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Base de datos de evaluación

Evaluation report

BTW 2001/800: Botswana MTCT Pilot Project

Author: Baggeley, R.

Executive summary


The Botswanan Prevention of Mother-to-Child Transmission (MTCT) of HIV Program was launched in Gaborone and Francistown in April 1999. Voluntary counseling and testing was offered to all pregnant women in government health facilities. Oral AZT was provided to HIV-positive women starting at 34 weeks of pregnancy and during labour, and AZT syrup was given to babies born to HIV-positive mothers. The intervention also included infant-feeding counseling and provision of infant formula to women who opt not to breastfeed. In the first 8 months of the program, out of 7,000 ANC clients, over 4,000 have been counselled, of which 46% have been tested, and 41% were found positive. To date, 221 women and 367 infants have received AZT.

Purpose / Objective

This review was carried out in order to assess the functioning of various elements of the program and, above all, to recommend whether it would be advisable to scale-up according to the plan foreseen in the Working Document.


Six questionnaires were specifically designed to address general logistics and procedures of the MTCT program, IEC, feeding, monitoring, manpower and laboratory issues. A questionnaire was also sent to a sample of counselors and will be analyzed at a later stage. Interviews were conducted with health care workers (midwives most of the time) in direct contact with antenatal care (ANC) clients. Twelve clinics and two hospitals were visited out of 25 clinics total in the program; six clinics in Gaborone, six clinics in Francistown, Princess Marina Hospital and Nyangabgwe Hospital.

Key Findings and Conclusions

The MTCT program content appears unclear to the vast majority of ANC clients. People view the MTCT program as an intervention targeting only children where there is 'nothing in it for them.' The efficacy of the intervention also appears unclear to them. It seems that the focus of IEC so far has been pregnant women only. The decision to enroll into MTCT program is often made by men or other family members such as mothers.

Men (often regarded as decision makers) and families in general have not been involved in the MTCT program. Their advice against MTCT participation is very often quoted as the reason for pregnant women not to agree to HIV testing.

Shortage of manpower was mentioned in almost all health care facilities. HCWs felt the need for help in order to be able to counsel appropriately. Nevertheless, problems seem to arise from the fact that not all health care workers in contact with ANC clients have been trained in MTCT. As a result, a small number of them have to take responsibility for all counseling activities in addition to their usual workload. ANC clients come to them with minimal knowledge about the program and HIV transmission in general which results in lengthy counseling sessions. The shifting of trained personnel to other departments or districts seems to only worsen the situation. Finally, the ANC workload is concentrated on morning sessions while afternoons are relatively free.

MTCT activities were often seen as extra burden to the HCWs in contact with ANC clients. Both ANC clients and HCWs seem not to perceive all the benefits associated with the program. A worrisome finding was that midwives did not seem convinced that they would be interested in the MTCT interventions should they become pregnant. When asked if they would enroll themselves in the program, a usual reply was 'No, I would be too scared' or 'What would be in it for me?' It seems hard for a health worker to convince a patient to be part of any health program, if they are not convinced about it themselves.

Out of 221 HIV+ women who have received AZT during their pregnancy:
1/3 started at 34 weeks
1/3 received 2 weeks or less
1/3 started during labor

which means that 2/3 of the patients received a suboptimal regimen with unclear efficacy.
These figures include women who at the start of the program were already advanced in their pregnancies and also women arriving in labor at referral hospital from districts outside the pilot area. Some health care workers reported the possibility that AZT was shared by different HIV-infected family members. There was increasing concern from patients about side effects of AZT (rumors are spreading such as AZT causing 'soft skull')

Women are worried about being identified as HIV positive in their communities as they come back from the clinic with large quantities of formula. Education about formula preparation is not always done. Because of time constraints women are often sent home without having had proper practical education about the way formula should be prepared.

Infant feeding guidelines appear conflicting to some health workers. It seems that recent information communicated to midwives about formula feeding in the context of MTCT, was regarded by some workers as conflicting with previous guidelines encouraging breastfeeding. As a result, factual information about infant feeding options is sometimes overlooked and expectant mothers are advised they should not breastfeed. This could have deleterious effects if women were to regard MTCT program as an AZT+formula feeding package and they were discouraged from accessing the intervention just because they refuse to formula feed.

The monitoring system appears too complex to many. Information collected is often duplicated in the Botswana obstetric record and the 17-page booklet, even though it has to be completed in several stages, discourages some HCWs at first sight! (doctors in particular). Forms are getting lost before they reach the site coordinator, either after the first visit or for subsequent follow-up appointments, resulting in missing data in the database. Filing of forms at different stage of completion is difficult at the clinic sites.

Recommendations made by various task forces, coordinating committees, reference group and consultants often seem appropriate and pertinent. Nevertheless, the implementation of some of these recommendations has been slow (IEC example).

The team was ill-equipped to examine the cost issue in details for lack of skills and documentation. So far, 1.5 million P have been spent and 2 million P are committed (total budget, spent or committed: 3.5 million P). In addition UNICEF has contributed 600,000 P so far.
It should be remembered, while using these figures for planning, that entire posts such as IEC, community outreach, training of FWEs, evaluation and drugs and related costs have been neglected. A large financial effort on these posts should be placed for the program to be successful.


After weighing the pros and cons, the Review Team concluded that scaling-up was advisable. However, a more modest time frame and some preconditions are suggested, including the implementation of the recommendations of this report. In expansion, consideration should be given to close monitoring of the programme in rural and remote areas. The use of nevirapine should be considered for a possible better program uptake and sustainability.

- More effort needs to be put into developing an adequate IEC strategy, so that women, their partners and families know more about the programme before reaching the clinic
- Communities need to be mobilised through a variety of efforts to support HIV+ women and their families
- Counseling skills among health care workers should be more widespread. The counselling sessions should be streamlined and made more routine. Counselors also need clearer information on the benefits of HIV-testing and of the MTCT program
- Women must be encouraged to enter into the program at an earlier stage of their pregnancy, while at the same time, nevirapine could be considered for HIV-positive women who attend too late for AZT
- Guidelines on infant feeding need to be clearer, and women who opt to formula feed need follow-up support
- Cadres, such as FWEs, need to be trained and involved in the follow-up of clients
- The monitoring system needs simplification
- PMTCT staffing at central level needs strengthening

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