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Evaluation report

2013 Eswatini: Evaluation of the Effectiveness of the National Prevention of Mother To Child Transmission of HIV (PMTCT) Programme at 6-8 weeks Post-partum in Swaziland

Author: Ministry of Health

Executive summary

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Implementation of PMTCT is one of the priority interventions in the fight against HIV/AIDS. In developed countries significant resources and low HIV sero-prevalence as well as provision of antiretroviral drugs to pregnant women has reduced HIV transmission rates from mother-to-child to as low as 2 percent. In developing countries and high HIV prevalence countries, a significant number of HIV infected mothers do not have easy access to comprehensive PMTCT interventions, resulting in a high burden of paediatric HIV infections. In 2005, the United Nations General Assembly (UNGASS) set a target to reduce paediatric HIV infections by 50 percent by 2010, but many countries did not meet this target  because of low coverage of PMTCT services.

In the absence of interventions to prevent mother-to-child transmission of HIV, about 15-25 percent of infants of HIV-infected women will be infected during pregnancy or delivery, and an additional 5-20 percent may become infected during breastfeeding.  PMTCT research in developing countries has focused on identifying simple, cost-effective PMTCT regimens to achieve wide coverage, and clinical trials have shown several drug regimens to be effective.

In 2010, the World Health Organization (WHO) revised its guidelines on the use of antiretroviral (ARV) drugs for the prevention of mother-to-child transmission of HIV. The new recommendations place increased emphasis on improving the mother’s health while providing maximum protection against HIV infection in her child.  These new guidelines provided countries with the hope of achieving virtual elimination of paediatric infections due to MTCT by 2015.


The overall aim of the evaluation was to conduct a national facility-based survey to monitor the effectiveness of the Swaziland National PMTCT programme.
The primary objective was to measure rates of early MTCT of HIV at 6-8 weeks postpartum.
Secondary objectives of the evaluation were to estimate coverage of key PMTCT interventions and services (e.g., HIV testing, CD4 cell count testing, infant antiretroviral (ARV) prophylaxis, infant feeding practices) and factors associated with uptake of PMTCT interventions.


A Cross-sectional facility-based survey was conducted at immunization service points in public health facilities in all four regions. This methodology was chosen because immunization uptake of DPT1 at 6 weeks is 83 percent for Swaziland. The evaluation targeted both known and unknown HIV-exposed infants, as well mothers who brought their infants at the 6-8 weeks visit. Interviews were conducted and infant DBS was collected after receiving consent from mothers.

Infants aged 6-8 weeks attending immunization services in health facilities with their mothers for their six week immunization were eligible. Mobile clinics, very sick infants and infants over the age of 8 weeks were excluded from the study.

The immunization data from the HMIS (DPT1) and EID data were used to quantify the number of children that could be expected within facilities over a period of time. Sample size was calculated on the basis of ascertaining a representative sample for MTCT rates 6-8 weeks after delivery. This resulted in 52 randomly selected facilities. Mother/infant pairs were consecutively or randomly selected from facilities (depending on facility). Data was collected using paper based study collection tools by trained data collectors (nurse) and checked by a Facility Supervisor for completeness and later verifications were made by regional supervisors. Due to challenges beyond the study team, the data collection process took about 4 months.

Completed study tools were then taken by the regional supervisor to the study office (Data Manager) weekly. The data manager first checked each questionnaire before handing over to data clerks who then entered all questionnaires into a designed data base. Identifications stickers were used to identify infant laboratory results which were also entered into the database by the data entry clerks. 

Findings and Conclusions:

The findings show that 99 percent of women seen post-natal had attended antenatal care, confirming the high ANC attendance in Swaziland. This shows that women who attend ANC have a high likelihood of coming for PNC services than women who do not come for ANC. Only 87 percent women bring their ANC cards for PNC, this poses a challenge as women information from ANC that would help with follow-up is not available during PNC follow-up.
According to the PMTCT guidelines, pregnant women should receive an HIV test every two months to ensure women receive relevant care once sero-converted and a last HIV test is to be done just before delivery. About 61 percent of women at PNC reported to have taken an HIV test during the last month of pregnancy.
Eighty eight percent HIV positive women had blood drawn for CD4 count. Again, the study did not go into detail why some HIV positive women’s CD4 count was not taken.
Findings also show that a majority of mothers breastfeed (88.9%) at least up to 6 weeks, as recommended by the PMTCT guidelines. Despite all efforts to ensure all women breastfeed, there are however those that are either on exclusive replacement feeding (8.9%) and those on mixed feeding practices (1.4%). This shows that there should be programmes or activities at facility level that try to strengthen exclusive breastfeeding for the first six months after birth, more so because about 31 percent of mothers reported to use un-piped sources of water and about 81 percent use pit-latrines as the main type of toilet. All these may put infants in danger of contacting diarrheal diseases, leading to increased infant mortality.

HIV transmission at 6-8 weeks postpartum in Swaziland is 2.2 percent . This transmission rate at 6-8 weeks is an assenting measurement as routine EID data also estimated HIV transmission to be at 2 (two) percent. HIV transmission at 6-8 weeks differs by region, with Lubombo having the highest HIV transmission (3.1%), and Manzini (1.31%) the least.


It necessary that the Ministry conducts a comprehensive evaluation study that would assess transmission rates above 8 weeks.

It is important that HIV-positive DNA PCR results is conducted since only 4 was conducted showing missed opportunities in terms of HIV testing among pregnant women.


For a copy of the report, please contact evalhelp@unicef.org or click here, as the file is 36.5MB.


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Report information





UNICEF, World Health Organization, Clinton Health Access Initiative, and Global Fund through NERCHA



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