Woldesenbet Selamawit A, Jackson Debra J, Lombard C J, Dinh Thu-Ha, Ramokolo Vundli, Doherty Tanya, Sherman Gayle G, Pillay Yogan, Goga Ameena E
*Health Systems Research Unit, South African Medical Research Council, Cape Town; †US Centers for Disease Control and Prevention, Center for Global Health, Division of Global HIV/AIDS, Pretoria, South Africa; ‡School of Public Health, University of the Western Cape, Cape Town, South Africa; §UNICEF, Knowledge Management and Implementation Research Unit, New York, NY; ‖Biostatistics Unit, South African Medical Research Council, Cape Town; ¶School of Public Health and Family Medicine, University of Cape Town, South Africa; #US Centers for Disease Control and Prevention, Center for Global Health, Division of Global HIV/AIDS, Atlanta, Georgia, US; **School of Public Health, University of the Witwatersrand, Johannesburg, South Africa; ††Centre for HIV and STI, National Institute for Communicable Diseases of the National Health Laboratory Services, Johannesburg, South Africa; ‡‡Department of Paediatrics and Child Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; §§National Department of Health, Pretoria, South Africa; ‖‖Department of Paediatrics, University of Pretoria, Pretoria, South Africa; and ***Health Systems Research Unit, South African Medical Research Council, Pretoria.
J Acquir Immune Defic Syndr. 2017 Apr 15;74(5):523-530. doi: 10.1097/QAI.0000000000001289.
In 2010, South Africa reported an early mother-to-child transmission (MTCT) rate of 3.5% at 4-8 weeks postpartum. Provincial early MTCT rates ranged from 1.4% [95% confidence interval (CI): 0.1 to 3.4] to 5.9% (95% CI: 3.8 to 8.0). We sought to determine reasons for these geographic differences in MTCT rates.
This study used multilevel modeling using 2010 South African prevention of mother-to-child transmission (PMTCT) evaluation (SAPMTCTE) data from 530 facilities. Interview data and blood samples of infants were collected from 3085 mother-infant pairs at 4-8 weeks postpartum. Facility-level data on human resources, referral systems, linkages to care, and record keeping were collected through facility staff interviews. Provincial level data were gathered from publicly available data (eg, health professionals per 10,000 population) or aggregated at province-level from the SAPMTCTE (PMTCT maternal-infant antiretroviral (ARV) coverage). Variance partition coefficients and odds ratios (for provincial facility- and individual-level factors influencing MTCT) from multilevel modeling are reported.
The provincial- (5.0%) and facility-level (1.4%) variance partition coefficients showed no substantive geographic variation in early MTCT. In multivariable analysis accounting for the multilevel nature of the data, the following were associated with early MTCT: individual-level-low maternal-infant ARV uptake [adjusted odds ratio (AOR) = 2.5, 95% CI: 1.7 to 3.5], mixed breastfeeding (AOR = 1.9, 95% CI: 1.3 to 2.9) and maternal age <20 years (AOR 1.8, 95% CI: 1.1 to 3.0); facility-level-insufficient (≤2) health care-personnel for HIV-testing services (AOR = 1.8, 95% CI: 1.1 to 3.0); provincial-level PMTCT ARV (maternal-infant) coverage lower than 80% (AOR = 1.4, 95% CI: 1.1 to 1.9), and number of health professionals per 10,000 population (AOR = 0.99, 95% CI: 0.98 to 0.99).
There was no substantial province-/facility-level MTCT difference. This could be due to good overall performance in reducing early MTCT. Disparities in human resource allocation (including allocation of insufficient health care personnel for testing and care at facility level) and PMTCT coverage influenced overall PMTCT programme performance. These are long-standing systemic problems that impact quality of care.
2010年，南非报告产后4至8周母婴早期传播（MTCT）率为3.5%。省级早期MTCT率从1.4%[95%置信区间（CI）：0.1至3.4]到5.9%（95%CI：3.8至8.0）不等。我们试图确定这些MTCT率存在地域差异的原因。
本研究采用多水平模型，使用来自530个机构的2010年南非预防母婴传播（PMTCT）评估（SAPMTCTE）数据。在产后4至8周从3085对母婴对中收集婴儿的访谈数据和血样。通过对机构工作人员的访谈收集有关人力资源、转诊系统、与护理的联系以及记录保存的机构层面数据。省级数据从公开可用数据（如每万人口中的卫生专业人员）收集，或从SAPMTCTE（PMTCT母婴抗逆转录病毒药物（ARV）覆盖率）按省级汇总。报告了多水平模型的方差分解系数和比值比（针对影响MTCT的省级机构层面和个体层面因素）。
省级（5.0%）和机构层面（1.4%）的方差分解系数显示早期MTCT没有实质性的地域差异。在考虑数据多水平性质的多变量分析中，以下因素与早期MTCT相关：个体层面——母婴抗逆转录病毒药物使用率低[调整后比值比（AOR）=2.5，95%CI：1.7至3.5]、混合喂养（AOR=1.9，95%CI：1.3至2.9）以及母亲年龄<20岁（AOR 1.8，95%CI：1.1至3.0）；机构层面——用于HIV检测服务的医护人员不足（≤2名）（AOR=1.8，95%CI：1.1至3.0）；省级层面——PMTCT抗逆转录病毒药物（母婴）覆盖率低于80%（AOR=1.4，95%CI：1.1至1.9）以及每万人口中的卫生专业人员数量（AOR=0.99，95%CI：0.98至0.99）。
省级/机构层面的MTCT没有实质性差异。这可能是由于在降低早期MTCT方面的总体表现良好。人力资源分配方面的差异（包括机构层面用于检测和护理的医护人员不足）以及PMTCT覆盖率影响了总体PMTCT项目的绩效。这些是影响护理质量的长期系统性问题。
