In-depth interviews were conducted with three provincial PMTCT officials and 22 PMTCT co-ordinators as well as through four focus group discussions with 21 sub-district officials and another four with 71 PMTCT clients. This is what they said: Barriers at provincial level These include poor management systems, inadequate human and physical resources and lack of co-ordination and integration of PMTCT with other health programmes, such as tuberculosis, sexually transmitted infections and nutrition. On poor management systems, the following was a typical remark from local service area managers: ‘The provincial financial system is not user-friendly, it keeps on changing and this causes delays with the loading of budgets and in creating costs at province, resulting in delays to process requests'. And on the issue of inadequate human and physical resources: ‘There are no permanent full time PMTCT posts; the programme uses seconded staff. This affects programme continuity, progress, quality, and supervision at lower levels'. Barriers at district and sub-district level Again inadequate human resources and the fact that there is no dedicated PMTCT staff is a sticking point: ‘Available staff is overloaded dealing with voluntary counselling and testing (VCT), HIV, sexually transmitted infections, the ordering of test kits, ordering of formula and distribution of anteretrovirals, in addition to overseeing PMTCT services'. There is limited geographical coverage: ‘When we started with the PMTCT programme at another sub-district, we had only one site serving a population of 460 000 people'. Then the programme is not accessible: ‘There is generally no reading material, information leaflets with pictures, no brochures and no videos on PMTCT'. Another problem is the lack of proper monitoring as there is no record-keeping to establish whether the programme is effective; and a lack of integration, co-ordination and communication results in confusion of roles and responsibilities between the HIV manager and the PMTCT co-ordinator in some sub-districts. Sub-district managers do not sufficiently share information among themselves, which affects progress in terms of PMTCT service delivery. Barriers at facility level There are limited PMTCT trained nurses in the facilities due to high staff turnover and transfer of staff. And the infrastructure at this level is poor: ‘In some facilities one consulting room is used for the support group meetings, ANC mothers counselling, antiretroviral drugs roll-out, VCT, testing, issuing formula and general health consultation'. Poor management systems are also a problem on this level: ‘Facilities have no effective drug monitoring system, uniform protocol for formula distribution, adequate inventory control, and monitoring and evaluation system'. The lack of support and supervision is a general setback: ‘Limited supervision, if any, is given to PMTCT patients due to time constraints as they have to oversee the VCT, STI, and PMTCT programmes as well as attend other meetings and workshops. There is no support from facility staff'. Barriers at household/community level From families women with HIV experience stigma and discrimination from spouses, parents, in-laws and community: ‘Our spouses, parents, in-laws and communities do not accept us, they think we contracted HIV because of being promiscuous; they distance themselves and gossip saying she has a disease with Amagama amathathu, meaning a disease with three words'. Traditional beliefs are also an obstruction: ‘Sometimes babies do not receive nevirapine 72 hours after delivery because of the belief that the new born baby should be given isicakati (a traditional drink) as their first feed for a couple of days; some mothers are not allowed to go to hospital 14 days following delivery as they are to receive home-based postnatal care (efukwini) provided by their families and some people believe that the new born baby should be taken to ilawini, which means to a "coloured" traditional healer to make sure they get a relief of evil spirits'. Some nurses have a negative attitude towards HIV-positive mothers: ‘Some used to shout at us saying we are too many and that they even regret why they tested us'. Another mother said: ‘I was tested and came for results; I was ill-treated and not given the results for my status. As I was leaving, the water broke and immediately I gave birth to the child. I didn't get nevirapine though the baby got the syrup'. It is not only the attitude of nurses that is an obstacle, but also a lack of dedication and organisation: ‘Nurses take their time during lunch and tea breaks and when it is time to knock off, they stop working irrespective of whether or not there are still patients in the queue; there is a general laxity in dealing with patients in very long queues; we sometimes spend the whole day in the queue and nurses don't bother'. The unavailability or limited supplies of nevirapine is a constant difficulty: ‘Sometimes when we go to the clinics to fetch formula on a scheduled date and we are told that the formula is finished and when the formula comes, we are not given the formula in retrospect. If it was out of stock that month you forfeit it'. Another said: ‘Sometimes clients deliver before getting the results and therefore without getting nevirapine if they have been found to be HIV'. Barriers are systemic in nature Many of the barriers are systemic in nature and relate to the functioning of the healthcare system in general as opposed to the functioning of the PMTCT programme specifically. The barriers identified in this study are common across other parts of South Africa. Lessons learned in this study should be considered when identifying best practices for expanding and providing PMTCT services.
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