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Page 2 of 7 Original Research

antiretroviral regimens for the prevention of mother-to-child HIV-positive, were issued a single-dose nevirapine (NVP) to be
transmission (PMTCT) of HIV. 2,3,4,5 South Africa was identified taken intrapartum, and also a single-dose NVP to be given to
as one of the 22 priority countries, and through strong the infant immediately after birth. A free 6-month supply of
political will and rapid evolution of the country’s PMTCT infant formula was also available for women living with HIV
guidelines, new paediatric HIV infections decreased by 84% who elected not to breastfeed.
between 2009 and 2015, with an estimated 330 000 infections
averted. The UNAIDS estimate for the MTCT rate for South The programme evolved in line with changes in the South
2
Africa in 2015 was 2%. This was consistent with findings African PMTCT and ART guidelines, and since 2009, the
from a national survey conducted in 2012–2013, involving programme has been supported by the Anova Health
over 9000 infant–caregiver pairs, with an MTCT rate of 2.6% Institute (Anova), a USAID/PEPFAR-funded non-profit
at 4–8 weeks. 2,6 organisation. The donor-funded support was initially
through direct service provision with placement of staff –
Donor funding has been critical in the establishment of the doctors, professional nurses, data collectors and lay
South African PMTCT and antiretroviral therapy (ART) counsellors – in public health facilities working alongside
programmes, with the country being the largest recipient of government employees. There was also infrastructure,
grants from the United States President’s Emergency Plan for pharmacy, and monitoring and evaluation support for the
AIDS Relief (PEPFAR). 7,8,9,10,11 President’s Emergency Plan for facilities providing HIV services. With the PEPFAR funding
AIDS Relief funding of HIV programmes in South Africa transitioning to technical support, the focus in support
started in 2004, with direct service provision through the shifted to mentoring and quality improvement of the
placement of staff and infrastructure in public healthcare programmes through monitoring and evaluation.
facilities. 8,10 From 2012, there was a transition in PEPFAR
funding from direct service provision to technical support, Evolution of the South African prevention of
with the South African government increasingly taking up mother-to-child transmission guidelines
8,11
ownership of the country’s HIV programme. By 2016, Prior to 2002, no antiretroviral (ARV) prophylaxis or treatment
more than 75% of South Africa’s HIV response was funded was available in the South African public health sector, and
by the government. 12 ARVs were only available as part of research projects. 15,16,17
From 2002 until 2007, only mother–infant single-dose NVP
This article reports on the outcomes of a large PMTCT was available for PMTCT (Table 1). Additional zidovudine
programme in Soweto, South Africa, over time, including the (AZT) monotherapy for PMTCT prophylaxis was introduced
coverage of ART among PWLHIV and the MTCT rate at in 2008, initially started at 28 weeks’ gestation, and from 2010
approximately 6 weeks of age. at 14 weeks’ gestation. 18,19,20 Antiretroviral therapy became
available in South Africa in 2004 and the eligibility criterion
Methods was a CD4 count of < 200 cells/µL, or World Health
21
Study setting and design Organization (WHO) stage 4 disease. CD4 count testing to
assess ART eligibility became routinely available from 2005.
We conducted a retrospective study of routinely collected The CD4 count threshold for ART initiation in pregnant
PMTCT data from 13 public healthcare facilities that have women increased to ≤ 350 cells/µL in 2010. 20
been part of the Soweto PMTCT programme since its
inception in 2002. Of the 13 facilities, one is a tertiary-level Up to September 2010, the antenatal clinics in the 12 primary
referral hospital (Chris Hani Baragwanath Academic healthcare facilities only provided antiretroviral prophylaxis
Hospital), and 12 are primary healthcare facilities, of which for PMTCT, and PWLHIV who were eligible for lifelong ART
six have delivery units. Soweto is an area of mixed urban and were referred to a separate ART initiation site. In that time
informal settlements, with an estimated population of period, the only antenatal clinic that initiated ART was at
approximately 1.7 million people. 13 Chris Hani Baragwanath Academic Hospital. At the primary
health clinics, pregnant women diagnosed with HIV infection
History of the Soweto prevention of were referred to an ART initiation site, which could be in a
mother-to-child transmission programme different section of the same health facility, or in a different

The Soweto PMTCT programme was established in 2000 as the facility. Over a period of 18 months, beginning in October
Demonstration of Antiretroviral Treatment (DART) programme 2010, nurse-initiated and managed ART (NIMART) was
initiated by the Perinatal HIV Research Unit (PHRU). introduced in the antenatal clinics, with PWLHIV receiving
14
The programme was initially funded by the Elizabeth their antenatal and HIV care in the same facility. Nurse-
Glaser Paediatric AIDS Foundation (EGPAF) with funding initiated and managed ART, a task-shifting initiative to
from the United States Agency for International Development increase the number of patients initiated on ART, meant that
(USAID), the Fonds De Solidarité Thérapeutique International professional nurses, including midwives, could initiate and
(FSTI) and the Gauteng Department of Health, and from manage patients on ART. Postpartum, the women were
22
14
2004 it was funded by PEPFAR, through the USAID. As part transitioned to adult HIV care for follow-up. From 2002 until
of the DART programme, pregnant women were offered 2011, a 6-month supply of free infant formula was available
voluntary counselling and testing for HIV and, if found to be for all WLHIV who elected not to breastfeed.

http://www.sajhivmed.org.za 340 Open Access