Maternal and Child Survival Memorandum Of Concern. 03/09/07

We, the undersigned would like to raise our urgent concerns about the quality and coverage of prevention of mother-to-child transmission of HIV (PMTCT) services in our country and the care and treatment of HIV-exposed and HIV-positive infants and their mothers. Improving PMTCT and HIV-related care and treatment services for HIV-exposed and HIV-positive infants and their mothers are two fundamental pillars of improving maternal and child survival in the current South African context. Whereas we recognise that progress has been made, infant and under-5 mortality rates remain unacceptably high, are largely preventable and are aggravated by inequitable access to care. We are concerned that the pace of and approach to implementation is falling short of the need and will not impact significantly on children’s rights to parental care, survival, well-being and prevention of disability.

There are several policy-related gaps and hurdles:

1. Updated and improved regimens for PMTCT and updated criteria for starting Highly Active Antiretroviral Therapy (HAART) in pregnancy are urgently needed to further reduce mother-to-child transmission of HIV and improve maternal health. At the very least the updated WHO recommendations should be adopted and implemented.

2. Policies that facilitate access to and uptake of counseling and testing for HIV need to be adopted: an opt-out approach to antenatal HIV testing early in pregnancy, repeat testing for HIV-negative women near delivery and infant testing are needed.

3. A policy regarding women who were not tested or do not know their status at the time of delivery including abandoned babies. Here post-exposure prophylaxis for babies is effective and warranted.

4. The coding system entrenches stigma around HIV and hinders improved coverage of PMTCT services. It must be eradicated and replaced by open communication between health workers and patients around HIV and documentation of HIV status on patient-held records e.g. under the special risks section on the Road to Health Card or antenatal card.

5. The SA guidelines on infant feeding in the context of HIV must be reviewed as a matter of urgency, as current infant feeding practices are unsafe and do not optimise child survival or the reduction of mother-to-child transmission of HIV.

6. The current national paediatric HIV guidelines need to be updated in accordance with minimum standards set by the World Health Organisation (WHO), and recent evidence from the Western Cape which shows reduced mortality when HIV-positive infants under 3-months of age are started on antiretroviral therapy (ART).

There are several implementation challenges:

7. Access to and quality of counseling should be improved: this includes counseling on HIV testing; how to remain HIV negative, infant feeding (exclusive formula or breast) and the importance of infant HIV testing.

8. There needs to be a fast-track mechanism for pregnant women to access treatment at sites which calls for integration/coordination of both the CCMT and PMTCT services which are often functioning independent of each other at many if not most sites.

9. All HIV-infected pregnant women should have a CD4 test on the same day as rapid HIV testing. HIV-infected women who fulfill national criteria for starting HAART i.e. with low CD4 counts should be proactively identified and all obstacles to starting HAART rapidly must be identified and resolved.

10. The recommendation of early infant diagnosis needs to become routine practice: From at least 4-6 weeks of age all infants born to HIV positive women must be tested for HIV (DNA PCR) and must be started on cotrimoxazole.

11. Furthermore, all infants and children who fall outside the PMTCT intervention programme, should have access to HIV testing (rapid and DNA PCR) to establish their status and where necessary initiate appropriate care. In extremely high prevalent areas, routine testing of all infants at immunization clinics should be considered. This necessitates widespread, rapid scaling-up of training of clinic and laboratory staff on infant diagnosis. Furthermore, systems to ensure a constant availability of consumables for testing, and to improve turn-around times of results need to be urgently developed.

12. Infant feeding: The dissemination system(s) for commercial infant formula must be reviewed to ensure an uninterrupted supply of commercial infant formula – current systems are leading to wide-spread shortages and promote mixed feeding. For those mothers who choose to exclusively breast feed, nutrition support should be provided in order to meet the additional energy requirements demanded through breastfeeding and balance the financial incentives of free commercial infant formula. All mothers, irrespective of their infant feeding plan, should receive skilled support to ensure appropriate feeding practice throughout the first year of life i.e. including the period of transition from breast to other feeds amongst mothers who initiate breastfeeding.

13. Current staff shortages or the lack of appropriately skilled health care personnel (health care providers and health workers) compromises the quality of PMTCT, HIV-related and general maternal and child health care services and must be urgently reviewed.

14. Widespread, standardized and on-going national training of health care personnel, including lay counselors and community health workers must be intensified so that the identification, staging, treatment and holistic care of HIV-infected infants and young children is improved. Furthermore the Integrated Management of Childhood Illness Strategy (IMCI) recommendation that HIV-exposed infants under the age of 1 year should be followed up monthly and monitored intensively needs to become routine practice. Both developmental screening and identification and management of TB exposure are extremely important.

15. Mechanisms must be in place for annual review of current policies, with rapid adoption and implementation of recommendations and dissemination of changes to health care personnel. We recommend that national expert technical committees be formed to assist with the former, and transparent and inclusive processes be introduced for the later.

B. We, the undersigned pledge our commitment to improving the health of our children and their mothers. We further pledge to intensify the support we already provide to the Department of Health, and to offer the following concrete assistance and support with immediate effect so that the recommendations outlined in this memorandum can be implemented:

1. We offer to:

a. serve on advisory / technical expert committees at national level so that current policy gaps can be addressed.

b. play an active role in advisory / technical expert committees at provincial level so that policies can be transferred to provincial level, and provincial and district implementation and monitoring and evaluation plans can be developed.

c. work in partnership with the Department of Health to increase the knowledge-base and skill of health care providers managing women and children infected with or affected by HIV.

2. Within the various provinces, districts and settings that we come from we are able to:

a. train health workers on managing women and children infected or affected by HIV, including the management of common and opportunistic illnesses in these women and children.

b. provide on-site support and mentorship for health workers at accredited antiretroviral (ARV) sites.

c. train and support sites that can potentially be accredited ARV sites.

d. conduct a swot analysis and an analysis of health system, psychosocial, and personal factors that hinder access to counseling and testing, HIV care, coverage of nevirapine, the availability of constant supplies of formula milk, and other key operational challenges.

e. plan interventions and alternate approaches to strengthen existing program implementation.

f. conduct relevant research that will contribute towards appropriate policy and improved implementation.

g. disseminate DOH policy and guidelines including the National Strategic Plan (2007-2011) to target groups or organisations towards furthering it’s realization.