The document discusses South Africa's PMTCT (prevention of mother-to-child transmission) programme. It notes that around 300,000 mothers need treatment each year, with transmission rates currently around 11% and a goal of reducing to 5% by 2011. Coverage of testing and treatment through public primary health facilities has reached 95%. Key players in PMTCT implementation include the government, donors, civil society organizations, and the private sector.

1. PMTCT programme overview SOURCE: South Africa HIV/AIDS response stakeholder interviews; Project team analysis PRELIMINARY In South Africa, an est. 300,000 mothers need treatment each year Transmission incidence is currently at 11% with a view to reducing to 5% by 2011 Almost universally available in public primary health facilities - 95% coverage in public sector antenatal service sites Overview Maternal testing & treatment : ART treatment of HIV + mothers during ANCs Delivery : delivery in government facilities, minimal exposure for infant Infant testing & treatment : staggered testing & treatment up to 18 months post-natal Structure Testing and treatment free of charge and integrated into existing health facilities Coverage and access to primary health care facilities for ante natal healthcare is critical for mothers to be tested and to be provided treatment Implemen-tation model Government provides majority funding with some support on technical areas from partners Financing

2. While coverage is 95%, treatment protocols must be formally amended to enable better data management 9 SOURCE: NDOH Annual report 2008/09, DHIS 2009 The overall goal of the PMTCT programme is 100% coverage of all pregnant women who need PMTCT UNAIDS estimate range from 110,000 to 280,000 women 2005: PMTCT services available at over 3,000 health sites nationwide 2008: Almost universally available in public primary health facilities having achieved the NSP target of 95% coverage in public sector antenatal service sites Until 2008 the antiretroviral component of the programme included a single dose of nevirapine which was estimated to reduce peri-partum transmission to around 12% From March 2008, the DoH amended the PMTCT protocol to include dual therapy for pregnant women This revised protocol was estimated to reduce peri-partum mother to child transmission to around 5-6% However, the National Indicator Data Set (NIDS) had not been amended by the end of 2008 to accommodate this change in the clinical protocol, adding to the poor management of PMTCT data 2009 2008 Treatment Coverage Proportion of HIV+ pregnant women receiving ARV to reduce the risk to MTCT (%) PRELIMINARY

3. However, PMTCT is believed to be the main factor in the significant reduction of childhood HIV prevalence over the past 10 years 8 SOURCE: HSRC survey reports; K Y E/K Y R reports, 2011 HIV prevalence Percent 2008 2005 2002 The PMTCT intervention is believed to be the main factor leading to a halving of the HIV prevalence level in children aged 2-14 years between 2002 and 2008 By 2008, 95% of public health facilities provided PMTCT services Many of the HIV-positive older children identified in the national surveys were infected vertically and are slow progressors (local and Zimbabwean estimates predict that about one-third of infected infants are slow progressors with median survival of 16 years) Children 2-14 PRELIMINARY

4. However, national transmission rate of HIV to babies born to HIV infected mothers is still over 10% 7 Adults Total number of HIV positive pregnant women identified and enrolled into the PMTCT programme: 2006: 186,646 2007: ~200,000 (6% increase) 2007 2006 17.508 8% MP WC 16.834 3.480 NC 12% 12% 16.748 12% NW LP 16.468 13% KZN 74.438 10% GP 60.965 11% FS 10.564 12% EC 28.469 10% SOURCE: KYE/KYR reports, 2011 The data show an overall national transmission rate of HIV to babies born to HIV-infected mothers at about 11% Data and transmission rates of mother-to-child by province, 2008 Proportion of HIV+ pregnant women enrolled in PMTCT programme (%) Children Around 70,000 babies are born with HIV every year Data indicates that the number of HIV-infected babies was likely declining due to the success of the PMTCT programme PRELIMINARY

5. Key PMTCT programme players and roles SOURCE: South Africa HIV/AIDS stakeholders interviews PRELIMINARY Donors and providers of technical assistance Provides analysis on resource needs Facilitates planning Provide TA Supports imple-mentation Monitors program Lead evaluations Sets global guidance and provides TA to government Civil society organisations Advocates for resources Plan for service delivery Implement programs (PMTCT, home based care, follow up) Report on programs Lead evaluations Advocates for PLWHA policies Allocates domestic resources Negotiates with donors Forecast treatment needs and allocates resources Monitors programs Reports to donors Government Private sector Allocates resources to treat workers Develops workplace programs Distributes ART to clinics Trains clinicians Provides treatment to workers and families No formal mecha-nisms in place No formal mecha-nisms in place Input through SANAC Strategy/ Policy Resource allocation (budgeting) Planning Implement-ation Monitoring & reporting Evaluation Conduct and participate in evaluations Sets national PMTCT policy and guidelines

6. Landscape of programme execution SOURCE: South Africa HIV/AIDS stakeholder interviews PRELIMINARY Strategy and policy is set at the national level, and guidelines are communicated effectively down to the implementing level Guidelines communicated through training – DoH training supercedes all others Generally done well, implementing agencies have taken ownership Resource allocation done at provincial level based on district health plans Lack of trained resources with financial management skills at all levels results in inaccurate budget allocation Operational planning is done at the facility level Plans are tied in with the budget which are then sent to district, and subsequently to provincial level Poor understanding of plans and lack of management capability results in funds being returned to the treasury at the year end or running out mid year Implementation is carried out by government hospital and facilities at the sub district level Coverage of PMTCT is 95% Major challenge in implementation is late bookings or un-booked pregnant women presenting in labour (particularly in rural areas) There is no centralised IT system for monitoring and reporting Challenges in collecting information as much of the data in facilities is paper based Little or no feedback against plans or targets No interpretation of the data collected in the previous stage for managerial implications Strategy/ Policy Resource allocation (budgeting) Planning Implementation Monitoring & reporting Evaluation

7. Structure of the HIV response is complex: PMTCT example SOURCE: Interviews 1 HIV/ AIDS, TB and STD director ILLUSTRATIVE PMTCT lead Provincial National District SANAC Treatment Task Team PMTCT lead Implementers District AIDS council DG=>MoH=> HIV Director Directorate for Treatment Premier=>MEC=> Head of department District HAST Director Provincial HAST 1 director PMTCT lead Provincial AIDS council PRELIMINARY NGOs NGOs NGOs Gvt clinics/ hospitals NGOs NGOs NGOs NGOs (provide TA/ mobile CT) NGOs NGOs NGOs National NGOs NGOs NGOs NGOs Treatment leads NGOs NGOs NGOs International donors NGOs NGOs NGOs Treatment leads NGOs NGOs NGOs National NGOs NGOs NGOs NGOs Treatment leads National & provincial PMTCT leads meet quarterly to exchange ideas & information