Identifying interventions to improve outcome of the South African prevention of mother-to-child transmission programme.

Lilian, Rivka Rochel
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South Africa’s Prevention of Mother-to-Child Transmission (PMTCT) programme is critical for eliminating vertical HIV transmission and reducing infant mortality. Early treatment of HIV-infection to curb infant deaths requires earlier diagnostic testing than the currently recommended six-week test. This study describes the continuum of PMTCT care at a Johannesburg hospital to identify interventions for improvement and investigates birth HIV testing for infants. Data from a cohort study at the hospital evaluating diagnostic assays in HIV-exposed infants were collated with routine clinical data, validated and analysed. Among 838 mother-infant pairs, 38% of mothers attended antenatal clinics early enough to receive optimal antenatal prophylaxis. Only 72% of infants accessed six-week testing at the hospital; a further 10% underwent testing elsewhere. Of 38 HIV-infected infants, 29 were infected in-utero and could have been identified at birth (sensitivity of 76.3% for birth testing), compared to only 26 (68%) diagnosed by six-week testing at the hospital. Majority (88%) of these 26 infants accessed antiretroviral therapy, but treatment was only initiated at a median age of 16.0 weeks and 43% of HIV-infected infants who initiated treatment had defaulted or died before the end of the study. Mathematical modelling demonstrated that birth testing would be superior to a six-week test to maximise infants diagnosed and life years saved, with the ideal algorithm being a birth and ten-week test. The PMTCT programme can be enhanced by earlier antenatal care for women and earlier infant diagnosis. Birth testing would diagnose HIV-infection before infants die or default from the PMTCT programme, thereby enabling effective monitoring of MTCT, and would allow earlier treatment initiation to reduce early infant mortality.
A dissertation submitted to the Faculty of Health Sciences, University of Witwatersrand, Johannesburg in fulfillment of the requirements for the degree of Master of Science in Medicine, Johannesburg , 2013