HIV This Week

Health workers’ views on quality of prevention of mother-to-child transmission and postnatal care for HIV-infected women and their children. Nguyen TA, Oosterhoff P, Pham YN, Hardon A, Wright P. Hum Resour Health. 2009;13;7:39.

Prevention of mother-to-child transmission has been considered as not a simple intervention but a comprehensive set of interventions requiring capable health workers. Viet Nam’s extensive health care system reaches the village level, but still HIV-infected mothers and children have received inadequate health care services for prevention of mother-to-child transmission. Nguyen and colleagues report here the health workers’ perceptions on factors that lead to their failure to give good quality prevention of mother-to-child transmission services. Semistructured interviews with 53 health workers and unstructured observations in nine health facilities in Hanoi were conducted. Selection of respondents was based on their function, position and experience in the development or implementation of prevention of mother-to-child transmission policies/programmes. Factors that lead to health workers’ failure to give good quality services for prevention of mother-to-child transmission include their own fear of HIV infection; lack of knowledge on HIV and counselling skills; or high workloads and lack of staff; unavailability of HIV testing at commune level; shortage of antiretroviral drugs; and lack of operational guidelines. A negative attitude during counselling and provision of care, treating in a separate area, and avoidance of providing service at all were seen by health workers as the result of fear of being infected, as well as distrust towards almost all HIV-infected patients because of the prevailing association with antisocial behaviours. Additionally, the fragmentation of the health care system into specialized vertical pillars, including a vertical programme for HIV, is a major obstacle to providing a continuum of care. Many hospital staff were not able to provide good care or were even unwilling to provide appropriate care for HIV-positive pregnant women The study suggests that the quality of prevention of mother-to-child transmission service could be enhanced by improving communication and other skills of health workers, providing them with greater support and enhancing their motivation. Reduction of workload would also be important. Development of a practical strategy is needed to strengthen and adapt the referral system to meet the needs of patients.

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Editors’ note : This study was undertaken to find out the opinions of health care workers, who are subjected to many accusations about gaps and weaknesses in their performance, in Hanoi’s programme to prevent mother-to-child HIV transmission. The fragmentation of the health system, their own stigma from colleagues and family because of their exposure to HIV-infected patients, and their personal fear of HIV exposure in the absence of protective clothing and post-exposure kits all combine to reduce their motivation. They identified specific problems in their training and skills updating, a heavy workload, and a lack of equipment and materials. Remedying these will take varying lengths of time but seeking pragmatic solutions in the short term to produce tangible results could improve both the quality of patient care and the job satisfaction of health care personnel looking after them.

Early assessment of the implementation of a national programme for the prevention of mother-to-child transmission of HIV in Cameroon and the effects of staff training: a survey in 70 rural health care facilities. Labhardt ND, Manga E, Ndam M, Balo JR, Bischoff A, Stoll B. Trop Med Int Health 2009; 14: 288-93.

Labhardt and colleagues set out to assess the availability of equipment and the staff’s knowledge to prevent mother-to-child Transmission (PMTCT) in rural healthcare facilities recently covered by the national PMTCT programme in Cameroon. In eight districts inventories of antiviral drugs and HIV test kits were made on site, using a standardised check-list. Knowledge of HIV and PMTCT was evaluated with a multiple-choice questionnaire based on typical clinical PMTCT cases. Staff participated subsequently in a 2-day training on HIV and the Cameroon PMTCT guidelines. Immediately after training and after 7 months, retention of knowledge was tested with the same questions but in different order and layout. Sixty two peripheral nurse-led clinics and the eight district hospitals were assessed. Whereas all district hospitals presented complete equipment, only six of the peripheral clinics (10%) were equipped with both complete testing materials and a full set of drugs to provide PMTCT. Thirty six peripheral facilities (58%) possessed full equipment for HIV-testing and 8 (13%) stocked all PMTCT drugs. Of 137 nurses, 102 (74%) agreed to the two knowledge tests. Fewer than 66% knew that HIV-diagnosis requires positive results in two different types of rapid tests and only 19% chose the right recommendation on infant-feeding for HIV-positive mothers. Correct answers on drug regimens in different PMTCT settings varied from 25% to 56%. All percentages of correct answers improved greatly with training (P < 0.001) and retention remained high 7 months after training (P < 0.001). Programmes to prevent mother-to-child transmission in settings such as rural Cameroon need to be adapted to the special needs of peripheral nurse-led clinics. Appropriate short training may considerably improve nurses’ competence in PMTCT. Other important components are regular supervision and measures to guarantee supply of equipment in rural areas.

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Editors’ note: Cameroon has set an ambitious objective of increasing the proportion of pregnant women who have access to HIV counselling and testing services from 10% to 50% by 2010. This study, conducted four to eight months after HIV test kits and antiretroviral drugs were distributed to health districts, found inadequate supplies of materials and low levels of staff awareness and knowledge of proper procedures. A two-day training programme including case-based interactive discussions led to sustained improvement in assessment scores. Guaranteeing the flow of equipment to peripheral clinics and maintaining health care worker competence through training and supportive supervision, will be key if Cameroon is to meet its 2010 objective.