Closing the gaps in PMTCT program coverage, early infant diagnosis and treatment.

描述(由申请人提供)：在南非，基本上消除艾滋病毒垂直传播是可以实现的。尽管产前艾滋病毒感染率很高，但南非预防母婴传播(PMTCT)方案中现有技术和指南的实施，特别是南非西开普省的长期全面方案的实施，已使全国垂直传播艾滋病毒的比例大幅下降至3.5%，西开普省降至3.3%。然而，由于在完成预防母婴传播和婴儿护理连续体所需的每个步骤中持续存在覆盖差距和下降，消除工作仍然难以实现，每年在西开普省出生的垂直感染婴儿超过1000人。无论未来可能引入不同的指南和服务设计选项，通过仔细监测系统故障和由此产生的干预措施，改善当前预防母婴传播和抗逆转录病毒治疗(ART)指南在护理连续过程中每一点的表现，是进一步减轻艾滋病毒对儿童影响的关键。通过这种积极的监测方法加强卫生系统将提供长期的好处，这些好处将补充并持续到药物方案或服务提供模式的未来变化之后。这一系统将促进一种模式，在这种模式下，被确认的未被预防母婴传播药物覆盖的婴儿艾滋病毒感染病例和感染艾滋病毒的婴儿被视为公共卫生紧急情况，需要紧急干预，以确定计划失败的原因，并减轻其对个别儿童的影响。该项目侧重于初级保健产科设施，旨在实施和评估现有服务平台的三项相互关联的增强措施，以反复确定并弥合所有预防母婴传播和婴儿早期诊断以及抗逆转录病毒治疗覆盖范围的差距。首先，产前、产科和婴儿诊所现有的纸质登记簿将被数字化，内部链接，并使用已应用于其他优先项目的适合背景的技术与实验室数据合并，即抗逆转录病毒治疗和结核病监测。合并的防止母婴传播电子登记册将与紧急向诊所报告孕妇CD4细胞计数低的实验室结果和婴儿艾滋病毒-聚合酶链式反应阳性结果的系统联系起来，并进行追踪，以确保及时启动抗逆转录病毒治疗。这将加强 卫生系统，以缩小这些关键的防止母婴传播覆盖差距。其次，建立一个常规的脐带血艾滋病毒检测系统，如果呈阳性，抗逆转录病毒药物(ARV)的存在将确定 并联系护理没有/未达到最佳围产期抗逆转录病毒药物的艾滋病毒感染婴儿，以确保采取干预措施防止出生后传播，及时对婴儿进行诊断，并在感染时进行抗逆转录病毒治疗。第三，建立临床质量保证、改进和审核计划。这将以电子登记和脐带血监测的数据为基础，这将产生覆盖差距的早期预警系统。利用这些数据，将与省和地方卫生部门的服务管理人员和提供者一起，定期和系统地分析预防母婴传播计划的失败，以期实现反复的服务改进。

DESCRIPTION (provided by applicant): Virtual elimination of vertical transmission of HIV is within reach in South Africa. Despite high antenatal HIV prevalence, implementation of currently available technology and guidelines in the South African Prevention of Mother-to-Child Transmission (PMTCT) program, and particularly the longstanding and comprehensive program in the Western Cape Province, South Africa, has resulted in substantial reductions in vertically transmitted HIV to 3.5% across the country, and 3.3% in the Western Cape. Yet, elimination remains elusive due to persistent coverage gaps and drop-offs at each of the steps required in completion of the PMTCT and infant care continuum, with upwards of 1000 vertically infected infants born in the Western Cape each year. Improving the performance of the current PMTCT and antiretroviral therapy (ART) guidelines at each point in the care continuum through meticulous surveillance of system failures with resultant intervention, are key to further mitigating the effect of HIV on children, irrespective of possible future introduction of different guideline and service design options. Strengthening the health system with this active surveillance approach will provide long term benefits that will both complement and endure beyond future changes in drug protocols or service delivery models. This system will foster a paradigm in which identified cases of infant HIV exposure not covered by PMTCT drugs and HIV infected infants are viewed as a public health emergency requiring urgent intervention to identify reasons for program failure and mitigate its effects in an individual child. This project focused on a primary care obstetric facility, aims to implement and evaluate three linked enhancements to the existing service platform that will iteratively identify and close all PMTCT and early infant diagnosis and ART coverage gaps. First, existing paper registers at antenatal, obstetric and infant clinics will be digitized, internally linked, and merged with laboratory data using context-appropriate technology that has been applied to other priority programs, namely ART and TB monitoring. The combined PMTCT e-register will be linked to a system of urgent reporting of laboratory results of low CD4 counts in pregnant women and positive infant HIV-PCR test results to clinics, with tracing to ensure prompt ART initiation. This will strengthen the health system to close these key PMTCT coverage gaps. Second, a system of routine cord blood testing for HIV, and, if positive, the presence of antiretroviral drugs (ARVs) will identify and link to care HIV-exposed infants with no/suboptimal peripartum ARVs to ensure interventions to prevent postnatal transmission, prompt infant diagnosis and ART if infected. Third, a program of clinical quality assurance, improvement and audit will be established. This will be based on data from both the e-register and cord blood surveillance that will generate an early warning system of coverage gaps. Using these data, PMTCT program failures will be regularly and systematically analyzed together with Provincial and Local Departments of Health service managers and providers, with a view to achieving iterative service improvements.