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Table 3 Key findings based on proposed CAS components

From: Integrating the prevention of mother-to-child transmission of HIV into primary healthcare services after AIDS denialism in South Africa: perspectives of experts and health care workers - a qualitative study

CAS component and key findingsIllustrative quotes
System
1. Experiences in PMTCT trials during and after AIDS denialism era“We had to get special permission to roll out the programme, and… when there was a court instruction to roll it out; but then they were still controlling the roll-out and we were all, like, pilot projects” – Expert 2.
“I think over the years what has happened is the pressure on the ground that has resulted in people changing their perspective and focus around PMTCT” – Expert 1.
“I’m just thinking back now, in general and for Cape Town in particular,…So basically, we received global funding, and in 2006, we appointed quite a number of PMTCT coordinators, as well as PMTCT registered professional nurses within the PHC setting…” – Expert 4.
“It was only AZT and Nevirapine that was given at that time. Then as time goes by then we changed” – FHCW 1.
“.....she started to run the PMTCT programme about 15 years ago, lots of patients were lost before that and statistics were quite high when it came to PCRs. They weren’t followed up appropriately. So, I think after the PMTCT programme started, there was somebody actually taking charge, invested in the patient’s wellbeing, and they were being followed up, and if any other issues arose besides PMTCT, it could also be managed more appropriately and be referred” – FHCW 2.
“I believe there was a problem with a theft on medication. As a result now, the nurses that are doing ANC, they don’t dispense medication” – FHCW 3.
Adaptive
2. Commitment to PMTCT integration“And in some settings, actually referring the patient involved having them moving from the facility to another to obtain the care for other conditions; and you’ve got to think of integration in terms of, at least, the making available within the same facility of other services” – Expert 6.
“…transferring clients to specialists may cause gaps and some women become missing, even for a short distance…, they disappear within 50 m to where you send them. They fall in hole in that walk and with this we can’t defragment the system” – Expert 10.
“It’s a logical move for midwives and other health workers who are working in maternity, antenatal, and postnatal and delivery services to treat mothers who are infected with HIV in a holistic way” – Expert 3.
“It’s quite good, because we try to integrate services…..So we do the PCRs when the mothers are here for immunisation, I mean, it can be sooner done at once” – FHCW 3.
“You want your baby to be immunised here; then we don’t want you to go up and down, you must also be here and your baby, so that we can see both of you ….But the mother and the baby must be on the same facility” FHCW 4.
“…because they see mother and child, then they also check which medication did the child get, or is the child a high risk infant or not? Does the mother still remain in care? All those check ups, PAP smears, they also check immunisations, deworming, nutrition,…everything possible” – FHCW 5.
3. Gradual move towards PMTCT acceptance and integration in the clinics“…PMTCT figures almost synonymous with antenatal care, because the chances of being HIV infected are so high, relatively, that you almost don’t see one without the other” – Expert 8.
“So most of our nurses, our midwives are now trained, so which means they’re offering integrated antenatal and antiretroviral treatment (PMTCT) and they’re also doing TB screening” – Expert 4.
“Western Cape was the only province to start integration of PMTCT and other ANC services and others did the same later. Different stakeholders used to meet once per week to discuss the progress and issues and everyone came together to assess how it was managed” – Expert 9.
“The community is more open-minded now of what is expected of them once they are pregnant…So, it was an eye-opener, also for the nurses, because and the community as well; because now they know, once they are pregnant, they are eager to know their status” – FHCW 6.
“…within the facility, it’s now good that we realised that there is a need for that continuity of care…..when we started this project of Child Health” – FHCW 1.
“I can say one in 5 years, we have only one child, one in 5 years that is positive. She didn’t come to the clinic when she was pregnant, and yet she was positive. You see, it can take one in 5 years for one child due to PMTCT; and we are not happy with that” – FHCW 4.
4. Increased awareness and community participation“It has so many adverse consequences affecting key public health indicators, such as maternal and under five and infant mortality, that it became a priority health problem for the health services to solve” – Expert 3.
“…bringing HIV care back to the community, now increasingly having what they call community-based club, and you are going to see for instance more room for those people, to deal with more urgent issues, because they are overcrowded” – Expert 6.
“….community support also plays a key role in supporting moms throughout this whole cascade. Peer support is important” – Expert 10.
“We have got programmes like MomConnect where they are enrolled and they get all the support, like where they are sent sms’s and stuff” – FHCW 6.
“Mothers to Mothers services which is well supporting the mothers who are pregnant and those after delivery, so they work hand in hand with antenatal labour ward as well as Child Health for continuity of care” FHCW 1.
“So, when we talk to them we get the social worker involved as well, then we will try and make a plan to see if there are not other family members because, I mean, any support, it doesn’t just have to be the partner, support in general is good” – FHCW 2.
5. Community health workers’ involvement“CHWs are part of health care system to link clinics to the communities and enforce adherence among their other roles. They need to be trained” – Expert 9.
“…if they were in place, in many communities, it would be relatively easy to send a message to those community health workers and teams” – Expert 3.
“They (CHWs) can go to the houses and they can reinforce adherence…and the idea is that they go into that household and look at all the problems. They look at the teenagers, they counsel them about contraception, and look at the mother that’s struggling with breastfeeding and at the father that’s smoking” – Expert 5.
“I will say they are helpful, because we use them as the bridge just to get to the communities, because they go the extra mile in this way that they go inside those houses; then they will go there and give talk…So we work hand in hand with them” – FHCW 7.
“…but mostly our community health workers are working with TB and HIV,… Only if, for example, we need to recall our babies for immunisation…. then they will recall those mothers for us. When we are doing some bloods screening and there is an abnormality, they can’t get that person from the phone, and then somebody has to go and do a home visit” – FHCW 3.
“After delivery, CHWs maybe they visit them (women) at home” – FHCW 8.
6. Clinical training and retraining for nurses“We trained nurses and they are delivering ART and none believed that in those days, training changes everything….” – Expert 10.
“…When everyone diagnosed with HIV was to be initiated to treatment and nurses had to be train on ART initiation. NIMART was created and trained them” – Expert 9.
“We said that the NIMART nurse who’s got a dispensing licence can also dispense the medication in the MOU, to make sure that the mom gets more of an integrated service…” – Expert 4.
“In South Africa, for special training, they have to do the NIMART training, and then they can dispense the drugs and look after the patients and the counselling…” – Expert 5.
“We wanted all the midwives to be NIMART trained, so they would be able to initiate, so they don’t send the patients from pillar to post. Then they get tired and don’t start their medication because they must wait in other queues” – FHCW 1.
“….just to send the staff to the trainings on PMTCT, on BANC….yes, I see who is running short, so that I send them for training through NIMART training programme” – FHCW 4.
“I do BANC and most of the time… I don’t have the HIV course, so I must run around and asking those sisters there for my patients all the time; and if they would send me for HIV training that would be resolved” – FHCW 8.
“…because, the staff have to be trained, and especially on the PMTCT guidelines when they change again, so, they change a lot and there should be uniformity” – FHCW 3.
Complex
7. Persistent barriers to PMTCT integration“If we have an electronic system that talks to each other and the patient has got a single number, we can track her…it’s not installed in all the computers and not everyone is trained how to use it...Other health problems like Hypertension is not integrated into the PMTCT services” – Expert 5.
“I think that there was resistance to change. I remember there was a time, just before we introduced the same day initiation. When we spoke to nurses about it, they said it’s impossible, we can’t do it; and so there are attitudinal issues and they needed support and training and encouragement. So people don’t really want to change necessarily, but when it’s policy, you say, well we don’t have a choice” – Expert 7.
“Some mothers book late, and so don’t benefit from the services available. Other mothers convert after they’ve been initially tested and they’re especially at high risk, so identifying and getting the mothers onto treatment is one of the big challenges; and then keeping mothers adherent is another challenge” – Expert 3.
“We wanted all the midwives to be NIMART trained, so they would be able to initiate, so they don’t send the patients from pillar to post. Then they get tired and don’t start their medication because they must wait in other queues” – FHCW 1.
“…for stigma purpose, because they know in our communities if you breastfeed then you are regarded as negative….So we have that challenge, breastfeeding for two weeks then stop, swap to formula feeding” – FHCW 7.
“I believe there was a problem with a theft on medication. As a result now, the nurses that are doing ANC, they don’t dispense medication. So now those mothers, they queue twice” – FHCW 3.
“Our waiting area is very congested. We don’t even separate them, you know, like kids as such and mothers…, and also there’s poor ventilation in there,… and then they come here and actually, those kids may leave this place more sicker” – FHCW 3.