MMed (Paediatrics), Faculty of health Sciences, University of the Witwatersrand / AIM: To evaluate aspects of the PMTCT programmes at selected hospitals and clinics in Gauteng. METHOD: A cross sectional survey of post partum women in Gauteng was undertaken during April- June 2006. Data was collected at four hospitals and eight Midwife Obstetric Units (MOUs) in four regions in Gauteng. Mothers, irrespective of HIV status, who delivered in the previous 48 hours were interviewed. This was followed by a review of the mother’s and infant’s records as well as relevant registers. RESULTS: Interviews with, and record reviews, of 182 mother-infant pairs were conducted/obtained; 69 (38%) at MOUs and 113 (62%) at hospitals. The majority (172 [95%]) of mothers were “booked” of whom 155 (85%) had undergone an antenatal HIV test. Forty-two mothers (23%) were HIV positive. Nevirapine was issued antenatally to 37/42 (89%) of eligible mothers; 30/42 (71%) took it during labour. Three women (8%) received the drug for the first time during labour; thus 33/42 (79%) of eligible mothers received nevirapine. Thirtytwo (76%) of babies born to HIV positive mothers received nevirapine. However, in only 24/42 of mother-infant pairs (57%) was receipt of nevirapine by both parties, recorded. There was no significant difference in nevirapine administration rates to mothers at clinics compared to hospitals (76% vs. 81%, p=0.71). Infants were more likely to receive nevirapine at clinics compared to hospitals (90% vs. 62%, p= 0.03). CONCLUSION: Four years after introduction of a PMTCT programme in Gauteng, nevirapine uptake and administration rates remained sub-optimal, with at least a quarter of eligible (identified) women and infants not receiving the intervention. The findings highlight the need to prioritise and consolidate PMTCT activities in the province.

MFamMed, Faculty of Health Sciences, University of the Witwatersrand, 2009 / BACKGROUND Until recent years, uptake of voluntary counselling and testing for HIV (VCT) and enrolment into the programme of prevention of mother-to-child transmission of HIV (PMTCT) was very poor among pregnant women. This study aims to identify factors influencing enrolment into the programme of PMTCT among post-partum women. METHODS Cross sectional interview of 200 consecutive post-partum women was conducted using an interviewer-administered questionnaire. Forms of those who declined to participate were kept and marked “refusal”. Data was analysed using Epi info software. RESULTS The response rate was 84.5%. VCT uptake was 96.9% among participants and PMTCT uptake among HIV+ve mothers was 90.9%. The mean age of participants was 25 years, ranged from 14 to 41 years. Women in the age-group 20-29 were more likely to accept VCT and enroll for PMTCT than women in the other age-groups (p=0.0114). CONCLUSIONS AND RECOMMENDATIONS Provision of clear and well-defined policy guidelines and strong commitment to implementation of these guidelines have been largely responsible for impressive uptake of VCT among participants and high rates of satisfaction with PMTCT programme among HIV-infected women. Training of more lay-counsellors is recommended for its cost-effectiveness.

A research report submitted to the Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, in partial fulfilment of the requirements for the degree of Master of Public Health. Johannesburg, April 2012 / Introduction Routine PMTCT programmes are highly effective in reducing the mother-to-child transmission (MTCT) rate of HIV, but generally fail in follow-up of HIV-exposed children. Loss to follow-up in the PMTCT programme translates into failure in primary prevention of new infections in HIV-exposed infants, failure to identify HIV disease early in children, and a missed opportunity for early referral of HIV-positive children to ARV sites. An assessment of what happens to babies born of HIV-positive mothers in the West Rand district of Gauteng province, South Africa has never been done, and neither has the extent to which these babies are followed up for the first 12 months, and the extent of loss to follow-up been documented. Aim The purpose of this study is to describe the referral and follow-up of babies born to HIV-positive women during July to December 2005 in the PMTCT programme in the West Rand district of Gauteng. Method This was a descriptive study involving a retrospective review of records for a cohort of babies born to HIV-positive mothers in the PMTCT programme in the West Rand during July 2005 to December 2005. All records of HIV-positive mothers seen over the six-month period at Leratong hospital and the two midwife obstetric units (MOUs) that refer patients to Leratong hospital were reviewed, as were records of their babies. A total of 887 Mother-infant pairs were consecutively enrolled in the study. Results Referral linkages within the PMTCT programme were found to be weak. Only 34% of babies enrolled in the PMTCT programme were successfully registered with PMTCT follow-up services. HIV PCR testing of babies enrolled in the PMTCT programme was relatively low. Overall only 41% of enrolled babies were tested for HIV infection. Of those babies who had a HIV PCR test, 16% were tested before or at six weeks with the majority of babies (84%) having a HIV PCR after six weeks. HIV PCR testing coverage at six weeks was 8.4%. Referral of confirmed HIV-positive babies to ARV sites was poor. Only 25% of all HIV PCR-positive infants were successfully referred to ARV sites. There was a high loss to follow-up in the PMTCT follow-up programme. The probability of an infant remaining in the PMTCT programme decreased from 0.5 at six weeks to 0.04 beyond 20 weeks. Conclusion Despite a high enrolment of babies in the PMTCT programme in the West Rand, referral linkages within the PMTCT programme are weak and there is a high loss to follow-up of infants in the PMTCT follow-up programme. HIV PCR coverage at six weeks is significantly low, and referral of confirmed HIV PCR-positive babies to ARV sites is also significantly low. Further research is needed to assess whether there has been an improvement in the follow-up of babies in the PMTCT programme in the West Rand since the time of this study.

MSc (Med), Faculty of Health Sciences, University ofthe Witwatersrand, 2007 / Background Mother-to-child transmission of HIV infection is the primary cause of paediatric HIV infections worldwide. High HIV infection rates in women of childbearing age (15-49 years) and efficiency of PMTCT have resulted in the high rate of HIV incidence and prevalence in children of sub-Saharan Africa. The stark contrast in the success of PMTCT interventions between the western countries and less developed countries indicates the need for further research to develop alternative, easier, and more effective population-based interventions. Methodology This was a retrospective cohort study of the medical records of approximately 300 HIV infected women enrolled in the Nevirapine Resistance study between May 2002 and February 2003. An assessment of the significance of changes in immunological parameters (CD4 counts, CD4 percentages, CD4/CD8 ratios) and HIV RNA from 3rd trimester to 6 weeks postpartum and causal associations vi between these changes and increased risk of PMTCT was then conducted using logistic regression models. Results Mothers with CD4 counts above 200cells/μL were approximately exhibited onethird the likelihood of transmitting HIV-1 to their infants than mothers with CD4 counts below 200 cells/μL [OR 0.35 (0.13, 0.95)]. High maternal HIV RNA levels demonstrated a stronger association with increased risk of PMTCT with women with postpartum viral loads greater than 100 000 copies/μL exhibiting ten times the likelihood [OR 10.15 (2.17-47.55)]. Statistically significant mean increases in CD4 and CD8 cell counts from 3rd trimester to postpartum were observed. Mean increases in CD4 and CD8 counts demonstrated no association with PMTCT. Conclusion CD4 cell counts and CD8 cell counts underwent statistically significant changes from 3rd trimester to postpartum. These changes seem not to represent any clinically significant change in maternal disease progression during this time period and were found not to be associated with PMTCT.

Introduction: Mechanisms facilitating mother-to-child transmission (MTCT) of HIV have not been elucidated. Small quantities of blood pass from mother to infant during childbirth, termed 'microtransfusion'; this is one possible mechanism for HIV entry into the infant's circulation. HIV-specific cellular immune responses have been detected in some uninfected infants born to HIV-infected women, indicating transient virus exposure or replication in these infants. Both microtransfusion and HIV-specific immune responses in infants born to HIV-infected women has not previously been investigated. Methods: 46 uninfected infants born to HIV-infected women were included in this study. Infants were grouped according to interventions utilised by the mother: none or antiretroviral therapy (ART; group A, n = 16), ART with elective caesarean section (elCS; group B, n = 12), highly active antiretroviral therapy (HAART) only (group C, n = 7), and HAART with elCS (group D, n = 11). HLA-A and -B alleles were typed for all mother-baby pairs to identify the non-inherited maternal allele (NIMA). Microtransfusion was detected using flow cytometry or by qPCR targeting the NIMA. HIV-specific immune responses were detected using 51Cr-release and IFN-?????? ELISpot assays. Results: Microtransfusion was detected in umbilical cord blood of 9 of 11 infants, and in peripheral blood of 4 of 11 infants up to 1 week old. One infant without detectable microtransfusion in umbilical cord blood had detectable maternal cells in peripheral blood. 8/46 infants had HIV-specific T cell responses, 5 were in group A, 2 in group B, and 1 in group C, while no infants in group D had detectable responses (p = 0.04). Blood samples from 2 of these 8 infants were also available for the analysis of microtransfusion. Microtransfused maternal cells were present in the umbilical cord blood of both infants. Conclusion: In this study, the number of infants with HIV-specific immune responses decreased with the use of MTCT interventions, indicating reduced exposure to HIV in these infants. This is the first study to demonstrate both microtransfusion and HIV-specific immune responses in uninfected infants. Microtransfusion may facilitate viral exposure, resulting in the development of potentially protective immune responses in infants born to HIV-infected women.

Introduction: Mechanisms facilitating mother-to-child transmission (MTCT) of HIV have not been elucidated. Small quantities of blood pass from mother to infant during childbirth, termed 'microtransfusion'; this is one possible mechanism for HIV entry into the infant's circulation. HIV-specific cellular immune responses have been detected in some uninfected infants born to HIV-infected women, indicating transient virus exposure or replication in these infants. Both microtransfusion and HIV-specific immune responses in infants born to HIV-infected women has not previously been investigated. Methods: 46 uninfected infants born to HIV-infected women were included in this study. Infants were grouped according to interventions utilised by the mother: none or antiretroviral therapy (ART; group A, n = 16), ART with elective caesarean section (elCS; group B, n = 12), highly active antiretroviral therapy (HAART) only (group C, n = 7), and HAART with elCS (group D, n = 11). HLA-A and -B alleles were typed for all mother-baby pairs to identify the non-inherited maternal allele (NIMA). Microtransfusion was detected using flow cytometry or by qPCR targeting the NIMA. HIV-specific immune responses were detected using 51Cr-release and IFN-?????? ELISpot assays. Results: Microtransfusion was detected in umbilical cord blood of 9 of 11 infants, and in peripheral blood of 4 of 11 infants up to 1 week old. One infant without detectable microtransfusion in umbilical cord blood had detectable maternal cells in peripheral blood. 8/46 infants had HIV-specific T cell responses, 5 were in group A, 2 in group B, and 1 in group C, while no infants in group D had detectable responses (p = 0.04). Blood samples from 2 of these 8 infants were also available for the analysis of microtransfusion. Microtransfused maternal cells were present in the umbilical cord blood of both infants. Conclusion: In this study, the number of infants with HIV-specific immune responses decreased with the use of MTCT interventions, indicating reduced exposure to HIV in these infants. This is the first study to demonstrate both microtransfusion and HIV-specific immune responses in uninfected infants. Microtransfusion may facilitate viral exposure, resulting in the development of potentially protective immune responses in infants born to HIV-infected women.

According to global statistics more than half of all people living with HIV are women, the majority of whom live in sub-Saharan Africa. South Africa adapted the WHO guidelines on PMTCT to the local situation. In South Africa the prevalence of HIV amongst pregnant women attending public antenatal care is high, although new infections are declining. Studies on missed opportunities in PMTCT have been conducted in other areas of South Africa, but none in the North West Province. Three health institutions deemed to have more patient attendance were chosen for the study from a particular sub-district. The purpose of this study was to identify and describe the missed opportunities in the PMTCT programme in a sub-district of the North West Province, the results of which may assist in the improvement of PMTCT services. A descriptive study design was used to identify and describe the missed opportunities in the PMTCT programme during pregnancy, labour and postnatal period. The sample consisted of 125 the records of pregnant women whose babies were born in January 2010. Entry to the health care facilities was gained through written permissions from the Department of Health and the facilities. Missed opportunities identified were that 0.8% (1/125) of pregnant women whose records were audited, was not tested for HIV infections and 9.6% (12/125) had no information on testing. Of the 35 women who were found to be HIV positive, only 74.3% (26/35) had confirmatory test done while it was not done in 2.9% (1/35). Furthermore, only 57.1% (20/35) had their blood for CD4 cell count taken, for 2.9% (1/35) no blood was taken for CD4 cell count and there was no information for the remaining 40.0% (14/35). Only 2.9% (1/35) HIV positive pregnant women continued with HAART during labour, 62.9% (22/35) received ARVs for PMTCT and for 34.2% (12/35) there was no information recorded. Prophylaxis for prolonged rupture of membranes was not given in 5.7% (2/35) of these women during labour. There were no records of any TB screening for such women and infant feeding counselling were never carried out. Lack of recording was the major problem identified in this study. / MCur, North-West University, Potchefstroom Campus, 2014

MPH, Faculty of Health Sciences, University of theWitwatersrand, 2011 / Introduction: In South Africa, over 25% of all babies born each year are exposed to HIV. The high antenatal HIV sero-prevalence rates coupled with high levels of maternal morbidity and mortality advocate for high quality maternal and child health care, which should include resilient PMTCT programs. This study aimed to explore infant feeding practices selected by HIV-positive women enrolled on a PMTCT program and describe some of the reasons for their choices, within the first 6 months postpartum. The study also reports on infant feeding practice and HIV status of the infant. Methodology: The study was a cross-sectional study which was carried out within the Perinatal Research Unit at Chris Hani Baragwanath hospital in Soweto. A sample of 200 women enrolled in the PMTCT program was interviewed, using a semi-structured questionnaire, during April 2007 – June 2007. Results: The study revealed that 84.5% of the study population had received infant feeding counseling. There was a high rate of exclusive formula feeding (EFF=84.5%), with lower exclusive breastfeeding (EBF=14%) and mixed feeding (MF=1.5%) rates. The corresponding HIV transmission rates were EFF – 26% (n=44/169); EBF – 75% (n=21/28); MF – 100% (n=3/3). The study demonstrated that babies born to mothers who did not receive information on infant feeding were twice as likely to be HIV positive (OR=2.43), which was statistically significant. The study also showed that the timing of the counseling was critical – all mothers who received counseling 6 weeks or more after delivery had HIV-positive babies. The overwhelming majority of women (78%) indicated that they would breast feed their babies if they were HIV-negative. Conclusion: The study demonstrated the vital role of infant feeding counseling in antenatal care and PMTCT programs. It illustrated that it was critically important that all HIV-infected women receive infant feeding counseling as soon as possible after the HIV diagnosis is made, prior to delivery and highlighted the importance of reinforcement of infant feeding choice at every antenatal care visit, for every woman. 5 The key recommendations focus on the need for: • Improved Antenatal care for all pregnant women • Improved care for HIV-positive pregnant women • Improvements in infant feeding counseling for HIV positive women • Integration of Maternal, Child health and PMTCT programs • Intensification of ongoing prevention efforts • The need for further research to: o identify some of the reasons HIV positive women choose certain infant feeding modalities throughout the country, and the challenges associated with these; and o critically evaluate the training that health care workers and counselors receive, regarding infant feeding counseling.

According to global statistics more than half of all people living with HIV are women, the majority of whom live in sub-Saharan Africa. South Africa adapted the WHO guidelines on PMTCT to the local situation. In South Africa the prevalence of HIV amongst pregnant women attending public antenatal care is high, although new infections are declining. Studies on missed opportunities in PMTCT have been conducted in other areas of South Africa, but none in the North West Province. Three health institutions deemed to have more patient attendance were chosen for the study from a particular sub-district. The purpose of this study was to identify and describe the missed opportunities in the PMTCT programme in a sub-district of the North West Province, the results of which may assist in the improvement of PMTCT services. A descriptive study design was used to identify and describe the missed opportunities in the PMTCT programme during pregnancy, labour and postnatal period. The sample consisted of 125 the records of pregnant women whose babies were born in January 2010. Entry to the health care facilities was gained through written permissions from the Department of Health and the facilities. Missed opportunities identified were that 0.8% (1/125) of pregnant women whose records were audited, was not tested for HIV infections and 9.6% (12/125) had no information on testing. Of the 35 women who were found to be HIV positive, only 74.3% (26/35) had confirmatory test done while it was not done in 2.9% (1/35). Furthermore, only 57.1% (20/35) had their blood for CD4 cell count taken, for 2.9% (1/35) no blood was taken for CD4 cell count and there was no information for the remaining 40.0% (14/35). Only 2.9% (1/35) HIV positive pregnant women continued with HAART during labour, 62.9% (22/35) received ARVs for PMTCT and for 34.2% (12/35) there was no information recorded. Prophylaxis for prolonged rupture of membranes was not given in 5.7% (2/35) of these women during labour. There were no records of any TB screening for such women and infant feeding counselling were never carried out. Lack of recording was the major problem identified in this study. / MCur, North-West University, Potchefstroom Campus, 2014

BACKGROUND: Kenya has made a commitment to virtually eliminate mother to child transmission of HIV (MTCT) by 2015. To achieve virtual elimination, the prevention of MTCT (PMTCT) programs must achieve high coverage and retain HIV-positive women throughout the PMTCT continuum of care. METHODS: A mixed methods study was conducted in three health facilities in Kenya. To quantify retention along the PMTCT care continuum, a retrospective chart review was conducted on HIV positive pregnant or recently-delivered women 18 or older presenting for antenatal care or delivery between January 2012 and May 2013. The primary outcome was retention at individual and facility levels through 18 months postpartum. Logistic regression analysis was performed to determine predictors of retention. Semi-structured in-depth interviews were conducted with HIV positive women and male partners to understand barriers and facilitators of retention in PMTCT care. A failure mode and effect analysis was conducted to identify potential failures along the PMTCT cascade. RESULTS: Across the study sites, only 9%, 10% and 16% of the cohort was fully retained. The retention decreased significantly along the PMTCT cascade from antenatal to the postnatal phase. Gestational age at first antenatal visit (p= 0.043) and the number of antenatal visits attended (p=0.036) were identified as significant predictors of non-retention in PMTCT care. The facilitators of retention included acceptance of HIV positive status, supportive male partners, disclosure of HIV status to male partners and family, peer counseling and psychosocial support, and positive experiences with healthcare providers. Identified barriers were the inverse of the facilitators and were reinforced by stigma, financial pressure, and stress. The failure modes identified along the cascade included: missed opportunities for HIV testing and delivery of PMTCT interventions at antenatal, poor quality of data, loss of infant’s HIV test results, long wait times, and poor linkage between health facilities. CONCLUSION: Retention along the PMTCT continuum of care was low at the study facilities. The facilitators and barriers of retention comprised an interaction of personal, societal and structural dynamics operating simultaneously. The results provide the needed context and important considerations in the improvement of PMTCT implementation strategies as Kenya transitions to provide lifelong ART.