Government-funded programmes and services for vulnerable - Unicef

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Department of Health ● ● ● ● lowering the criteria for eligibility of pregnant women to have lifelong ART so that more women are placed earlier on ART. The aim is to reduce the number of mothers who die from HIV infection during pregnancy or during the post-natal period. providing more effective prophylaxis to prevent vertical transmission in pregnant women who do not qualify for lifelong ART; making breastfeeding safer for HIV-exposed infants through the provision of prophylactic ART to these infants; initiating ART in all HIV-infected infants younger than one year, as this has been shown to significantly reduce mortality. These innovations were only introduced in 2010 and it remains to be seen as to how effectively they will be implemented, given the systemic difficulties within the current healthcare system, as well as the more specific difficulties and gaps which have prevented full realisation of many of the other healthcare policies and programmes (discussed below). This section now turns its attention to how the inadequate HIV/AIDS policies resulted in gaps and disjunctures in the child and maternal HIV/AIDS policies and programmes listed in Table 4.1. Infant and young child feeding support High infant mortality rates linked to HIV/AIDS There are many policies in place to address malnutrition and HIV/AIDS in South Africa. However, the high levels of infant and child mortality are testimony to inadequate implementation of these policies. In South Africa, 20 000 babies are stillborn every year and another 22 000 die before they reach one month of age. In total, 75 000 children die before they reach their fifth birthday. Many of these deaths are preventable, as many are caused by malnutrition and HIV/AIDS (DoH et al. 2008). Poor knowledge of safe infant feeding practices One of the primary modes of HIV transmission to infants is through inappropriate infant feeding practices by HIV-positive mothers. A study in rural KwaZulu-Natal on breastfeeding knowledge among health workers found their knowledge about feeding options and choices, breastfeeding and the facts about HIV transmission to babies to be outdated and contrary to the latest World Health Organisation recommendations (Sonal et al. 2004). This lack of knowledge was evident among doctors, nurses and community health workers, although in the study in question, knowledge among community health workers was the worst. Insufficient information and counselling on infant feeding practices A lack of adequate and sustained support in terms of information and counselling, as well as sustained patient follow-up, results in many mothers adopting incorrect feeding choices, even when they have received counselling on feeding choices. 65 The quality of infant feeding counselling is of serious concern and was found by the Good Start study 66 to be poor. The information provided to women is inadequate to enable them to make appropriate and safe feeding choices. The counselling provided does not prepare women for the challenges of adhering to their feeding choice. Ongoing community-based support for women in the post-partum period is crucial to sustaining infant feeding choices. Ultimately, poor infant feeding practices are contributing to lower infant HIV-free survival. 65 Infant and Young Child Feeding Policy, 2007 66 Policy Brief, June 2007 131
Government-funded programmes and services for vulnerable children in SA The recent changes to the PMTCT guidelines and the guidelines on the management of HIV in children have the potential to make a positive difference to the level and quality of support on infant feeding choices for HIV-positive mothers. It is, however, still early days and these guidelines only commenced at the beginning of 2010. As such, it remains to be seen how well systemic challenges within the health system can be overcome to realise the potential of these guidelines. It is cause for concern that these new guidelines, being split into as many guiding documents as they are, are difficult to piece together and in fact do introduce confusion through inconsistent provisions appearing on the same issue in different documents. One such contradiction appears in the PMTCT guidelines and the guidelines for the management of HIV in children. The latter guidelines provide that exclusive breastfeeding for six months is the preferred option and that mothers who choose to formula feed will be required to purchase their own formula (section 4.1). The PMTCT guidelines contradict this in the provision that mothers who choose to formula feed will be provided with at least six months of free age- and weight-appropriate formula. Inconsistencies such as these add to the already troubling confusion and poor quality of feeding option counselling that has been provided up until now. Insufficient provision of nutritional support The infant and young child feeding policy makes provision for nutritional support to HIVinfected pregnant women and those who choose to breastfeed. However, Hendricks et al. (2003) found in their study that HIV-positive pregnant and lactating women were not put on the nutritional support programme, primarily because clinic staff were not aware that they were entitled to this benefit. PMTCT programme Insufficient HIV testing and provision of prophylaxis Approximately 168 000 of the 800 000 public sector births in 2006 were to HIV-positive women. Only 50 per cent (74 052) of these HIV-positive pregnant women received nevirapine prophylaxis. Furthermore, the testing rate of babies in public sector births is very low. Of the 800 000 births in 2006, the HIV status of only 3 per cent of the babies was known and, of these 3 per cent, the transmission rate was 18 per cent, which is much higher than the targeted 5 per cent transmission rate (Barron et al. 2006; Ministry of Health 2007). These statistics are the product of the previously limited PMTCT policies and programmes. The 2010 amendments to these policies have been designed to remedy the shortcomings, but whether the desired impact will be achieved depends on the proper and timeous application of the various progressive guidelines and the ability to overcome the more systemic health challenges which impact on all healthcare programmes and services. Poor coverage of antenatal visits The coverage of antenatal visits in South Africa is high for one visit, standing at 94 per cent, but it drops to 73 per cent for four visits or more and to below 30 per cent for antenatal visits before 20 weeks. This means that there are significant missed opportunities for counselling, testing and introducing the PMTCT programme to the pregnant mothers and infants that are not accessing antenatal clinics and maternity health facilities (DoH et al. 2008). In addition, the care that is provided at the visits that do take place does not include sufficient access to counselling and HIV testing. Access to the PMTCT programme is via HIV testing by a pregnant woman at her antenatal facility. If she 132
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Government-funded programmes and services for vulnerable - Unicef

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