Campaign approach increases enrolment of pregnant women on ART in South Africa

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 Syndromes shows.

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 (p<0.001).

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 intervention sites.

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.

Only one-in-two 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 HIV.

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 facilities.

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:

• A galvanising and time-bound aim;

• A set of clear evidence-based healthcare interventions;

• A system to organise the participation of numerous hospitals and healthcare organisations; and

• A 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 approaches:

• Generating momentum through strong public endorsement and advocacy from the district health managers and leaders;

• Setting ambitious targets that reflected the need;

• Gathering relevant data that tracked the steps of the ART referral pathway;

• Feeding data back to front-line healthcare teams at monthly perinatal meetings;

• Simplifying pre-ART preparation steps; and

• Creating 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 antiretroviral treatment.

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.”