Quality and turnaround times of viral load monitoring under prevention of mother-to-child transmission of HIV Option B+ in six South African districts with a high antenatal HIV burden.

BACKGROUND: Barriers to monitoring maternal HIV viral load (VL) and achieving 90% viral suppression during pregnancy and breastfeeding still need to be understood in South Africa (SA). OBJECTIVES: To measure quality of VL care and turnaround times (TATs) for returning VL results to women enrolled in the prevention of mother-to-child transmission of HIV (PMTCT) programme in primary healthcare facilities. METHODS: Data were obtained from a 2018 cross-sectional evaluation of the PMTCT Option B+ programme in six SA districts with high antenatal and infant HIV prevalence. Quality of VL care was measured as the proportion of clients reporting that results were explained to them. TATs for VL results were calculated using dates abstracted from four to five randomly selected facility-based client records to report overall facility 'short TAT' (≥80% of records with TAT ≤7 days). Logistical regression and logit-based risk difference statistics were used. RESULTS: Achieving overall short TAT was uncommon. Only 50% of facilities in one rural district, zero in one urban metro district and 9 - 38% in other districts had short TAT. The significant difference between districts was influenced by the duration of keeping results in facilities after receipt from the laboratory. Expected quality of VL care received ranged between 66% and 85%. Client-related factors significantly associated with low quality of care, observed in two urban districts and one rural district, included lower education, recent initiation of antiretroviral treatment and experiencing barriers to clinic visits. Experiencing clinic visit barriers was also negatively associated with short TATs. CONCLUSIONS: We demonstrate above-average quality of care and delayed return of results to PMTCT clients. Context-specific interventions are needed to shorten TATs.

Uptake of antenatal care in high HIV-prevalence settings: Results from three population-based surveys in South Africa.

BACKGROUND: Despite substantial progress in reducing pregnancy-related preventable morbidity and mortality, these remain unacceptably high in developing countries. In 2016, the World Health Organization (WHO) revised recommendations for antenatal care (ANC) from a 4-visit model to a minimum of 8 ANC contacts to reduce perinatal mortality further and improve women's experience of care. The guidelines also recommend that the first ANC visit (ANC-1) should occur during the first trimester. OBJECTIVES: To describe the uptake of routine ANC and its associated factors in South Africa (SA) prior to the 2016 WHO recommendations, when the country recommended 4 ANC visits, to bring to light potential challenges in achieving the current recommendations. METHODS: Secondary data analyses were performed from 3 facility-based, cross-sectional national surveys, conducted to measure 6-week mother-to-child transmission of HIV and coverage of related interventions in SA. These surveys recruited mother-infant pairs attending selected public primary healthcare facilities for their infants' 6-week immunisation in 2010, 2011 -2012 and 2012 -2013. Quantitative questionnaires were used to gather sociodemographic and antenatal-to-peripartum information from Road to Health cards and maternal recall. The inclusion criteria for this secondary assessment were at least 1 ANC visit, the primary outcome being uptake of ≥4 ANC visits. A multivariable logistic regression model was used to: (i) identify maternal factors associated with ANC visits; and (ii) establish whether receiving selected ANC activities was associated with frequency or timing of ANC-1. RESULTS: Of the 9 470, 9 646 and 8 763 women who attended at least 1 ANC visit, only 47.5% (95% confidence interval (CI) 45.4 -49.6), 55.6% (95% CI 53.2 -58.0) and 56.7% (95% CI 54.3 -59.1) adhered to ≥4 ANC visits, while 36.0% (95% CI 34.5 -37.5), 43.5% (95% CI 42.0 -45.1) and 50.8% (95% CI 49.3 -52.2) attended ANC-1 early (before 20 weeks' gestation) in 2010, 2011 -2012 and 2012 -2013, respectively. Multiparity and lower socioeconomic status were significantly associated with non-adherence to the 4-visit ANC recommendation, while a later survey year, higher education, being married, >19 years old, HIV-positive, planned pregnancy and knowing how HIV is transmitted vertically were strongly related to ≥4 ANC visits. The number of women who received selected ANC activities increased significantly with survey year and ≥4 ANC visits, but was not associated with timing of ANC-1. CONCLUSIONS: Despite increases in the uptake of ≥4 ANC visits and early ANC-1 rates between 2010 and 2013, these practices remain suboptimal. Adhering to ≥4 ANC visits improved coverage of selected ANC activities, implying that strengthening efforts to increase the uptake of ANC from at least 4 to 8, could improve overall outcomes.

Effectiveness and cost effectiveness of syndromic sexually transmitted infection packages in South African primary care: cluster randomised trial.

OBJECTIVES: To evaluate the effectiveness and cost effectiveness of syndromic sexually transmitted infection (STI) packages on appropriate treatment and preventive management during primary care consultations. METHODS: Cluster randomised trial of 37 Durban primary care clinics randomised to use syndromic packages (containing antibiotics, condoms, partner notification cards, and written information) or not. We assessed outcomes using simulated patients who reported STI symptoms and recorded how they were managed, before and after implementation (269 and 256 simulated patient consultations). We adjusted for baseline values and intra-clinic correlation of outcomes statistically. We used health department information to estimate the extra resources needed to provide the packages to 20 clinics for 1 year and their costs. RESULTS: Simulated patients in intervention clinics were more likely to receive appropriate syndromic STI management (correct treatment plus condoms offered plus partner notification cards offered; prevalence rate ratio 2.3; 95% confidence intervals (CI) 1.6 to 3.0) and to receive more STI advice and information (odds ratio 1.5; 95% CI 1.01 to 2.1). Women were less likely to receive appropriate syndromic STI management. The intervention increased STI information provision in women more than in men. The extra cost per extra patient appropriately managed was $1.51. CONCLUSIONS: Syndromic packages improved syndromic STI management at a reasonable cost and should be used more widely.

Quality of primary care for sexually transmitted diseases in Durban, South Africa: influences of patient, nurse, organizational and socioeconomic characteristics.

Quality of sexually transmitted disease (STD) primary care in South Africa varies widely but reasons for this are poorly understood. We investigated 37 randomly sampled clinics providing STD care, with simulated patients, and staff interviews and record review. Census data provided local socioeconomic indicators. Multiple regression identified independent predictors of quality. Of 271 simulated patient visits, 79% were correctly treated and 39% were correctly managed. Women received worse care, and care tended to be poorer in mainly African and mainly coloured (mixed race) areas. African and Indian nurses were more likely to provide correct treatment. Previous STD training was marginally associated with correct treatment. Quality assessments using simulated patients were not generally associated with assessments using staff interviews and record review. There were frequent missed opportunities for STD prevention and treatment, and evidence of racial but not socioeconomic inequalities.