A targeted campaign among
health workers, using quality-improvement (QI) health system methods, can
significantly improve access to ART for pregnant women living with HIV in
resource-poor settings, a study published in the advance online edition of the Journal of Acquired Immune Deficiency
In this prospective,
non-randomised, controlled study in two large health districts in KwaZulu Natal province, South Africa, the average number of referrals of pregnant women
for ART at all sites more than doubled from 79 each month (95% CI: 69-89) at
baseline to 188 each month (95%, CI: 108-140) six months after the intervention
In stark contrast to the control
district, where rates remained mostly unchanged, the number of women starting
ART increased more than five-fold from 21 each month (95% CI: 2-40) at baseline
to 124 each month (95% CI: 108-140) after the intervention (p<0.001), at the
Results, the authors note,
add to the literature showing how QI health systems strengthening methods can
improve performance of large-scale health programmes. “In this case, added to the
traditional QI methods that use data-driven front-line decision making to
improve performance, a 'campaign' strategy was effective in rapidly improving
the performance of a key component of the PMTCT cascade.”
In both resource-rich and
resource-poor settings, ART interventions have shown that mother-to-child
transmission rates can be reduced to less than 2%.
The level of commitment to the elimination
of new paediatric infections is without precedent, yet every year close to
400,000 children worldwide still acquire HIV.
pregnant women in the countries in east and southern Africa with the highest HIV burden is
tested for HIV; approximately two out of three of those who test positive will
get some form of antiretroviral treatment.
Without identifying pregnant,
HIV-positive women and getting them onto treatment promptly, transmission to children will continue, as will deaths among mothers.
In 2010, in KwaZulu Natal, antenatal HIV
prevalence ranged between 31.1 and 42.3% in eleven districts. Estimated
perinatal transmission rates among infants at six weeks of age ranged from 4.4
to 10.1% in 2009. Over 40% of maternal deaths from 2008 to 2010 were due to
In spite of changes in South
African policy, and the availability of key resources and medications, rates of
pregnant women starting ART have remained low, the authors write.
In 2008, close to 100% of
women in South Africa attending an antenatal care clinic got tested for HIV. Yet
among all pregnant women eligible for ART, only 12.8% had visited an ART clinic
and only 8.7% actually started ART.
Pregnant, HIV-positive women
with low CD4 cell counts and in need of ART are the most vulnerable.
Approximately 40% of HIV-positive mothers have CD4 counts under 350 cells/mm3, accounting
for 80% of transmissions to infants and 80% of HIV-associated maternal deaths.
Simple, continuous QI health
system interventions – using local data to inform health providers about their
own performance – have been used successfully to improve the quality of, and
access to, health care – including HIV care and treatment in other settings.
Since 2008, a health systems
improvement team (the 20,000+ team) from the University of KwaZulu Natal has
supported efforts to improve delivery of HIV care to pregnant women in Ugu
District. By mid-2009, rates of HIV and CD4 testing improved, as did provision of single and
dual ART to pregnant women in the antenatal period, yet few eligible
women were starting ART.
So the district health
management team asked the 20,000+ team to help design and
guide a campaign among district health workers based on QI principles to
fast-track eligible HIV-positive women onto ART.
With a population of over
700,000, mostly in rural areas, Ugu Health District has 65 healthcare
A comparison district in KwaZulu Natal,
Umzinyathi, was selected as it has demographic and health system characteristics
that closely match Ugu's.
The campaign approach was based
on a conceptual model, used in the US and UK to successfully improve delivery
of evidence-based interventions, with four key elements:
galvanising and time-bound aim;
A set of
clear evidence-based healthcare interventions;
to organise the participation of numerous hospitals and healthcare organisations;
measurement framework focused on the primary aim.
The campaign set a six-month
goal of developing a reliable district-wide system in Ugu to find and start 90%
of eligible women on ART during their pregnancy. Eligibility – following South
African guidelines – included all women with CD4 counts under 350 cells/mm3
or with WHO clinical stage 3 or 4 HIV disease.
The campaign lasted from September
2009 until March 2010.
Assessments were made at
baseline (six months prior to September 2009), during the intervention (at six
months) and post-intervention (six months after March 2010).
The authors highlighted the campaign's
momentum through strong public endorsement and advocacy from the district
health managers and leaders;
ambitious targets that reflected the need;
relevant data that tracked the steps of the ART referral pathway;
data back to front-line healthcare teams at monthly perinatal meetings;
pre-ART preparation steps; and
roving ART initiation teams.
Training for nursing staff in
starting patients on ART was considered an essential intervention within the
campaign. New South African treatment guidelines raised awareness among nurses
and pregnant women of the importance of enrolling pregnant women on
While these changes may have
contributed to higher rates of women starting ART in the post-intervention
period in both districts, the authors stress that improvements in Ugu happened
before the new policies were in place.
The close association of the
timing of the improvements with the onset and rollout of the campaign lends
further support to the cause-and-effect relationship of the campaign and
increase in rates of starting ART, the authors add.
The rapid timeline and
anticipated low incremental costs of the campaign (no personnel were added to
the health system) make this a good model for replication in similar
resource-poor settings, write the authors.
“The use of pre-existing
meetings and natural systems linkages increase the likelihood of sustainability;
the reliance and strengthening of the existing public health information system
was a strong programme asset.”
The main limitation of the
study is the lack of a randomised comparison district.
The authors conclude that, “while
this district may have been optimally positioned for success, given its prior
experience with QI methods and highly functioning district management
infrastructure…although the cost-effectiveness…was not formally assessed, it
shows the potential for the campaign approach to improve access to essential
maternal, newborn and child health interventions including lifelong ART.”