Biomedical interventions contributing to “getting to zero”
The following article is an overview of the impact that prevention of mother-to-child transmission, nurse-initiated and managed antiretroviral treatment and HIV-counselling and testing has made over the last few years in South Africa. With World AIDS Day coming up, these three initiatives are at the forefront of getting-to-zero.
Prevention of mother-to-child transmission
Ten years after initiating the prevention of mother-to-child transmission (PMTCT), 95% of all South African health facilities were providing this service. South Africa was also one of four countries worldwide that has achieved more than 80% coverage of antiretroviral (ARV) prophylaxis to prohibit mother-to-child transmission (MTCT) (Karim, 2013).
The annual national PMTCT evaluation study (UWC, 2013) reported an early MTCT rate of 3.5% in 2010. In 2011, the early MTCT had been reduced to 2.7%. The results for the 2012 study are expected late in 2013 (UWC, 2013).
Despite its widespread success, PMTCT still face some challenges, for example, loss to follow-up, limited laboratory capacity for CD4 cell counts and results management systems, and inadequate funding (Rollins & Coovadia, 2013).
Rollins and Coovadia (2013) mentioned four key points regarding PMTCT:
- ARV drug interventions that prevent HIV transmission through breastfeeding have influenced and transformed the public health policy scene regarding HIV and breastfeeding.
- In settings where diarrhoea, pneumonia, and malnutrition are common causes of child mortality, breastfeeding by mothers on ARV drugs is likely to give HIV-exposed infants the greatest chance of survival.
- Implementation research on how to retain HIV-infected mothers in care, and reliably provide them with ARV drugs and support for breastfeeding, is needed to realise the vision of eliminating new HIV infections in children.
- Clinical research is needed to identify new ARV drugs or nondrug interventions such as immune approaches to prevent residual HIV transmission through breastfeeding.
Nurse initiated and managed antiretroviral treatment
In 2009, South African political leaders called for intensifying research on prevention, testing and care of patients and ART. At the end of 2009, it was estimated that approximately 1.2 million people would be requiring ART over the following two years, which would exceed the capacity of the healthcare system if treatment were continued by doctors only (Nyasulu et al, 2013). Therefore, doctor-led ART delivery was recognised as not being suitable in developing countries with a high HIV burden and limited human resources for health. This was considered an obstacle in implementing policies for HIV treatment. Task shifting to nurse-managed care in primary care settings was therefore required. From April 2010, nurses began initiating ARVs to patients after they had received training to bridge the gap between knowledge and practice. Legal provision for nurses to prescribe ART has been provided based on Section 56 (6) of the Nursing Act of 2005. This section provides for emergency situations, and the need for nurse-initiated and managed antiretroviral treatment (NIMART) was classified as an emergency (KTU, 2013).
In 2010, there was a presidential mandate that public health facilities should make ARVs available and that nurses should be trained to prescribe and manage patients on these drugs. By April 2011, 2552 health facilities were initiating patients on ART (Nyasulu et al., 2013).
Since then, task-shifting has proved to strengthen maintaining patients on ART, as well as to decrease the burden of managing uncomplicated cases at hospitals. Through NIMART, patients benefited by getting ARVs from health facilities closer to home, saving transport costs and time (Nyasulu et al, 2013). The introduction of NIMART therefore improved access to ART and is more cost-effective
Yet NIMART was not without its challenges which included an increased workload at primary health clinic level, staff shortages, and insufficient consulting rooms—all of which are addressed successfully.
The continued success of NIMART proves the value of incorporating the capacity building, mentoring and training of nurses into the planning of HIV-services (Nysaulu et al, 2013).
HIV counselling and testing
According to the South African Department of Health (DoH, 2013), the HIV counselling and testing (HCT) campaign was put in place to scale up an integrated HIV-prevention strategy based on:
- Behaviour change
- Use of barrier methods
- Providing medical male circumcision
- Scaling up of management of STIs
- Early prevention of PMTCT
- Massive scale up of HIV-testing facilities in public and private facilities.
The ultimate achievement of the HCT campaigns includes an increase from 2.6 million to 18 million individuals being counselled and tested from 2010 to 2013. In 2010, at the inception of the campaign, it was projected that 11% of the 15 million South Africans targeted for HIV testing would turn out to be HIV-positive. However, of the 10.2 million tested in the National HCT Campaign by the end of 2010, 18% were found to be HIV-positive (Bodibe, 2011).
One of the challenges of voluntary counselling and testing is the high demand and time required, as this takes about 35-40 minutes for an individual to go through the entire process (Bodibe, 2011).
Earlier this year the South African Minister of Health, Dr Aaron Motsoaledi, said that he believed that the country would be able to reach the target of testing and initiating 1.5 million new individuals on ART by 2016. Therefore, he suggested a revitalisation of the HCT campaign to support “getting to zero”: “The campaign has proven to be a powerful vehicle for the social mobilisation of the awareness of HIV/AIDS and TB.” He further added that in order for the revitalisation to be achieved, government departments must assess their state of readiness by mapping out their resources, setting appropriate budgets and developing capacity to conduct workplace HIV counselling and testing opportunities (Khumalo, 2013).
In conclusion, being knowledgeable on the significant progress of these government initiatives can only instill the hope that we are on the correct path to “getting-to-zero”.
- Bodibe, K. (2011) HCT Campaign: the numbers so far Living with AIDS [Online] Accessed on 11 November 2013.
- Department of Health (DOH) (2013). HIV and AIDS [Online] Accessed on 11 November 2013.
- Karim, S. (2013) South Africa’s recent achievements in combatting the HIV epidemic [Online] Accessed on 12th November 2013.
- Khumalo, G. (2013) HCT Campaign to be revived [Online] Accessed on 11 November 2013.
- Knowledge Translation Unit (KTU) (2013) NIMART [Online] Accessed on 13 November 2013.
- Nyasulu, J. C. Y., Muchiri, E., Mazwi, S., Ratshefola, M. (2013) NIMART rollout to primary healthcare facilities increases access to antiretrovirals in Johannesburg: An interrupted time series and analysis. South African Medial Journal, 103 (4), 232-236.
- Rollins, N., Coovadia, H. M. (2013) Breastfeeding and HIV transmission in the developing world: past, present, future (Review). Wolters Kluwer Health, 8 (5), p.467-473.Lippincott Williams and Wilkins.
- University of the Western Cape (UWC) (2013) Reducing HIV transmission from mothers to their infants: evaluating national progress [Online] Accessed on 19th November 2013.
Author: Jodilee Erasmus (B.Soc Sci)
Reviewed by: Hendra van Zyl (MPH), Jean Fourie (MPhil), Michelle Moorhouse (MBBCh, DA) and Alfred Thutloa (MPhil)
Date: December 2013
Erasmus, J. (2013) Biomedical interventions contributing to “getting to zero”, AfroAIDSinfo. Issue 13 no. 12, Science (Open access).
28 November, 2013