5.1 antenatal 1st visit before 20 weeks rate - hst.org.za health barometers/district+health... ·...

425 059 452 423 446 269 551 109 588 012 598 935 638 710 675 305

1 140 788 1 126 592 1 099 389 1 108 077 1 093 391 978 170 979 532 1 013 796Antenatal 1st visit - total

Antenatal 1st visit before 20 weeks

2010/11 2011/12 2012/13 2013/14 2014/15 2015/16 2016/17 2017/18

Num

ber

0200 000400 000600 000800 000

1 000 0001 200 0001 400 0001 600 0001 800 000

87

Section A: PMTCT

5 Prevention of mother-to-child transmissionManala Makua, Ahmad Haeri Mazanderani, Gayle Sherman, Naomi Massyn

This chapter covers three core national indicators used to assess the progress and performance of the prevention of mother-to-child transmission (PMTCT) programme. Data are from the District Health Information Software (DHIS). The indicators are:

✦ Antenatal 1st visit before 20 weeks rate

✦ Infant PCR test positive around 10 weeks rate

✦ HIV test around 18 months uptake rate.

5.1 Antenatal 1st visit before 20 weeks rateThe antenatal 1st visit before 20 weeks rate measures the number of women who have a booking visit (first visit) before they are 20 weeks (about half way) into their pregnancy as a proportion of all antenatal 1st visits. The numerator is the number of antenatal 1st visits before 20 weeks and the denominator is the total number of antenatal 1st visits. The National Department of Health’s (NDoH) Annual Performance Plan (APP) 2017/18 aggregated target is 67% which is the average of the provincial targets.a

Antenatal care (ANC) is a public health strategyb that provides pregnant women with an opportunity to receive critical interventions to improve the health of the mother and baby, and to reduce poor pregnancy outcomes and maternal and neonatal mortality. Antenatal care attendance is associated with, among others, counselling women for the Human Immunodeficiency Virus (HIV), initiation of antiretroviral therapy (ART), and monitoring of viral load suppression, thus preventing intra-uterine and intra-partum transmission of HIV from mother to the infant. Improved early ANC booking before 20 weeks in South Africa will help to further achieve the last Mile Plan to eliminate the risk of mother-to-child transmission of HIV (MTCT).c

National overview

The national antenatal 1st visit before 20 weeks rate has been increasing in the past three years following the implementation of MomConnect.d The antenatal 1st visit before 20 weeks rate increased from 50.0% in 2013/14 to 53.9% in 2014/15. The rate then increased from 61.2% in 2015/16 to 65.2% in 2016/17 and to 66.6% in 2017/18, almost reaching the aggregated target of 67% for 2017/18. The total number of women who attend ANC services before 20 weeks gestation increased from 551 109 in 2013/14 to 675 305 in 2017. The increase in the antenatal 1st visit before 20 weeks rate is associated with the increase in access to an intervention indicator such as the antenatal client initiated on ART rate. The national antenatal client initiated on ART rate increased from 76.3% in 2013/14 to 93.9% in 2017/18. The impact of the increase in antenatal 1st visit before 20 weeks rate may have also contributed to a reduction of the maternal mortality in facility ratio from 133.3 to 105.7 per 100 000 live births between 2013/14 to 2017/18. Figure 1 below illustrates the improvement trends in the last eight years in the number of antenatal 1st visit before 20 weeks.

Figure 1: Number of antenatal 1st visit before 20 weeks trends, 2010/11 – 2017/18

Source: DHIS.

a National Department of Health. Annual Performance Plan, 2017/18 – 2019/20. Pretoria: National Department of Health. 2017.

b World Health Organization. WHO recommendations on antenatal care for a positive pregnancy experience. Geneva: World Health Organization; 2016. ISBN–13: 978–92–4–154991–2.

c National Department of Health. last Mile Plan for Elimination of MTCT in South Africa. Pretoria: National Department of Health. 2016.

d http://www.health.gov.za/index.php/mom-connect. [Accessed 13 November 2018].

Antenatal 1st visit before 20 weeks rate by province, 2017/18

Percentage [Source: DHIS]

GP

LP

NC

EC

FS

NW

WCKZN

MP

20 40 60 80

73.8

61.4

64.8

72.1

65.6

64.0

69.7

66.4

63.2SA: 66.6

ProvincesECFSGPKZNLPMPNCNWWC

88

Section A: PMTCT

Provincial overview

The antenatal 1st visit before 20 weeks rate varied between provinces. The rate increased in six of the nine provinces between 2016/17 and 2017/18 with the greatest increase of 3.0 percentage points in Gauteng (GP). limpopo’s (lP) rate declined by 2.5 percentage points in the same period (Table 1).

Table 1: Antenatal 1st visit before 20 weeks rate by province, 2013/14 – 2017/18

2013/14 2014/15 2015/16 2016/17 2017/18 Percentage point difference between 2016/17 and 2017/18

Eastern Cape 43.3 48.8 59.7 63.8 64.8 1.0Free State 56.8 58.6 62.9 65.8 65.6 -0.2Gauteng 43.7 48.4 55.0 58.4 61.4 3.0KwaZulu-Natal 56.2 57.3 64.8 70.2 72.1 1.9Limpopo 45.8 50.7 60.7 65.7 63.2 -2.5Mpumalanga 49.0 56.6 65.9 71.7 73.8 2.1Northern Cape 55.5 57.6 62.4 64.7 64.0 -0.7North West 50.6 54.3 60.6 63.7 66.4 2.7Western Cape 61.0 65.8 67.7 69.6 69.7 0.1

Source: DHIS.

Figure 2 shows that Mpumalanga (MP) had the highest rate at 73.8% and although Gauteng had an increase in the rate of 3.0 percentage points between 2016/17 and 2017/18, the rate of 61.4% was still the lowest. Gauteng’s antenatal 1st visit before 20 weeks rate continues to be the lowest among the provinces since 2013/14. The antenatal 1st visit before 20 weeks rate reported on in this chapter only relates to the public sector as private institutions do not submit data to the provincial Departments of Health. Gauteng had the highest medical scheme coverage in the country (27.7%) and it can thus be inferred that many pregnant women therefore use the private sector for antenatal care.

Figure 2: Antenatal 1st visit before 20 weeks rate by province, 2017/18

District overview

The antenatal 1st visit before 20 weeks rate in 18 districts was lower than the national average of 66.6% and includes four of the five districts in the Free State (FS) (Figure 3). Fourteen of the 18 districts achieved a rate between 60.3% and 66.4%, three districts had rates around 59% and only Alfred Nzo in the Eastern Cape (EC) had a rate below 50% at 47.8%.

Antenatal 1st visit before 20 weeks rate by district, 2017/18


A Nzo: DC44Johannesburg: JHB

J T Gaetsewe: DC45Ruth Segomotsi Mompati: DC39

Tshwane: TSHSekhukhune: DC47

Capricorn: DC35ZF Mgcawu: DC8

City of Ekurhuleni: EKUMangaung: MAN

Vhembe: DC34Waterberg: DC36Joe Gqabi: DC14

Frances Baard: DC9Lejweleputswa: DC18

T Mofutsanyana: DC19Fezile Dabi: DC20Cape Town: CPT

N Mandela Bay: NMAO Tambo: DC15

Buffalo City: BUFBojanala Platinum: DC37

G Sibande: DC30Pixley ka Seme: DC7

Ngaka Modiri Molema: DC38C Hani: DC13Mopani: DC33

West Rand: DC48Dr K Kaunda: DC40

Sarah Baartman: DC10Ugu: DC21

uMgungundlovu: DC22eThekwini: ETH

King Cetshwayo: DC28Nkangala: DC31Amathole: DC12

West Coast: DC1Sedibeng: DC42Amajuba: DC25uThukela: DC23

Harry Gwala: DC43Namakwa: DC6

Central Karoo: DC5Cape Winelands: DC2

Zululand: DC26uMkhanyakude: DC27

iLembe: DC29Eden: DC4

Xhariep: DC16uMzinyathi: DC24Ehlanzeni: DC32

Overberg: DC3

20 40 60 80

70.5

79.5

67.6

62.0

60.3

71.0

68.7

59.1

69.8

47.8

70.8

66.9

64.6

66.8

68.2

66.7

70.0

75.3

72.9

70.3

78.8

71.5

70.1

76.9

69.8

74.6

71.7

66.2

65.6

63.1

65.6

78.7

67.8

61.8

66.4

59.3

64.9

73.874.1

78.0

80.1

70.8

74.4

67.0

68.1

69.2

59.8

63.163.4

61.160.3

68.3

SA: 66.6


89

Section A: PMTCT

Figure 3: Antenatal 1st visit before 20 weeks rate by district, 2017/18

CPT

NMA

BUF

ETH

EKUJHB

DC10

DC12

DC13

DC14

DC15

DC44

DC16

DC18DC19

DC20

MAN

DC42DC48

TSH

DC21

DC22

DC23

DC24

DC25 DC26 DC27

DC28

DC29

DC43

DC33

DC34

DC35

DC36

DC47

DC30

DC31

DC32

DC45

DC6DC7

DC8DC9

DC37

DC38

DC39DC40

DC1

DC2

DC3

DC4

DC5

LegendProvinceDistrict

ANC_B20W 40.6 - 58.858.9 - 66.366.4 - 72.472.5 - 78.678.7 - 90.4

EKUJHB

DC42

DC48

TSH

Gauteng

90

Section A: PMTCT

Local municipality/sub-district overview

Map 1 indicates that, while a province has reached the national target or had a rate above the national rate, there were several local municipality/sub-district (lM/SD) with low antenatal 1st visit before 20 weeks rates. An example is North West (NW) with an antenatal 1st visit before 20 weeks rate of 66.4% in 2017/18 but Kagisano-Molapo and Naledi lMs in the Dr Ruth Segomotsi Mompati district had rates of 56.0% and 56.2% respectively. On the other hand, lMs like Bushbuckridge in Ehlanzeni had a rate of 87.4% while the district rate was 79.5% and Mpumalanga provincial rate was 73.8%.

Map 1: Antenatal 1st visit before 20 weeks rate by local municipality/sub-district, 2017/18

Source: DHIS.

Key findings ✦ The national antenatal 1st visit before 20 weeks rate increased from 61.2% in 2015/16 to 65.2% in 2016/17 and then

to 66.6% in 2017/18 – almost reaching the aggregated target of 67% for 2017/18.

✦ The increase in the antenatal 1st visit before 20 weeks rate is associated with the increase in access to an intervention indicator such as the antenatal client initiated on ART rate. The national antenatal client initiated on ART rate increased from 76.3% in 2013/14 to 93.9% in 2017/18.

✦ The increase in the antenatal 1st visit before 20 weeks rate can also be linked to the introduction of MomConnectd

in August 2014. The number of antenatal 1st visit before 20 weeks increased from 588 012 in 2014/15 and beyond.

✦ The impact of the increase in antenatal 1st visit before 20 weeks rate may have also contributed to a reduction of the maternal mortality in facility ratio from 133.3 to 105.7 per 100 000 live births between 2013/14 and 2017/18.

✦ Mpumalanga had the highest rate among the provinces at 73.8% and although Gauteng had an increase in the rate of 3.0 percentage points between 2016/17 and 2017/18, the rate of 61.4% was still the lowest.

✦ Overberg in Western Cape (WC) had the highest antenatal 1st visit before 20 weeks rate in 2017/18 at 80.1% with Alfred Nzo (EC) having the lowest rate at 47.8%.

Recommendations ✦ Drilling down to facility level will assist in identifying the pockets of low performance, and in developing focused

and specific interventions to address challenges such as social barriers that influence access to health facilities before 20 weeks of gestation.

Infant PCR test positive around 10 weeks rate by province, 2017/18


NC

EC

NW

MP

FS

GP

LP

KZN

WC

1 2 3

1.0

1.1

0.8

1.1

1.4

0.7

1.1

0.5

1.2

SA: 0.9


91

Section A: PMTCT

✦ More specific interventions are essential in ensuring that vulnerable groups such as teenagers who fall pregnant also attend ANC as soon as possible.

✦ Private sector data should also be collected and entered into the DHIS.

5.2 Infant HIV PCR test positive around 10 weeks rateSince June 2015, all HIV-exposed infants born in South Africa are expected to have an HIV polymerase chain reaction (PCR) test at birth (to detect intra-uterine infection) and a repeat test at 10 weeks of age (to detect intra-partum and early postnatal infection). It is recommended that infants who test HIV PCR positive have a second HIV PCR test to confirm their status.

The positivity rate among HIV-exposed infants around 10 weeks of age can be calculated using the National Indicator Data Set (NIDS)e data elements ‘infant PCR test positive around 10 weeks’ as the numerator and ‘infant PCR test around 10 weeks’ as the denominator. This indicator represents the positivity rate of infants who underwent HIV PCR testing between 6–12 weeks of age.

South Africa is still to fully implement a unique health identification system that can assist with de-duplicating patient level data and the DHIS and National Health laboratory Service (NHlS) data are currently unable to accurately determine testing coverage and mother-to-child transmission rates at 10 weeks of age. Although the DHIS indicator ‘HIV PCR positivity at around 10-weeks’ excludes confirmatory positive results from infants who have already tested HIV-positive at a particular facility, confirmatory results of infants who engage testing services at other facilities may be included. Similarly, confirmatory positive results of infants who have tested HIV PCR positive prior to 6 weeks of age may be counted. Hence, the current inability to accurately de-duplicate positive results may be associated with the positivity rate at around 10 weeks of age being an overestimation of intra-partum/early postnatal transmission rates. Furthermore, in districts with poor testing coverage, the positivity rate is expected to be higher than the true transmission rate as symptomatic high-risk infants are more likely to be tested than asymptomatic low-risk infants.

National and provincial overview

In 2017/18, the infant PCR test positive around 10 weeks rate in South Africa was 0.9% (Figure 4). This reflects an improvement from the previous year, which reported a 1.3% positivity rate, and is lower than the National Strategic Plan (NSP)f target for 2018/19 of 1.3%. All provinces have seen a decrease in the infant PCR test positive around 10 weeks rate between 2016/17 and 2017/18, with Gauteng and Mpumalanga demonstrating the largest decrease, from 1.7% to 1.0% (for Gauteng) and 1.7% to 1.1% (for Mpumalanga). The Northern Cape (NC) had the highest infant PCR test positive around 10 weeks rate of 1.4% in 2017/18 and the Western Cape the lowest at 0.5%.

Figure 4: Infant PCR test positive around 10 weeks rate by province, 2017/18

e National Department of Health. 2017 National Indicator Data Set. Pretoria: National Department of Health. April 2017.

f South African National AIDS Council. let Our Actions Count. South Africa’s National Strategic Plan on HIV, STIs and TB 2017–2022. Pretoria: South African National AIDS Council, 2017.

92

Section A: PMTCT

Table 2 shows the number of infants PCR test positive around 10 weeks and infants PCR test around 10 weeks by province between 2016/17 and 2017/18. The total number of infant PCR tests around 10 weeks done in South Africa were 180 790 in 2017/18 and increased from 151 246 in 2016/17. The total number of infants PCR test positive around 10 weeks decreased from 2 013 to 1 636 in the same period. In all provinces the number of infant PCR tests around 10 weeks increased. Mpumalanga conducted 7 289 more PCR tests around 10 weeks in 2017/18 than in 2016/17 but the number of PCR test positive around 10 weeks remained around 190.

Table 2: Number of infants PCR test positive around 10 weeks and infants PCR test around 10 weeks by province, 2016/17 – 2017/18

PCR test positive around 10 weeks

Infant PCR test around 10 weeks

PCR test positive around 10 weeks

Infant PCR test around 10 weeks

Eastern Cape 214 13 584 244 20 084Free State 88 6 621 99 8 700Gauteng 665 38 640 414 41 865KwaZulu-Natal 449 45 267 361 51 075Limpopo 163 13 967 123 14 768Mpumalanga 190 11 213 195 18 502Northern Cape 31 1 863 30 2 111North West 118 8 078 103 9 773Western Cape 95 12 013 67 13 912South Africa 2 013 151 246 1 636 180 790

Source: DHIS.

District overview

At district level, the infant PCR test positive around 10 weeks rate varied widely in 2017/18 – the highest rate being 3.6% in John Taolo Gaetsewe (NC) and the lowest being 0.0% in Namakwa (NC) and Central Karoo (WC) districts. The districts with the highest 10 week positivity rate per province were West Coast (WC) at 0.6%, the same as the previous year; ilembe (KwaZulu-Natal (KZN)) at 0.9% compared to 1.5% the previous year; Waterberg (lP) at 1.1% compared to 2.0% the previous year; Nkangala (MP) at 1.3% compared to 2.1% the previous year; Tshwane (GP) 1.5% compared to 3.4% the previous year; Dr Ruth Segomotsi Mompati (NW) at 1.6% compared to 1.7% the previous year; Joe Gqabi (EC) at 1.9% compared to 2.5% the previous year; Fezile Dabi (FS) at 2.1% compared to 1.4% the previous year; and John Taolo Gaetsewe (NC) at 3.6% compared to 1.2% the previous year.

Greater variation in transmission rates was noted at lM/SD level (Map 2), which likely reflects variability in population density and testing coverage.

CPT

NMA

BUF

ETH

EKUJHB

DC10

DC12

DC13

DC14

DC15

DC44

DC16

DC18DC19

DC20

MAN

DC42DC48

TSH

DC21

DC22

DC23

DC24

DC25 DC26 DC27

DC28

DC29

DC43

DC33

DC34

DC35

DC36

DC47

DC30

DC31

DC32

DC45

DC6DC7

DC8DC9

DC37

DC38

DC39DC40

DC1

DC2

DC3

DC4

DC5


PCR_10PR 0.0 - 0.50.6 - 1.21.3 - 2.32.4 - 4.14.2 - 7.7

EKUJHB

DC42

DC48

TSH

Gauteng

93

Section A: PMTCT

Map 2: Infant PCR test positive around 10 weeks rate by local municipality/sub-district, 2017/18

Source: DHIS.

Key findings ✦ The infant PCR test positive around 10 weeks rate in South Africa was 0.9% in 2017/18 and decreased from 1.3% in

2016/17.

✦ The total number of infant PCR tests around 10 weeks done in South Africa was 180 790 in 2017/18 and increased from 151 246 in 2016/17. The total number of infant PCR test positive around 10 weeks decreased from 2 013 to 1 636 in the same period.

✦ All provinces have seen a decrease in the infant PCR test positive around 10 weeks rate between 2016/17 and 2017/18, with Gauteng and Mpumalanga demonstrating the largest decreases. Northern Cape had the highest infant PCR test positive around 10 weeks rate of 1.4% in 2017/18.

✦ At district level, the infant PCR test positive around 10 weeks rate ranged considerably in 2017/18 – the highest rate being 3.6% in John Taolo Gaetsewe (NC) and the lowest being 0.0% in Namakwa (NC) and Central Karoo (WC) districts. Greater variation of transmission rates was noted at lM/SD level, which likely reflects variability in population density and testing coverage.

Recommendations ✦ The high infant PCR test positive around 10 weeks rate in John Taolo Gaetsewe (NC) should be investigated.

5.3 HIV test around 18 months uptake rateThe HIV test around 18 months uptake rate is calculated using infant rapid test around 18 months as the numerator and live births to HIV positive women as the denominator. Previous testing guidelines have recommended that all HIV-exposed infants have HIV rapid testing done at 18 months of age. However, some provinces, such as Mpumalanga, have begun testing all infants (regardless of HIV-exposure) whereas other provinces, such as the Western Cape, only test HIV-exposed infants. Hence, considerable variation in coverage between provinces is noted.

National and provincial overview

Due to the varying testing practices among provinces, the reported 78.9% national HIV test around 18 months uptake rate is difficult to interpret. Provinces with testing coverage above 100% (Figure 5), such as Mpumalanga, Northern Cape and

HIV test around 18 months uptake rate by province, 2017/18


WC

GP

NW

LP

EC

KZNFS

NC

MP

50 100 150

54.7

101.6

96.2

21.8

103.9

58.5

62.4

147.0

64.0

SA: 78.9


94

Section A: PMTCT

Free State, can be explained by universal testing of all infants. Hence, these high percentages actually reflect poor testing coverage as there are approximately three times the number of HIV-unexposed infants compared with HIV-exposed infants (the latter being equivalent to live births to HIV-positive women, the denominator used to calculate the testing coverage).

Figure 5: HIV test around 18 months uptake rate by province, 2017/18

District overview

Similar to the provincial level, the considerable variability in testing coverage at 18 months of age among districts can be described by different testing practices as in the case of Mpumalanga and Western Cape (Figure 6 and Map 3). Seventeen districts reported HIV test around 18 months uptake rates above 100% in 2017/18. All districts in the Western Cape had very low uptake rates due to the fact that only HIV-exposed infants were tested.

HIV test around 18 months uptake rate by district, 2017/18


Cape Winelands: DC2Cape Town: CPT

Ruth Segomotsi Mompati: DC39Central Karoo: DC5

Eden: DC4West Coast: DC1

Namakwa: DC6Ngaka Modiri Molema: DC38

West Rand: DC48O Tambo: DC15

Sekhukhune: DC47City of Ekurhuleni: EKUSarah Baartman: DC10

C Hani: DC13Overberg: DC3

Waterberg: DC36Amajuba: DC25

Buffalo City: BUFMopani: DC33

Vhembe: DC34Tshwane: TSH

Frances Baard: DC9Dr K Kaunda: DC40

Joe Gqabi: DC14Fezile Dabi: DC20

Sedibeng: DC42Johannesburg: JHB

eThekwini: ETHuMkhanyakude: DC27

Bojanala Platinum: DC37N Mandela Bay: NMA

uMgungundlovu: DC22A Nzo: DC44

Zululand: DC26T Mofutsanyana: DC19

Capricorn: DC35Mangaung: MAN

G Sibande: DC30uMzinyathi: DC24

Lejweleputswa: DC18Ugu: DC21

iLembe: DC29Amathole: DC12

J T Gaetsewe: DC45uThukela: DC23

ZF Mgcawu: DC8Xhariep: DC16

King Cetshwayo: DC28Ehlanzeni: DC32

Harry Gwala: DC43Pixley ka Seme: DC7

Nkangala: DC31

50 100 150

41.1

69.4

56.7

61.0

128.0

148.6

120.2119.8

96.3

51.8

155.5

75.6

64.2

88.8

131.7

112.6

145.0

38.8

71.1

115.8

93.7

17.4

28.8

19.5

32.7

45.1

34.3

131.3

34.7

165.3

137.6

60.6 60.7

37.8

78.7

27.5

55.8

101.7

40.3

56.4

49.2

149.1

183.2

115.3

90.8

84.0

53.8

60.7

38.8

42.4

128.6

43.5

SA: 78.9


95

Section A: PMTCT

Figure 6: HIV test around 18 months uptake rate by district, 2017/18

CPT

NMA

BUF

ETH

EKUJHB

DC10

DC12

DC13

DC14

DC15

DC44

DC16

DC18DC19

DC20

MAN

DC42DC48

TSH

DC21

DC22

DC23

DC24

DC25 DC26 DC27

DC28

DC29

DC43

DC33

DC34

DC35

DC36

DC47

DC30

DC31

DC32

DC45

DC6DC7

DC8DC9

DC37

DC38

DC39DC40

DC1

DC2

DC3

DC4

DC5


HIV18MUR 17.4 - 45.149.2 - 71.175.6 - 100.0101.7 - 137.6145.0 - 183.2

EKUJHB

DC42

DC48

TSH

Gauteng

96

Section A: PMTCT

Map 3: HIV test around 18 months uptake rate by district, 2017/18

Source: DHIS.

Key findings ✦ The country remains unable to accurately enumerate the 18-month HIV transmission rates required to accurately

calculate an 18-month case rate of HIV infection. Reliable estimates are required for the purposes of monitoring elimination of mother-to-child- transmission.

Recommendations ✦ Implementation of the new HIV testing guidelines of children aged 18 months.

✦ The deaths in infants born from HIV-positive women before the age of 18 months should be taken into consideration for the denominator in the next revision of the NIDS as an assumption is made that all infants born from HIV-positive women are alive at 18 months.

5.1 antenatal 1st visit before 20 weeks rate - hst.org.za health barometers/district+health... ·...

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