Assessing progress and barriers to elimination of mother-to-child transmission and decreasing HIV-related maternal deaths in the Johannesburg Health District

Mnyani, Coceka Nandipha
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Background South Africa has the largest HIV epidemic globally, with a prevalence among pregnant women estimated at 30.8% in 2015. Consequent to this high HIV prevalence rate, which has plateaued around 30% over the past decade, South Africa was identified as one of the priority countries for elimination of mother-to-child transmission of HIV (eMTCT) and decreasing HIV-related maternal deaths. The aim of this thesis was to evaluate the evolution of the Soweto PMTCT and antiretroviral therapy (ART) programme, in Johannesburg, one of the largest and oldest in the country with data spanning almost two decades. The evaluation is on the impact of the programme on MTCT rates and HIV-related maternal mortality, in a high HIV prevalence urban setting. Methods This thesis includes six studies that chronicle progress and challenges in eMTCT and decreasing HIV-related maternal mortality. The studies address three objectives: (i) to describe progress made in implementation of efficacious PMTCT interventions and ART coverage in HIV-infected pregnant women; (ii) to identify patient-related risk factors for MTCT; and (iii) to assess the impact of evolving HIV management guidelines and increased availability of ART on maternal mortality in HIV-infected women. Three studies address the first objective and include two secondary analyses of routinely collected PMTCT data, and a cross-sectional study to assess quality of care in the Soweto PMTCT programme. The second objective is addressed by two studies, one a case-control study and the other a cross-sectional survey, both identifying patient-related risk factors for MTCT. The third objective is addressed by a 19-year record review assessing trends in maternal deaths in HIV-infected women. Results Findings from this thesis show how successful implementation of evolving PMTCT and ART guidelines, in a high HIV prevalence setting, have led to a significant vi decrease in the MTCT rate to levels below 2% at early infant diagnosis. There is also a decrease in the maternal mortality ratio (MMR) among HIV-infected women, coinciding with the expansion of the South African ART programme. While reporting on these are public health successes, this thesis also identifies remaining challenges. Through evaluating aspects of the continuum of care along the PMTCT cascade in the studies that make up this thesis, three overarching themes emerge. These are delayed or lack of access to antenatal care, delayed HIV diagnosis and ART initiation among pregnant women, and suboptimal quality of care in PMTCT and ART programmes as reflected in the healthcare workers’ and patients’ knowledge of PMTCT interventions. Conclusion The findings have important implications for policy and practice. Challenges identified in accessing antenatal care, HIV diagnosis and ART initiation among pregnant women and quality of HIV care all intersect and increase the risk of MTCT and maternal mortality in HIV-infected women. These are both patient-related and health system-related. Targeted interventions are needed to build on the gains made.
A thesis completed by published work, submitted to the School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, in fulfilment of the requirements for the degree Doctor of Philosophy Johannesburg, South Africa 07 June 2018.