How quality improvement transformed PrEP uptake for pregnant and breastfeeding women in Johannesburg

In previous HIVE blogs, we introduced the Vertical Transmission Prevention (VTP) Quality Improvement (QI) strategy being implemented across HIVE-supported districts. But learning sessions alone do not improve health outcomes. The real impact began when healthcare workers, district managers, and HIVE teams translated improvement plans into everyday practice.

The journey began in October 2025 with the first QI learning session, bringing together district managers, clinicians, data teams, and HIVE Technical Field Officers to identify priority gaps in VTP services and develop facility-specific Quality Improvement Plans (QIPs).

However, the learning sessions were only the starting point. Following the sessions, HIVE Technical Field Officers worked alongside facility teams through regular supportive supervision visits, mentoring healthcare workers to implement their QIPs while providing practical, on-site training. HIVE Technical Leads complemented these efforts by strengthening district capacity through data review meetings, mentorship, and collaboration with district management teams. Together, these interventions embedded continuous quality improvement into routine service delivery.

Turning challenges into action

The Johannesburg Health District illustrates what can happen when data verification, mentorship, and local leadership work together to improve HIV prevention services. Of the district’s ten HIVE-supported facilities, eight identified increasing antenatal care (ANC) PrEP initiation as their priority improvement project. Baseline data showed that fewer than 20% of eligible HIV-negative pregnant women were being initiated on PrEP, and some facilities were not routinely offering PrEP during pregnancy.

Root cause analyses revealed several contributing factors. Healthcare providers lacked confidence in counselling pregnant women on PrEP, were uncertain about documentation requirements, and used use of data collection tools inconsistently. Data quality gaps further limited facilities’ ability to monitor performance and respond quickly to emerging challenges. Rather than viewing these challenges as barriers, the district used them as opportunities for improvement.

Supportive supervision visits focused on practical skills development, strengthening providers’ confidence to counsel pregnant and breastfeeding women on HIV prevention while improving the quality and consistency of routine documentation. In response, facilities introduced several practical, low-cost improvements, including:

• Daily WhatsApp data review discussions to rapidly identify and resolve reporting gaps
• A PrEP refusal register to better understand why eligible clients declined PrEP
• Stronger collaboration with Health Promotion teams to improve client education
• Facility-specific PrEP initiation targets for pregnant and breastfeeding women
• A breastfeeding PrEP monitoring tool to strengthen continuity of care beyond pregnancy 

Eight months of progress

Within eight months (November 2025 to May 2026), the district had achieved measurable improvements. Average ANC PrEP initiation across the ten HIVE-supported facilities increased from fewer than 20% to 53.9%, with several facilities now initiating more than 50% of eligible HIV-negative pregnant women on PrEP.

Importantly, many of the improvements introduced during implementation have now become part of routine district operations. Daily WhatsApp data reviews continue to support rapid problem-solving, while monthly VTP data review meetings have strengthened accountability and the routine use of data for decision-making.

“Since HIVE QI sessions, the district has improved with reporting and recording of ANC PrEP. .. Although HIVE is focusing on 10 facilities, we managed to start monitoring this data and even requested it to be included in the DPMR whereby each sub-district reports monthly performance. Inclusion of district and sub-district HIM teams during HIVE sessions assisted with improvement of data quality monitoring.
In the recent meeting held for HIVE QI sessions, we managed to see facilities that did well with the roll out of Lenacapavir. This motivated other facilities to improve Lenacapavir for both ANC and breastfeeding because recent tools used for data presentation includes breastfeeding mothers.” – Acting District VTP Manager: Ms Lumka Ntloko

Building a foundation for Lenacapavir

These improvements also prepared the district to introduce new HIV prevention technologies. When Lenacapavir was introduced, the Johannesburg Health District was well positioned to support its rollout. Within the first month, the ten HIVE-supported facilities accounted for 52.2% of all Lenacapavir initiations across the district, demonstrating the district’s readiness to rapidly introduce new HIV prevention options.

While these achievements cannot be attributed to HIVE alone, district leaders credit strengthened provider confidence, improved data quality, routine performance monitoring, and closer collaboration between clinicians, monitoring and evaluation teams, and district management with creating the conditions for successful implementation.

Beyond the HIVE project

The Johannesburg Health District’s experience demonstrates that sustainable improvement is possible when quality improvement is owned by facilities, supported by district leadership, and integrated into Ministry of Health systems.

As HIVE continues supporting the institutionalization of VTP quality improvement across the supported districts, the focus extends beyond improving indicators. The goal is not only to improve programme indicators, but to embed a lasting culture of continuous learning, data-driven decision-making, and collaborative problem-solving that strengthens maternal and child health services well beyond the life of the HIVE project, which concludes in December 2026.