Improving a mother to child HIV transmission programme through health system redesign: quality improvement, protocol adjustment and resource addition

Abstract

Background: Health systems that deliver prevention of mother to child transmission (PMTCT) services in low and middle income countries continue to underperform, resulting in thousands of unnecessary HIV infections of newborns each year. We used a combination of approaches to health systems strengthening to reduce transmission of HIV from mother to infant in a multi-facility public health system in South Africa.

Methodology/principal findings: All primary care sites and specialized birthing centers in a resource constrained sub-district of Cape Metro District, South Africa, were enrolled in a quality improvement (QI) programme. All pregnant women receiving antenatal, intrapartum and postnatal infant care in the sub-district between January 2006 and March 2009 were included in the intervention that had a prototype-innovation phase and a rapid spread phase. System changes were introduced to help frontline healthcare workers to identify and improve performance gaps at each step of the PMTCT pathway. Improvement was facilitated and spread through the use of a Breakthrough Series Collaborative that accelerated learning and the spread of successful changes. Protocol changes and additional resources were introduced by provincial and municipal government. The proportion of HIV-exposed infants testing positive declined from 7.6% to 5%. Key intermediate PMTCT processes improved (antenatal AZT increased from 74% to 86%, PMTCT clients on HAART at the time of labour increased from 10% to 25%, intrapartum AZT increased from 43% to 84%, and postnatal HIV testing from 79% to 95%) compared to baseline.

Conclusions/significance: System improvement methods, protocol changes and addition/reallocation of resources contributed to improved PMTCT processes and outcomes in a resource constrained setting. The intervention requires a clear design, leadership buy-in, building local capacity to use systems improvement methods, and a reliable data system. A systems improvement approach offers a much needed approach to rapidly improve under-performing PMTCT implementation programmes at scale in sub-Saharan Africa.

Conflict of interest statement

Competing Interests: The authors have declared that no competing interests exist.

Figures

Figure 1. Percentage of HIV+ mothers receiving AZT before labour (A); and on HAART at time of delivery (B).

Legend: Statistical process control p-charts showing changes (p2 weeks before labour (provincial protocol) and (B) on HAART at time of delivery in labour ward (p

Figure 2. Percentage of HIV positive women receiving intrapartum administration of NVP and AZT.

Legend: The quality of the data, and the reliability and variation of care in the administration of PMTCT in labour improved after the QI approach was introduced to the labour ward.

Figure 3. Percentage of infants tested for HIV (A) and percentage of infants testing HIV+ (B).

Legend: A. Percent of HIV-exposed infants tested for HIV in Eastern sub-district (Eastern) vs. remainder of the Metro District (District) B. Percent of HIV-positive infants in Eastern sub-district vs remainder of Cape Town Metro District . “1” = start of the innovation phase, and “2” = start of spread phase.