Lessons from the evaluation of the South African National Female Condom Programme.

BACKGROUND: Understanding of the facilitators and challenges to female condom (FC) uptake has been limited due to lack of evaluation of national FC programmes. SETTING: The FC has been an integral component of South Africa's (SA) HIV prevention programme for 20 years and is the largest government-funded FC programme worldwide. METHODS: The national FC evaluation used a mixed-methods approach and consisted of key informant interviews and a telephone survey in a national sample of public and non-public sites. A sub-sample of sites participated in client and provider interviews, and a self-administered client survey. A review of distribution statistics from South Africa's District Health Information System was also conducted. RESULTS: All 256 public-sector and 28 non-public-sector facilities reported having ever distributed FCs. Less than 5% of these facilities reported stock-outs and less than 3% reported they had a supply of expired female condoms. Systems for male condom (MC) and FC distribution were complementary, with similar ordering, delivery and reporting processes. FC promotion by providers (n = 278) varied with regard to FC training, whether attitudes about FCs influenced providers offer of FCs, and how they counselled clients about FCs. Of the 4442 self-administered client surveys in 133 facilities, similar proportions of women (15.4%) and men (15.2%) had ever used FCs. Although FCs were available at almost all sites surveyed, only two-thirds of clients were aware of their availability. CONCLUSION: Data highlight the role of providers as gatekeepers to FC access in public and non-public sectors and provide support for further FC programme expansion in SA and globally.

Disease profile of children under 5 years attending primary health care clinics in a high HIV prevalence setting in South Africa.

OBJECTIVE: To describe the presenting complaints and disease profile of children attending primary health care (PHC) clinics in two provinces of South Africa. METHODS: Participants were sick children 2-59 months old presenting for care at PHC clinics in KwaZulu-Natal (KZN) and Limpopo provinces from 2006-2007. Children were assessed by an expert Integrated Management of Childhood Illnesses (IMCI) practitioner. Children for whom parental/guardian consent was obtained were tested for HIV. RESULTS: A total of 1357 children attending one of 74 clinics were assessed. HIV seroprevalence overall was 7.1%, but was significantly higher in KZN than Limpopo (7.5 vs. 2.4%; OR = 3.3, 95%CI 1.9-5.8%). Commonest presenting complaints were cough (72%), skin conditions (22%) and diarrhoea (19%). Of 1349 children, 120 (8.9%) had a weight below the third percentile; 108/1357 (8.0%) children required urgent referral, most commonly for severe pneumonia (53.7%) and severe malnutrition (16.7%). In multivariate analyses, severe pneumonia, growth faltering and urgent referral were independently associated with younger age, residence in KZN and HIV infection (P < 0.05). CONCLUSIONS: Many children with severe illnesses and undiagnosed HIV infection present to PHC facilities. PHC staff require skills to correctly manage these conditions and undertake HIV testing. Although IMCI provides evidence-based guidelines, implementation must be improved to achieve adequate coverage of life-saving interventions.

Paediatric HIV management at primary care level: an evaluation of the integrated management of childhood illness (IMCI) guidelines for HIV.

BACKGROUND: Integrated Management of Childhood Illness (IMCI) is a WHO/UNICEF strategy to improve child survival in resource poor settings. South Africa adopted IMCI in 1997, and IMCI guidelines were adapted to include identification and management of HIV infected and exposed children. This study describes the validity of the IMCI/HIV algorithm when used by IMCI experts, the use of IMCI/HIV guidelines by IMCI trained health workers in routine clinical practice, and the burden of HIV among children under 5 years attending first level health facilities. METHODS: Seventy seven randomly selected IMCI trained health workers were observed in 74 health facilities in two provinces of South Africa. Consultations were observed with 1357 sick children; each child was reassessed by an IMCI expert to confirm the correct findings. Consent was requested for HIV testing of all children who attended with a parent or legal guardian. Positive rapid HIV tests were confirmed with HIV PCR in children aged less than 18 months. HIV positive children had a CD4 count and HIV clinical staging done. RESULTS: Of 1064 children with HIV results available, 76 (7.1% CI: 5.7% - 8.9%) children were confirmed HIV positive. IMCI experts using the HIV algorithm classified 54/76 (71.1% CI: 59.5%-80.9%) HIV positive children as suspected symptomatic HIV, and 15/22 remaining HIV positive children were identified as HIV exposed. Therefore, 69/76 (90.8% CI: 81.9-96.2) HIV infected children were identified by IMCI experts. No classification was made for HIV by observed health workers in 899/1357(66.2%) children.906/1243(72.9%) mothers had been tested previously for HIV, of whom 221(24.4%) reported testing positive. Of 221 children therefore identified as HIV exposed, only 78(35.3%) had been tested for HIV within routine services. CONCLUSION: The HIV algorithm is a valid tool for identifying HIV infected and exposed children when correctly and comprehensively implemented. However, it is not being used by IMCI trained health workers in routine practise, leading to a failure to implement life saving interventions.

An evaluation of the quality of IMCI assessments among IMCI trained health workers in South Africa.

BACKGROUND: Integrated Management of Childhood Illness (IMCI) is a strategy to reduce mortality and morbidity in children under 5 years by improving case management of common and serious illnesses at primary health care level, and was adopted in South Africa in 1997. We report an evaluation of IMCI implementation in two provinces of South Africa. METHODOLOGY/PRINCIPAL FINDINGS: Seventy-seven IMCI trained health workers were randomly selected and observed in 74 health facilities; 1357 consultations were observed between May 2006 and January 2007. Each health worker was observed for up to 20 consultations with sick children presenting consecutively to the facility, each child was then reassessed by an IMCI expert to determine the correct findings. Observed health workers had been trained in IMCI for an average of 32.2 months, and were observed for a mean of 17.7 consultations; 50/77(65%) HW's had received a follow up visit after training. In most cases health workers used IMCI to assess presenting symptoms but did not implement IMCI comprehensively. All but one health worker referred to IMCI guidelines during the period of observation. 9(12%) observed health workers checked general danger signs in every child, and 14(18%) assessed all the main symptoms in every child. 51/109(46.8%) children with severe classifications were correctly identified. Nutritional status was not classified in 567/1357(47.5%) children. CONCLUSION/SIGNIFICANCE: Health workers are implementing IMCI, but assessments were frequently incomplete, and children requiring urgent referral were missed. If coverage of key child survival interventions is to be improved, interventions are required to ensure competency in identifying specific signs and to encourage comprehensive assessments of children by IMCI practitioners. The role of supervision in maintaining health worker skills needs further investigation.