Missing Visits, Missing Opportunities: Losses From Care During PMTCT At Primary Health Care Clinics In Johannesburg, South Africa

Abstract

Background: Effective prevention of mother to child transmission (PMTCT) of HIV requires early initiation and retention in care for  HIV-infected pregnant women. South Africa’s 2010 PMTCT guidelines were based upon the World Health Organization’s Option A; new guidelines were issued in April 2013 based on Option B. Under Option A, all pregnant women were to be tested for HIV at their first antenatal care (ANC) visit, all HIV-infected pregnant women were to be initiated on azidothymidine (AZT) and to have blood drawn for CD4 testing at their first ANC visit. Those with CD4 counts <350 were then to be initiated on lifelong antiretroviral therapy (ART). To date, very little information exists to evaluate if pregnant women are receiving PMTCT services as envisioned in South African health policy. The primary objective of this study was to evaluate the proportion of HIV-infected women attending ANC visits on schedule and receiving appropriate antiretroviral treatment during their pregnancy. Methods: We conducted a prospective, observational cohort study using routinely collected clinic register data for pregnant women newly diagnosed with HIV presenting at two primary health care clinics in Johannesburg, South Africa from Aug 2012 – Feb 2013 from first ANC visit for up to 60 days. Results: 107 and 51 pregnant women (>18 years) testing HIV+ at first ANC visit were enrolled at each clinic, for a total of 158. Women presented at a median age of 26 years (IQR: 24 — 30), during their 2nd pregnancy, at 24 weeks gestation (IQR: 19-28). 19 women did not have records of initiating CD4 testing at their first ANC visit. The median CD4 count was 340 (IQR: 197-468). 72 (46%) were eligible for lifelong ART (triple therapy) according to the guidelines in place at the time. While all patients should have returned to the sites within a week to obtain CD4 test results, 52 patients (33% of 158) did not return within 60 days of their first ANC visit. Among the 106 (67% of 158) women who did return to the clinic at least once within 60 days of their first visit and could have received their CD4 results, only 53 (50% of 106) had a CD4 results visit recorded in a clinic register. For the 67% of women who did return at least once within 60 days of their first ANC visit, the median number of days from their first visit to second visit was 28 (IQR: 8 — 34). Only 91 women (58% of 158) had a record of AZT being dispensed at their first ANC. Only 2 out of 72 women eligible for lifelong ART (3%) initiated ART within 30 days of their first ANC visit. Only 10 out of 67 women with CD4>350 (15%) received an uninterrupted 60-day supply of AZT. Conclusion: Loss to initiation of both mono- and triple- ARV therapy, loss to follow-up, and treatment interruptions were common during ANC care for HIV-infected women during the evaluation period. Lessons learned from Option A implementation should inform roll-out of systems for Option B.

Conference: ICASA 2013, Cape Town, SA