To truly improve child survival, Prof. Rollins stressed that there needs to be better integration of PMTCT, ART and maternal and child health services across the continuum of care — starting with testing and prevention services.
Receipt of PMTCT services is of course dependent upon the mother’s choice to participate in the programme, including, first and foremost, her willingness to be tested for HIV. Refusal to consent to the HIV test remains one of the biggest hurdles for sdNVP uptake.
More has to be done to encourage women to learn their status, said Prof Rollins, and to take advantage of the opportunity that antenatal testing offers. According to another study presented at the meeting, offering mothers an HIV test again (in the labour wards postpartum), could provide a last chance to deliver sdNVP to her infant — and this offer was accepted by about 60% of women (Theron).
Prevention services among those women who test HIV-negative during pregnancy also need to be improved. In Dr Rollin’s study, the rates of mother to child transmission were extremely high among women who reported that they were uninfected (which indicates they may have seroconverted after antenatal screening).
However, PMTCT is not limited to the administration of sdNVP — the use of ART among those who have low CD4 cell counts can have an even greater impact upon transmission rates. Dr Jacobs-Jokhan stressed the QAP programme encourages clinical staging and CD4 testing of women who test positive, and referral of those who qualify for ART. But experience in other settings suggests that there can be difficulty integrating ART and PMTCT programmes in practice — which means that few of these women indeed start on ART in time. Notably, only 5 out of 535 pregnant women included in the KZN survey were actually on ART at the time of delivery — when surely more of them must have qualified for ART.
Women who have CD4 cell counts less than 200 “represent about 12-15% of all HIV-infected pregnant women,” said Prof Rollins, “but they account for 40-50% of all mother to child transmissions.” Furthermore, if the mother dies of HIV, all of her children are three to four times more likely to die — so getting mothers onto treatment is essential.
And PMTCT cannot stop at delivery. After childbirth, providing counselling and support on infant feeding choices and proper follow-up for both the child and its mother are extremely important.
“We need to bridge that gap between antenatal care and postnatal services,” said Prof Rollins. Improved documentation of participation in PMTCT (starting with integrating mother and child health cards) could be crucial for continuity of care or to enabling mothers and children to get into care again.
But poor record keeping could effectively derail the programmes good intentions to provide improved support, follow-up and continuity of care for both child and parents —especially when they go to larger hospitals such as those Dr Naidoo described. Inadequate documentation could also have been one of the contributing factors for why so few of the children in the Durban hospital audit were able to access ART in time before they died.
It is not absolutely clear from Dr Naidoo’s study that the poor documentation was the fault of the antenatal clinic/PMTCT side (although this might be inferred from both the QAP presentations and the low reported DOH figures for PMTCT coverage in the country) or whether the child’s history was poorly transferred when he or she was admitted to the hospital.
“Regardless, the patient’s notes are the working document that the management is based on, and failure to record or transfer information from the Road to Health Card [child health card] to the patient notes is a failure to perform a proper clinical examination and assessment of every child,” said Dr Naidoo. However, he stressed that the complete absence of any information about the child’s receipt of PMTCT services, “was the audit’s most striking finding of all.”
At the very least, the audit shows that some children are falling through the cracks when PMTCT, maternal and child health services and the ART programme are not adequately coordinated — and that integration may be easier said than done.
According to Prof Rollins, if PMTCT targets are to be met, integrated services will need to be planned and managed.
“We need to think about prioritisation and the dedication of resources. Integration has been the new mantra for the last several years but we don’t know how to integrate. We don’t need just a framework, we need detailed implementation plans on how to put it together at the district level,” he said.
But he stressed that improved mother and child health should be the endpoint for these programmes, not just delivery of sdNVP prophylaxis (or whatever the particular prophylactic regimen being used). “Survival, and not just the avoidance of transmission should be our paradigm for the future,” he concluded.