INTRODUCTION: In South Africa fewer health professionals (HPs) work in rural areas compared to urban areas, despite rural communities having greater health needs. This study explores factors influencing recruitment and retention of three categories of HPs in KwaZulu-Natal and has implications about how to retain them in rural areas. METHODS: A cross-sectional, descriptive survey was conducted in 8 hospitals, 5 rural and 3 urban, in one district in KZN in 2011. Data were collected on single day in each hospital and all HPs on duty were requested to participate. We compared responses from rural and urban based HP as well as professional nurses (PNs), doctors, and allied HPs. : 417 questionnaires were completed: 150 from HPs in rural and 267 from HPs in urban hospitals. Perceptions of living/working in rural areas is negative and the quality of health care provided in rural areas is perceived as poor by all categories of HP. Rural-based HPs were more likely to report living apart from spouse/partner (72.1% vs 37.0%, p < 0.001) and children (76.7% vs 36.9%, p < 0.001), and living in hospital accommodation (50.8% vs 28.9%; p < 0.001. CONCLUSIONS: Decisions made by HP about where to work are complex, multifactorial and should be tailored to each category of health professional.

BACKGROUND: South African infant and child mortality remains high, with many deaths occurring outside the formal health services. Delayed health care seeking represents a large proportion of these deaths. AIM: To generate knowledge about the role of, and influences on, caregivers with regard to decision-making about when and where to seek care for sick children. SETTING: Two communities in KwaZulu-Natal. METHODS: A qualitative, exploratory design employing participatory research techniques was used to undertake focus group discussions with community members. RESULTS: Health care seeking for a sick child was described as a complex process influenced by multiple carers using multiple providers. Decision-making about seeking health care for a sick child was not an individual effort, but was shared with others in the household and guided by how the symptoms were perceived, either a Western illness or African illness. A sick child could either be treated at home or be taken to a variety of places including clinics, private doctors, traditional healers, faith healers and hospitals. Traditional healers were associated with the treatment of illnesses perceived to be traditional. Few participants said that they would take their child back to the original health provider if the child remained ill, but would move from one provider to another until the child's health improved. CONCLUSION: The formal health system needs to ensure that sick children are identified and managed appropriately to reduce child deaths. Knowledge and understanding of health care seeking behaviour for sick children by carers is an important aspect. Interventions need to be designed with these contextual issues in mind.

BACKGROUND: Community health workers (CHWs) are a component of the health system in many countries, providing effective community-based services to mothers and infants. However, implementation of CHW programmes at scale has been challenging in many settings. AIM: To explore the acceptability of CHWs conducting household visits to mothers and infants during pregnancy and after delivery, from the perspective of community members, professional nurses and CHWs themselves. SETTING: Primary health care clinics in five rural districts in KwaZulu-Natal, South Africa. METHODS: A qualitative exploratory study was conducted where participants were purposively selected to participate in 19 focus group discussions based on their experience with CHWs or child rearing. RESULTS: Poor confidentiality and trust emerged as key barriers to CHW acceptability in delivering maternal and child health services in the home. Most community members felt that CHWs could not be trusted because of their lack of professionalism and inability to maintain confidentiality. Familiarity and the complex relationships between household members and CHWs caused difficulties in developing and maintaining a relationship of trust, particularly in high HIV prevalence settings. Professional staff at the clinic were crucial in supporting the CHW's role; if they appeared to question the CHW's competency or trustworthiness, this seriously undermined CHW credibility in the eyes of the community. CONCLUSION: Understanding the complex contextual challenges faced by CHWs and community members can strengthen community-based interventions. CHWs require training, support and supervision to develop competencies navigating complex relationships within the community and the health system to provide effective care in communities.

OBJECTIVE: To report the rates of mother-to-child transmission (MTCT) of the human immunodeficiency virus (HIV), and the coverage of interventions designed to prevent such transmission, in KwaZulu-Natal. METHODS: Mothers with infants aged < 16 weeks and fathers or legal guardians with infants aged 4-8 weeks who, between May 2008 and April 2009, attended immunization clinics in six districts of KwaZulu-Natal were included. The mothers' uptake of interventions for the prevention of MTCT was explored. Blood samples from infants aged 4-8 weeks were tested for anti-HIV antibodies and, if antibody-positive, for HIV desoxyribonucleic acid (DNA). FINDINGS: Of the 19 494 mothers investigated, 89·9% reported having had an HIV test in their recent pregnancy. Of the 19 138 mothers who reported ever having had an HIV test, 34.4% reported that they had been found HIV-positive and, of these, 13.7% had started lifelong antiretroviral treatment and 67.2% had received zidovudine and nevirapine. Overall, 40.4% of the 7981 infants tested were found positive for anti-HIV antibodies, indicating HIV exposure. Just 7.1% of the infants checked for HIV DNA (equating to 2.8% of the infants tested for anti-HIV antibodies) were found positive. CONCLUSION: The low levels of MTCT observed among the infants indicate the rapid, successful implementation of interventions for the prevention of such transmission. Sampling at immunization clinics appears to offer a robust method of estimating the impact of interventions designed to reduce such transmission. Large-scale elimination of paediatric HIV infections appears feasible, although this goal has not yet been fully achieved in KwaZulu-Natal.

OBJETIVO: Notificar los índices de transmisión maternofilial (TMT) del virus de la inmunodeficiencia humana (VIH) y la cobertura de las intervenciones diseñadas para prevenir dicha transmisión en KwaZulu-Natal. MÉTODOS: Se incluyeron las madres con hijos con edad igual o inferior a 16 semanas y los padres o tutores legales con niños de edades comprendidas entre 4 y 8 semanas que hubieran asistido a los centros de vacunación de seis distritos de KwaZulu-Natal entre mayo de 2008 y abril de 2009. Se evaluó la aceptación de las madres respecto a las intervenciones para la prevención de la transmisión del VIH de la madre al niño. Se analizaron las muestras de sangre de niños de entre 4 y 8 semanas para comprobar la presencia de anticuerpos anti-VIH y, en el caso de obtener un resultado positivo para dichos anticuerpos, se comprobó la presencia del ácido desoxirribonucléico (ADN) del VIH. RESULTADOS: El 89,9% de las 19 494 madres que participaron en el estudio afirmaron haberse realizado una prueba del VIH en su último embarazo. De las 19 138 madres que afirmaron haberse realizado alguna vez una prueba del VIH, un 34,4% aseguró que la prueba para el VIH resultó positiva en su caso y, de ese porcentaje, un 13,7% inició un tratamiento crónico con antirretrovirales y un 67,2% recibió zidovudina y nevirapina. En total, el 40,4% de los 7981 niños estudiados obtuvieron un resultado positivo de anticuerpos anti-VIH, lo que indica su exposición al VIH. Solo el 7,1% de los niños sometidos a las pruebas del ADN del VIH (equivalente al 2,8% de los niños a quienes se les realizó pruebas de anticuerpos anti-VIH) obtuvieron un resultado positivo en dicha prueba. CONCLUSIÓN: Los bajos niveles de TMT del VIH observados en los niños reflejan una puesta en práctica rápida y fructífera de las intervenciones para la prevención de dicha transmisión. Las tomas de muestras en los centros de vacunación parecen constituir un método sólido para calcular el impacto de las intervenciones diseñadas para reducir dicha transmisión. La eliminación de las infecciones pediátricas del VIH a gran escala parece viable, si bien este objetivo no está completamente conseguido en KwaZulu-Natal.

OBJECTIF: Présenter les taux de transmission mère-enfant (TME) du virus de l'immunodéficience humaine (VIH), ainsi que la portée des mesures conçues pour prévenir cette transmission, dans le KwaZulu-Natal. MÉTHODES: Ont été incluses des mères de nourrissons d'un âge < à 16 semaines et des pères ou des tuteurs légaux de nourrissons âgés de 4 à 8 semaines qui, entre mai 2008 et avril 2009, avaient fréquenté des centres de vaccination dans six districts du KwaZulu-Natal. On a étudié l'adhésion à ces mesures de prévention de la TME par les mères. On a recherché les anticorps anti-VIH dans les échantillons de sang des nourrissons âgés de 4 à 8 semaines puis, en cas de présence de ces anticorps, on a procédé à la recherche de l'acide désoxyribonucléique (ADN) du VIH. RÉSULTATS: Parmi les 19 494 mères ayant participé à l'étude, 89,9% ont signalé avoir fait réaliser un dépistage VIH lors de leur récente grossesse. Parmi les 19 138 mères ayant signalé avoir eu un dépistage VIH, 34,4% ont signalé que le résultat avait indiqué qu'elles étaient séropositives et parmi celles-ci, 13,7% avaient commencé une thérapie antirétrovirale à vie et 67,2% avaient reçu de la zidovudine et de la névirapine. Globalement, on a constaté la présence d'anticorps anti-VIH chez 40,4% des 7 981 nourrissons ayant fait l'objet de cette recherche, indiquant leur exposition au VIH. Seuls 7,1% des nourrissons ayant fait l'objet du test d'ADN du VIH (équivalent à 2,8% des nourrissons chez lesquels la présence d'anticorps VIH avait été détectée) présentaient des échantillons positifs. CONCLUSION: Les faibles niveaux de TME observés chez ces nourrissons indiquent la mise en place rapide et réussie des mesures de prévention contre cette transmission. Le prélèvement d'échantillons dans les centres de vaccination semble offrir une méthode solide d'estimation de l'impact des mesures destinées à réduire cette transmission. L'élimination à grande échelle des infections à VIH chez l'enfant paraît réalisable, en dépit du fait qu'elle n'ait pas été entièrement atteinte dans le KwaZulu-Natal.