title: The role of quality improvement in achieving effective large-scale prevention of mother-to-child transmission of HIV in South Africa.
abstract: BACKGROUND
  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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, South Africa.
authors.forename: Pierre
authors.initials: P
authors.lastname: Barker
authors.forename: Peter
authors.initials: P
authors.lastname: Barron
authors.forename: Sanjana
authors.initials: S
authors.lastname: Bhardwaj
authors.forename: Yogan
authors.initials: Y
authors.lastname: Pillay
mesh_terms: D023241:Antiretroviral Therapy, Highly Active / Q000379:methods*; D042241:Early Diagnosis; D005260:Female; D015658:HIV Infections / Q000517:prevention & control* / Q000635:transmission; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D018445:Infectious Disease Transmission, Vertical / Q000517:prevention & control*; D008403:Mass Screening / Q000458:organization & administration*; D009035:Mothers; D011159:Population Surveillance / Q000379:methods*; D011247:Pregnancy; D011315:Preventive Medicine / Q000458:organization & administration*; D016730:Program Development; D015397:Program Evaluation; D058996:Quality Improvement / Q000458:organization & administration*; D015203:Reproducibility of Results; D012959:Socioeconomic Factors; D013019:South Africa / Q000453:epidemiology