Health system weaknesses constrain access to PMTCT and maternal HIV services in South Africa: a qualitative enquiry

In-depth interviews identified considerable weaknesses within operational HIV service delivery. These manifested as missed opportunities for HIV testing in antenatal care due to shortages of test kits; insufficient staff assigned to HIV services; late payment of lay counsellors, with consequent absenteeism; and delayed transcription of CD4 cell count results into patient files (required for ART initiation). By contrast, individual factors undermining access encompassed psychosocial concerns, such as fear of a positive test result or a partner's reaction; and stigma. Data and information systems for monitoring in the three peri-urban facilities were markedly inadequate.A single system- or individual-level delay reduced the likelihood of women accessing ART or PMTCT interventions. These delays, when concurrent, often signalled wholesale denial of prevention and treatment. There is great scope for health systems' reforms to address constraints and weaknesses within PMTCT and ART services in South Africa. Recommendations from this study include: ensuring autonomy over resources at lower levels; linking performance management to facility-wide human resources interventions; developing accountability systems; improving HIV services in labour wards; ensuring quality HIV and infant feeding counselling; and improved monitoring for performance management using robust systems for data collection and utilisation.In 2002, a national programme to prevent mother-to-child transmission of HIV (PMTCT) was established in South Africa, followed by an antiretroviral treatment (ART) initiative in 2004. To enhance ART access for pregnant women and address high mortality among women and children, eligibility criteria for ART initiation were revised in April 2010 to include all women with a CD4 cell count below 350 cells/mm3 [1,2]. This marked a notable departure from previous ART criteria of an AIDS-defining condition or a CD4 count below 200 cells/mm3 [3,4], and is consistent with WHO guid