To the Editors:
Most pregnant women now have access to HIV antenatal services; however, many do not receive the complete package of prevention of mother-to-child transmission (PMTCT) of HIV interventions in low-income settings.1,2 Due to the inadequate quality of these services, HIV-positive pregnant women and their unborn children do not benefit as much as they could from PMTCT interventions, which have demonstrated effectiveness when applied appropriately.3
South Africa has the world's greatest burden of HIV-infected children and the greatest number of pregnant women requiring PMTCT (average antenatal HIV seroprevalence of 30%).4,5 Although HIV transmission in South Africa has decreased in recent years,6 significant deficiencies in PMTCT systems remain.1,7 CD4 cell testing in pregnant women (78%) and early infant HIV diagnosis are inadequate and represent ongoing missed opportunities in the PMTCT program.6 Improvement in the productivity, competence, and responsiveness of health personnel to reduce inefficiencies in services are also required.1 In addition, limited integration of child and maternal health services result in HIV-exposed infants not receiving essential interventions.8
Although the scale-up of PMTCT services has accelerated, there remains a great shortage of skilled healthcare workers in sub-Saharan African HIV programs.9,10 Recently, clinical mentoring to support nurses providing lifelong antiretroviral treatment (ART) has been suggested to improve skills.11 Clinical mentoring has also recently been shown to improve the management of HIV-infected children in a low-income setting.12 However, little data exist on the effectiveness of clinical mentorship for nurses in PMTCT programs. We evaluated the effectiveness of a Quality Nurse Mentor (QNM) health systems strengthening intervention in improving PMTCT processes and outcomes, which has been introduced at 31 South African maternal and child health facilities in high HIV-prevalence districts.
QNMs support maternal and child health nurses working in rural and periurban primary healthcare clinics. QNMs strengthen services by building staff capacity and clinical management skills through ongoing mentoring and support, and ensure proper application of national PMTCT guidelines.13 QNMs are expected to maximize the efficiency and effectiveness of the PMTCT program in an integrated and comprehensive clinical service. QNMs were introduced by Kheth’Impilo a South African nongovernmental organization that supports public ART, antenatal and delivery sites. Kheth’Impilo employs medical and pharmacy staff and provides a community-based adherence support program. The first QNM was placed in 2008, and the intervention was subsequently scaled up in 7 districts of 3 provinces (Eastern Cape, KwaZulu-Natal, and Mpumalanga), which have antenatal HIV-prevalence rates ranging between 30% and 46%.5
The requirements of a QNM include a tertiary degree/diploma in nursing with a minimum of 5 years of experience; extensive knowledge of PMTCT, midwifery, maternal, and child health; a driver's licence; and good leadership skills. Each QNM covers 7–8 facilities within a particular area. QNMs ensure that all elements of the PMTCT cascade are adhered to. They achieve this by working with facility nurses using a data-driven approach to identify nonadherence to the cascade. The QNMs visit each facility at least fortnightly and ensure that patient records and facility registers reflect the clients' clinical management. Any data gaps within the registers are considered gaps in service delivery that are addressed either with the specific nurse or with the facility manager when widespread. PMTCT indicators for each facility are also monitored monthly by QNMs to assess progress in health facility performance. Facility-based clinical data are thus actively utilized to improve the quality of services by identifying attrition in PMTCT clinical pathways, and facility staff and management are engaged when developing strategies to address service delivery gaps. Staff training sessions are conducted to assess progress and to identify problem areas. QNMs also promote linkages between antenatal and child health services to improve HIV testing of HIV-exposed infants and referral of HIV-infected infants for ART.
An observational before–after study was conducted at 31 public, nurse-led antenatal and delivery facilities at which the QNM intervention was started. All pregnant women (and their children) attending maternal facilities between April 2010 and September 2011 were considered eligible for inclusion. Clinical care was provided according to the 2010 South African PMTCT clinical guidelines.13 Routine clinical data aggregated over 3-month periods at facilities as part of the District Health Information System in South Africa were analyzed.
Participants were divided into 2 groups: pregnant women who first attended facilities before and those who first attended after commencement of the QNM intervention. Women who first attended facilities during the 3-month period during which a QNM initially commenced work in the district were excluded from analyses. Outcomes were compared for the periods before and after QNMs were introduced. The outcomes were as follows: Proportion of antenatal women HIV tested at initial visit, proportion of HIV-negative women retested for HIV at 32 weeks of gestation, proportion of newly diagnosed HIV-positive women receiving a CD4 cell test, proportion of HIV-positive women (not on ART) receiving zidovudine (ZDV) antenatally, estimated uptake of HIV DNA polymerase chain reaction (PCR) testing of HIV-exposed infants at age 6 weeks, estimated HIV test uptake at age 18 months, and proportions of positive HIV tests at 6 weeks and 18 months. Uptake of childhood HIV testing was estimated as the number of children tested divided by the total number of HIV-positive women during each period. Proportions were compared using risk ratios (RRs), 95% confidence intervals (CIs), and Pearsons χ2 test. This study was approved by the University of Cape Town Research Ethics Committee.
A total of 27,458 pregnant women were included, of whom 4951 (18.0%) first attended antenatal facilities before the introduction of QNMs and 22,507 (82.0%) thereafter. Repeat HIV testing at 32 weeks of gestation increased from 38.5% to 46.4% (RR = 1.20; 95% CI: 1.15 to 1.26; P < 0.0001) after the introduction of QNMs (Table 1). ZDV uptake for eligible women improved from 80.9% to 88.1% (RR = 1.09; 95% CI: 1.07 to 1.13; P < 0.0001). The estimated proportion of infants tested for HIV at 6 weeks after birth increased from 68.5% to 76.7% (RR = 1.12; 95% CI: 1.08 to 1.16; P < 0.0001). Estimated uptake of HIV testing in 18-month-old children increased almost 2-fold from 12.4% to 22.9% (RR = 1.84; 95% CI: 1.63 to 2.08; P < 0.0001). PCR test positivity at 6 weeks decreased from 3.4% (95% CI: 2.5% to 4.5%) to 2.7% (95% CI: 2.4% to 3.1%; RR = 0.80; 95% CI: 0.58 to 1.09; P = 0.16). The proportion of positive HIV tests at 18 months decreased by >50% from 9.1% (95% CI: 5.8% to 13.5%) to 4.1% (95% CI: 3.3% to 5.0%; RR = 0.45; 95% CI: 0.29 to 0.71; P = 0.0005).
Despite relatively high baseline coverage, PMTCT cascade processes further improved after the introduction of QNMs, and a corresponding decrease in HIV transmission was evident. QNMs seem to be effective in addressing the smaller but significant changes that are necessary to reach elimination of MTCT goals in the context of higher baseline program coverage within the current expansion and improvement in PMTCT program in sub-Saharan Africa.
The QNMs ensure that nurses are held responsible for inadequate service provision as evaluated in clinical records. Nurses were previously unsupervised but are now mentored, supported by, and accountable to the QNM. The data-driven approach ensures that documentation completion is improved. This is not only supervisory but also acts as positive affirmation of work well done when nurses see PMTCT cascade elements improving and HIV transmission decreasing. Support and mentoring have been introduced in a nonthreatening manner, and close relationships have been forged between facility managers and QNMs. Although employed outside of government, QNMs work closely with government colleagues and share a common focus regarding national protocols and targets, resulting in acceptance of the services they provide. Clear collaborative management was promoted whereby stakeholders were made aware of gaps in the cascade and remedial actions taken collectively with the support of the QNM.
Ongoing challenges in PMTCT programs include presentation of women in late pregnancy,7 undetected seroconversion of women during late pregnancy and breastfeeding with subsequent transmission to their infants,14 and poor long-term follow-up of infants and mothers.15
This is among the first evaluations of clinical mentorship for nurses in PMTCT programs in resource-limited settings. The strengths of this evaluation include that data were analyzed from a large number of sites with heterogeneous demographic and geographic settings from high HIV-prevalence settings. As the context is likely to be similar to other sub-Saharan settings, implementation of this intervention and its impact are expected to be generalizable to other sub-Saharan countries. Limitations include the use of cross-sectional data from routine settings, and the observational design of the evaluation. As data were aggregated at facility level, control for individual-level confounding could not be performed.
In conclusion, this novel intervention seems to improve PMTCT health systems effectiveness, and further such initiatives should be considered in resource-limited settings. Quality improvement may be attained with limited resources where available staff are supported and mentored.
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