The HIVE Effect: Scaling Up Quality Care to Eliminate Vertical Transmission
Through HIVE – the HIV Impact Network for Vertical Transmission Elimination, PATA is currently working within 60 facilities across Nigeria, Mozambique, and South Africa with a mission to create a knowledge-exchange platform that improves the quality of services for pregnant and breastfeeding women and their infants.
At the heart of HIVE is Quality Improvement (QI) and linking and learning to ensure that every facility aligns with the latest Vertical Transmission Prevention (VTP) guidelines and works to prevent the vertical transmission of HIV.
The Road to 2030: Why Quality Improvement Matters
To end AIDS by 2030, the World Health Organization (WHO) has set a clear benchmark: countries that promote exclusive breastfeeding reduce vertical transmission rates to below 5%. While there have been major strides since the introduction of antiretroviral therapy (ART), data shows that there is still a long way to go:
- Nigeria and Mozambique: Vertical transmission rates remain high at 8.5% and 11% respectively
- South Africa: While the transmission rate is at 2.7% (below UNAIDS 65% target), the country does not yet qualify for WHO elimination validation. This is primarily due to low antenatal care (ANC) coverage — currently at 67% against a target of 90%
The reality is that many pregnant women living with HIV are still not on treatment, and those who are HIV-negative remain vulnerable to HIV due to physiological changes, behavioural, structural and social factors, which also increase the risk of transmission to their infants.
To close these gaps, HIVE is focusing on six key districts, Chris Hani and Johannesburg Health in South Africa, Adamawa and Delta states in Nigeria, and Nampula and Zambezia Districts in Mozambique, to demonstrate how QI approaches can accelerate progress.
The QI process
In October 2025, our HIVE team conducted quality improvement learning sessions across our supported districts/states. When we reviewed the data, one indicator stood out as a universal challenge: Oral pre-exposure prophylaxis (PrEP) initiation for pregnant women. Initiation rates were significantly lower than the general population, with some facilities reporting zero initiations.
Diagnosing the Problem: The Fishbone model
To understand why, facility teams used the Fishbone Method (a cause-and-effect tool) to dig deeper. They identified several key bottlenecks:
- Limited in-service training meant many providers didn’t feel comfortable offering PrEP
- Shortages of PrEP-specific stationery led to poor data capturing and inconsistent reporting
- Pregnant women often refused PrEP due to the number of pills they were already taking, coupled with persistent stigma and religious beliefs
- Limited familiarity with the updated VTP guidelines meant missed opportunities for care
Testing Change: The PDSA Cycle
The HIVE team didn’t only identify the problems; we started testing solutions. PATA field technical officers went to facilities, from November 2025 through January 2026, to provide hands-on mentorship and supportive supervision for QI implementation. They collaborated with district and provincial managers to guide facilities through the Plan–Do–Study–Act (PDSA) cycle of QI.
We are already seeing “quick wins”. In the Johannesburg Health District, for example, non-clinical cadres like Health Promoters were trained on VTP. They began leading health education in clinics, schools, and even on community radio. This didn’t just reduce the burden on nurses; it generated community-wide demand for oral PrEP.
This process is already fostering greater ownership of quality at the facility level and building a culture of continuous improvement. Notably, these are the first quality improvement learning sessions focused specifically on VTP across all three countries, and are being integrated into existing systems
As” of Quality Improvement
With 2026 underway, the HIVE facilities are conducting their first three-month review sessions. PATA field technical officers are supporting them in compiling their data to reflect on progress and determine whether to continue with current interventions or improvement strategies, or introduce new priorities, while maintaining oral PrEP monitoring in the background. This is a space for the “4 As” of quality improvement:
- Adapt strategies that are working
- Adopt best practices from peer facilities
- Adjust interventions that need a nudge
- Abandon approaches that the evidence shows aren’t working
Looking Ahead: Preparing for Lenacapavir
The lessons we are learning about oral PrEP — how to mentor providers, track uptake, and address stigma — are the perfect dry run for the rollout of new technologies like long-acting injectable PrEP (Lenacapavir).
Instead of starting from scratch when new drugs arrive, we are building the systems now. By embedding QI principles into the DNA of the health facilities, we aren’t just reporting success; we are building a culture of continuous improvement that will bring the goal of eliminating vertical transmission closer to reality.
