The role of quality improvement in achieving effective large-scale prevention of mother-to-child transmission of HIV in South Africa.

INTRODUCTION: After a late start and poor initial performance, the South African Prevention of Mother-To-Child Transmission (PMTCT) programme achieved rapid progress in achieving effective national-scale implementation of a complex intervention across a large number of different geographic and socioeconomic contexts. This study shows how quality-improvement methods played a significant part in PMTCT improvements. METHODS: The South African rollout of the PMTCT programme underwent significant evolution, from a largely ineffective, context-insensitive, top-down cascaded training approach to a sophisticated bottom-up health systems' intervention that used modern adaptive designs. Several demonstration projects used quality-improvement methods to improve the performance of the PMTCT programme. These results prompted a national redesign of key elements of the PMTCT programme which were rapidly scaled up across the country using a unified, simplified data-driven approach. RESULTS: The scale up of the quality-improvement approach contributed to a dramatic fall in the nationally reported transmission rate for mother to child transmission of HIV. By 2012, measured infection rate of HIV-exposed infants at around 6 weeks after birth was 2.6%, close to the reported transmission rates under clinical trial conditions. CONCLUSION: Quality-improvement methods can be used to improve reliability of complex treatment programmes delivered at primary-care level. Rapid scale up and effective population coverage can be accomplished through a sequence of demonstration, testing and rapid spread of locally tested implementation strategies supported by real-time feedback of a simplified indicator dataset and multilevel leadership support.