The study found many instances where opportunities for HIV testing were missed in antenatal care, diminishing any chance of a care continuum. Most obvious missed opportunities stemmed from shortages of staff and test kits. Further, opportunities for preventing HIV are not maximised in labour wards, and counselling to reduce postnatal transmission during infant feeding is generally inadequate. Moreover, paediatric HIV testing, the gateway for infant testing and care, remains under-utilised. Even in the Johannesburg facility, the most-resourced hospital, a series of systems and individual factors delayed HIV services for pregnant women. These factors are interdependent: a single delay reduces the likelihood of women accessing ART and PMTCT, but delays occurring in tandem often signal a comprehensive denial of prevention and treatment.
Health personnel comprise the critical link between patients and health systems. Our analysis suggests that there is great scope for health systems' changes, much of which centres on health personnel capacity and performance. To better address the needs of HIV-positive pregnant or postnatal women, site-specific recommendations include: reviewing HIV staffing levels in the Eastern Cape and ensuring a sufficient number of conventional or lay staff is assigned to HIV service provision. In that province, human resource policies, planning and training must focus on recruitment and retention, attending to shortages of personnel in rural and peri-urban areas, while other interventions at the facility-level should address working conditions, offer incentives and provide professional development opportunities. Evidence on improving productivity, competence and responsiveness of health workers indicates that specific elements should be included, such as ensuring autonomy over resources at lower levels; linking performance management interventions to facility-wide human resources management; and developing accountability systems to ensure that health workers and managers are responsible for their performance [37
In the Johannesburg site, lay counsellors must be assured proper payment and conditions of service, including regular pay, debriefing, training and career pathing. Further, improved communication and referral networks are required between antenatal care, postnatal care and paediatric units in the same facility.
This study shows that women often look to health providers for information, answers, comfort, counselling and support - not only for physical ailments but for psychological distress related to their HIV status, including stigma. Mental health is much-neglected in South Africa generally, and particularly for women [38
]. South African women face conditions of poverty, gender inequality and social disadvantage. In addition to living with HIV, women may suffer from intimate partner violence or other forms of abuse. Nurses and social workers, in particular, can assist women to navigate the myriad challenges they face and address their mental health, including maternal and postnatal depression and other anxiety and stress-related disorders. On-site support groups and health worker advice with coping are important sources of psycho-social assistance.
Across the four facilities, the training and repeat training of health personnel (nurses and lay counsellors) in quality HIV and infant feeding counselling is essential. Improved monitoring and evaluation for performance management are equally important in enhancing service delivery [39
]. In South Africa, van der Merwe et al. underscore that strengthening linkages and integrating key components of ART within antenatal care reduces "time-to-treatment initiation" for pregnant women [40
]. Others have advocated for strengthening of facility supervision with emphasis on the use of antenatal and labour-ward checklists to record and monitor facility activities. They also emphasize the role of data collection, analysis and utilization to improve health services [41
]. Equally, Chopra et al. recommend building "a culture of using data to improve care" in South Africa [42
The study has several limitations. These include potentially incurring reporting bias, as interviews within clinical sites might cause patients to downplay negative experiences due to fear of poor subsequent treatment from the hospital, even though consent forms explicitly emphasized confidentiality. Further, the analyses, interpretation and conclusions may not be generalisable to other parts of the country, even though many findings were common across the two sites.
Finally, to achieve improved maternal, newborn and child health, it is critical to exploit the opportunities for preventing HIV in children and treating HIV in women and children at all points in the care continuum [43
]. Using evidence-based approaches to address the identified gaps in the health system is a necessary first step in ensuring that women and children benefit from HIV services that are presently available, yet remain out of reach for too many South African women and children.