature Date





152

APPENDIX D:
RESEARCH PROJECT TIME FRAME

WORKPLAN (January 2010 August 2011)

ACTIVITY


TIME FRAME DELIVERABLE
Proposal development January 2010 A full dissertation proposal
Proposal submission and
presentation to higher degree
committee
November 2010 The study to be approved by
the committee
Proposal review by ethics
committee
March 2011 Ethical clearance
Application to the University of
Venda to conduct a study
April 2011 The University permission to
conduct the study
Application to North West
Department of Health to
conduct the study
May 2011 To get ethical clearance
Data collection

May 2011 Gathering data for the study
Data analysis

June 2010 Management and to analyse
data
Writing report

July 2011 Completing the study results
Report submission August 2011 Obtaining the masters degree
in Public Health under the
school of Health Sciences.











153

APPENDIX E:
Research Grant Proposals Budget Brake Down
ESTIMATED 2010 to 2011 RESEARCH BUDGET
I request a total Sponsorship of R 56 870.00 to undertake the study described below. The
estimated costs of R56 870.00 will enable the researchers to conduct research although out
Mafikeng clinics.

Equipment Requested Amount Justification
Printer 950.00
Equipments such as printer, own
personal laptop computer and
back up memory card are
required in order to complete
research successfully and also to
minimize cost although out the
research process.
Computer (Dell Laptop) 10500.00
Back up Memory 1200.00
8 Gig memory stick 220.00
Monthly 3G Air time 100.00
Airtime to search for literature
review and consult with the
supervisor.
Printing Materials 4500.00
This include material such as,
Note books, Exam pad, A4 Page
papers, Toners
Computer Software (STATA or SPSS) 2000.00
Amount of R13000 will be used
for purchasing statistical
software packages such as SPSS
or STATA, this amount also
include printing and spiral
binding of research copies, to
pay typist and proof reader and
to buy food during research
consultation with the supervisor
and during data collection.
Printing and Spiral binding 1500.00
Typist 1000.00
Proof Reader 2000.00
Food 6500.00
Travelling 26400.00
Claim for 1600 KM for 6 month
including traveling from
Mafikeng to UNIVEN and
return, this will also include
travelling to conduct research at
Mafikeng clinics.
Total Budget 56870.00
The estimated costs of R 56
870.00 will enable the
researchers to conduct research
although out Mafikeng clinics.






154

APPENDIX F:
INFORMED CONSENT LETTER

DEAR RESPONDENT

My name is NDIVHUHO MANGALE; I am a masters student at the University of Venda
conducting research on Evaluation of the implementation of PMTCT interventions at
Mafikeng clinics. The study finding will benefit the department of health to improve quality
of PMTCT services. You are kindly requested to participate in this research project. You will
be provided with the close ended questionnaire to complete, only if you agree to take part and
participate in this project. There are researcher would like to inform you that there wont be
any risk or cost as the results of taking part in the study. There are no direct benefits,
remunerations or incentives to be given to the respondents before and after participating in
the study.

I would be grateful if you would spend a little time talking with me. I will not write down
your name, and your answers will be treated with strict confidentiality. Your participation is
voluntary, and you are not obliged to answer any questions you do not want to answer. This
interview will take about an hour of your time. I greatly appreciate your taking the time to
speak with me.

Your cooperation will be highly appreciated

Yours Faithfully

--------------------------------- --------------------------------
Mangale Ndivhuho (Mr) Date
Researcher






155

APPENDIX G:

LETTER TO THE DEPARTMENT OF HEALTH







The Secretariat
The Department of Health and Social Development
Provincial Research Committee
Private Bag X 2068
North West Province
Mmabatho
2735

Dear Sir/ Madam

Re: APPLICATION FOR APPROVAL TO CONDUCT RESEARCH

I am a student for Masters Degree in Public Health at the University of Venda (UNIVEN).
As part of my degree requirement I would be conducting a study on The evaluation on the
implementation of PMTCT interventions and my subjects will be health care professionals
who are rendering PMTCT interventions in Mafikeng local clinics.

The duration of the interview will be 45 minutes to an hour. The date and time of the
interview will be negotiated with you in order to avoid any interruption to the running the
health care services. I would like to assure you that all information gathered will be utilized
for the purposes of this study only.

Attached is the copy of the Ethics approval Research Proposal, Research instruments and
Letter from UNIVEN showing proof of registration for a masters degree for this study.

I hope my letter will meet your approval.

Yours sincerely
Ndivhuho Mangale (Mr.)
Masters in Public Health Student

Signature ............... Date.



ENQ: MR N. Mangale P O BOX 798
Cell: (076)3899120/ (084)4704936 PHIPHIDI
Tel (W): (018)3818055 0994
Fax: (086)5668178 03 November 2010

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161

Alexa Barnby
Language Specialist
Editing, copywriting, indexing, formatting, translation

Mr N Mangale

16 May 2012

QUOTATION
Description
of services
No pages
in source
text
Work required
Tariff per
page (300
words)

TOTAL
Editing of
dissertation
122
Language and
technical editing
R26 R3173-00

This quotation is valid for a period of 30 days from above date.

Payment:
We require a 50% payment up front, i.e. R1586-00.
The balance to be paid on receipt of the completed work.
Bank account details for payment are given below.

Yours sincerely

Alexa Barnby
Banking details
Name of account: AK Barnby
Bank: Nedbank
Current account: 1249290120
Branch code: 124910 (or 123009 if the former does not work)

Mobile: 071 872 1334 barnbak@unisa.ac.za
Tel: 012 361 6347
Fax: 086 610 9420