Over the past decade, tremendous gains have been made to prevent mother-to-child transmission of HIV (PMTCT) globally. From 2009 to 2011 alone, the number of new annual pediatric HIV infections dropped by approximately one-quarter , due to the introduction of highly efficacious antiretroviral regimens and the rapid expansion of comprehensive services [2,3]. Despite significant strides, however, as many as 330 000 infants are still infected with HIV each year, nearly all in resource-constrained settings . Recent national and international policy changes hold the promise of bringing more effective interventions to HIV-infected women and their families, but only if innovative ways are found to bridge substantial implementation gaps in a sustainable manner.
Global efforts to reduce pediatric HIV have been hampered by the delivery of effective services to all in need. Attrition has been noted at all points along the ‘PMTCT cascade,’ those steps an HIV-infected mother and her HIV-exposed infant must successfully navigate to gain maximal benefit from the available health interventions [5–7]. These include being offered HIV testing, accepting HIV testing, being told of a positive HIV result, being offered antiretroviral prophylaxis or treatment, and adhering to prescribed regimens through pregnancy, delivery, and breastfeeding. Because mothers and infants who fall out of care – or fail to access services at all – experience higher rates of HIV transmission, these inefficiencies directly diminish program impact at the individual and population levels [8▪,9].
Many strategies have been proposed to address the problem of attrition along the PMTCT cascade. Chief among them is the integration of PMTCT services within the broader framework of maternal, newborn, and child healthcare (MNCH). There are many convincing arguments for such an approach, focused on the mother–infant pair (e.g., better access to services, reduced visit burden for patients, decreased stigma) and the health system at large (e.g., greater investment in infrastructure and human resource capacity) [10–13]. Despite general policy consensus about the value of integrated services, however, the scientific evidence supporting ‘best practice’ models remains limited. In this report, we review the emerging data around service integration and identify priority areas requiring further study in this rapidly evolving field.
The integration of HIV prevention, care, and treatment into the existing health services has tremendous potential for strengthening systems, improving efficiencies, ensuring sustainability, and broadening the impact of health investments. The rationale from the patient perspective is equally compelling, as this approach provides greater reach into catchment populations and offer patient-level conveniences (e.g., single visit for multiple health needs) that can themselves promote adherence and retention in care. For these reasons, there has been a strong and consistent emphasis on service integration within the context of PMTCT. Early programs relied on the established infrastructure of MNCH for HIV testing, infant feeding counseling, and simple antiretroviral prophylaxis provision (e.g., single-dose nevirapine), particularly during antenatal care. Recent shifts in PMTCT policy mandate similar approaches that extend into the postpartum period. In addition, the Option B+ strategy [i.e., lifelong antiretroviral therapy (ART) to all HIV-infected pregnant women] will require expansion of HIV treatment services beyond their current capacity in order to meet the increased patient demand . This scale-up may be best achieved through integrated PMTCT-MNCH services, particularly in rural and remote areas with relatively small patient volumes.
Because of the high degree of service integration existent with most PMTCT programs, to date few studies have examined the comparative advantages and disadvantages of such an approach [15,16]. Emerging data within the field of primary care, however, provide evidence of the incremental benefit possible through integrated models. In South Africa, Uebel et al.[17▪,18] reported small but significant reductions in mortality at facilities that scored high for total integration, ART integration (i.e., care provided by all nurses in the facility), and internal integration (i.e., care provided by all nurses in the HIV treatment unit). In Zambia, Topp et al. demonstrated increased time spent by providers during non-HIV clinic visits following integration of HIV services in the primary care setting, highlighting the potential for collateral health benefits. However, adoption of such models may come at a cost. In the Zambia study, waiting times increased for all patients at newly integrated sites, delays largely attributed to inadequate staffing levels and longer breaks between consecutive patient visits . Investigators in Mozambique found higher rates of attrition among patients attending integrated clinics for more than 6 months (hazard ratio: 1.75, 1.04–2.94) . Although integrated health systems may streamline service provision, reduce stigma, and broaden coverage, in most settings such models cannot address existing gaps in health infrastructure such as staffing shortages and physical space . Integrated health approaches themselves require investment, perhaps leveraged through existing resources for HIV care [23,24], to realize their full potential.
INTEGRATION IN THE EVOLVING FIELD OF PREVENTION OF MOTHER-TO-CHILD HIV TRANSMISSION
There is a growing medical literature describing integrated PMTCT and MNCH services, ranging from program reports to cluster-randomized trials. Below, we highlight three key areas that have received emphasis over the past several years:
Increasing uptake of antiretroviral regimens during pregnancy
In most high prevalence settings, nurses and midwives in antenatal settings typically dispense zidovudine and nevirapine to HIV-infected women who do not yet require HIV treatment for their own health. As governments have adopted Option B/B+, however, there has been a reluctance to endorse similar practices with three-drug combination regimens, because of inherent complexities of toxicity management and treatment monitoring. Because most programs lack sufficient numbers of certified ART prescribers, the relative merits of integrated antenatal-ART services versus enhanced linkages between the two departments continue to be a topic of debate.
There are emerging data demonstrating the gains that may be associated with integrated services. Killam et al. demonstrated a two-fold increase in ART initiation when services were provided in the context of integrated services; however, the overall proportions remained low (14 versus 32%). These findings were supported by recent work from South Africa, which compared proportions of ART-eligible women initiating HIV treatment during pregnancy through three models: a passive referral system (21%), an enhanced referral system that used peer navigators (49%), and an integrated model where nurse-midwives provided ART care within the antenatal clinic (86%). The integrated model was associated with the shortest median time from eligibility determination to ART initiation (7 days), compared with active (15 days) and passive (29 days) referral, an important consideration for perinatal HIV prevention [26▪▪]. Early results from the Study of HIV and Antenatal care Integration in Pregnancy, a 12-site cluster-randomized in rural Kenya, demonstrated similar findings. Women in sites with integrated services started ART quicker and were more likely to remain adherent to their regimens [27,28▪▪]. Qualitative work indicated acceptability and general support for fully integrated models, both from patients and health providers [29,30]. It should be noted that these studies enrolled only the subset of women who met general adult ART eligibility criteria. As health policy shifts to the universal provision of maternal combination antiretroviral regimens during pregnancy and breastfeeding (i.e., Option B/B+) , the feasibility of these integrated strategies must be reconsidered in the context of higher patient volumes and greater resource demand.
Improving retention in the postnatal period
Although positive health outcomes have been reported with integrated services in the antenatal period, experiences in the postnatal period have been mixed. Separate studies in Zimbabwe and Tanzania demonstrated improvements in the follow-up care for HIV-exposed infants when visits were aligned with the national immunization schedule [32,33▪▪]. In Tanzania, however, the proportion of children who received vaccines decreased over time in four rural sites by 23–35%. Interestingly, in four urban sites, the proportion of children receiving vaccinations remained stable or increased over the same time period [33▪▪]. These early results suggest that, in some settings, the platform for postpartum maternal and/or newborn care may be inadequate to support integrated care, particularly if the mother elects to breastfeed for an extended period.
How best to integrate services for both mother and infant during breastfeeding remains an unanswered question. This likely requires reorganization of current health access points for women and children after delivery. In many settings, postpartum women return to primary ‘outpatient’ clinics for their own care in the months after delivery. Although infants follow an extended immunization schedule, there are often significant gaps between the timed visits. An integrated approach that provides coordinated care for the mother–infant pair holds promise. In a 17-site pilot study in Malawi, investigators reported high coverage of cotrimoxazole dispensation (94%), infant HIV DNA PCR testing (84%), and early infant diagnosis results reporting (87%) among the 220 participating women and their newborns . Although highly encouraging, the study period (April to December 2010) preceded the era of postnatal PMTCT prophylaxis in Malawi.
The introduction of antiretroviral drug dispensation into the already strained health service platform could also have a negative impact on adherence outcomes. In Uganda, a significant drop-off was observed in the proportion of eligible mother–infant pairs receiving postpartum antiretroviral drug dispensations (i.e., infant nevirapine syrup) over the course of five scheduled appointments – from 90% at the first visit to approximately 10% at the fifth . In rural Zambia, similar results were reported among a cohort of women receiving antiretroviral combination regimens following delivery, with one-fifth documented as lost to follow-up by 12 months postpartum [36▪]. In Malawi, early reports from the nationwide roll-out of the Option B+ program demonstrated a greater than seven-fold increase in ART uptake among pregnant and breastfeeding women. However, the program retention at 12 months – a time when most women were still breastfeeding – was only 77%, emphasizing the need targeted retention measures for this population [37▪▪].
Identifying at-risk infants missed by traditional program models
HIV testing during pregnancy represents a critical entry point into care for infected women; for this reason, screening has been incorporated into antenatal care in most settings. Opt-out HIV testing and repeat third-trimester testing are now considered routine in most programs, greatly enhanced by the availability of reliable but inexpensive rapid antibody tests. Diagnostic testing of HIV-exposed newborns has been scheduled to coincide with the regular immunization schedule in most national programs. The first of these tests is almost universally recommended at 4–6 weeks of age using DNA PCR technology. Follow-up tests may continue up until 18 months of age, depending on local infant feeding practices.
This traditional model relies on the timely diagnosis of HIV-infected women during pregnancy, with careful postpartum follow-up of their HIV-exposed infants. Such an approach fails to identify those who have dropped out of – or never entered – the PMTCT cascade; it also misses women who acquire HIV late in pregnancy. Because childhood immunization typically achieves very high coverage, routine HIV testing of postpartum women in immunization services may greatly improve entry into postnatal PMTCT services . In Malawi, the provision of maternal HIV testing in immunization clinics resulted in a more than seven-fold increase in uptake, when compared with the usual venue of the general ‘under-5’ pediatric clinic (84 versus 11%, P < 0.001). Among HIV-exposed children eligible for HIV DNA PCR testing, uptake of infant HIV testing was also significantly higher (100 versus 90%, P = 0.03) [39▪▪]. Similar findings were observed elsewhere in the region, when maternal and infant HIV testing was incorporated into routine immunization visits [33▪▪]. By facilitating re-entry into the PMTCT cascade, such approaches provide opportunities to reduce breastfeeding transmission with antiretroviral prophylaxis or treatment and to engage mothers in long-term care.
CHALLENGES AND NEW OPPORTUNITIES IN PROGRAM INTEGRATION
To reach the ambitious global targets for virtual pediatric HIV elimination and improved maternal survival by 2015, programs must achieve near-universal coverage of effective PMTCT services, including retention in care through the breastfeeding period [40,41]. PMTCT integration within existing MNCH platforms is essential to this success; however, despite significant advancements in the recent years, knowledge gaps remain. Below, we highlight key priorities for implementation research.
Rigorous studies are needed to evaluate the presumed benefits that underpin current policy around service integration. Although analogous work has been conducted in other populations, there are characteristics unique to HIV-infected pregnant women and the clinical settings in which they receive care. Given the notable increases in resource demand, further research is needed to confirm the improved health outcomes associated with service integration in the context of Option B/B+. The impact of integration at the level of health systems also requires systematic evaluation, to quantify efficiencies gained both centrally and at the facility level. In addition, detailed assessments of patient-side costs should be carefully considered. The financial costs born by patients are often overlooked within parallel, vertical service delivery models, but represent an area where integrated models may hold important advantages that could lead to improved adherence and retention in care.
Greater focus must be placed on the quality of services provided. This requires intensive monitoring and evaluation efforts, with clear feedback loops to healthcare providers regarding site and individual performance. A formal management framework is also needed to systematically identify gaps and design meaningful interventions to address them. A number of approaches have shown promise, including continuous quality improvement and rapid response initiatives [42–44]. The success of such rigorous methodologies in ‘real world’ settings, particularly among ones of severe resource constraint, relies on careful planning, evaluation, and targeted investments within the public health system. If sustained, such activities can help to ensure that HIV outcomes are optimized without unduly comprising – and perhaps even raising – the standard of foundation MNCH services.
As the duration of antiretroviral coverage has increased through the breastfeeding period (and in some cases beyond), adherence and long-term retention have taken on renewed emphasis in the context of PMTCT [45▪,46]. Combination strategies to improve adherence and retention require further evaluation; ‘minimum packages’ of proven interventions (e.g., two-way SMS reminders) should be incorporated to enhance institutional follow-up in antenatal, delivery, and postpartum care. Effective strategies are also needed to ensure effective transition of postpartum mothers from the MNCH units to adult HIV treatment departments, either during or after breastfeeding. HIV-exposed infants who become HIV-infected require similar linkage strategies to ensure rapid initiation of treatment .
Service platforms created by Option B+ may serve as entry points for other family members, particularly in rural areas with limited access to HIV treatment. Successful engagement of male partners has been shown to improve maternal and infant outcomes . Models that directly provide HIV care and treatment services to partners through the MNCH platform could provide further benefit, particularly around adherence and retention. Implemented effectively, such an approach would enhance the strengths of integrated health systems and provide a framework for further scale-up of general adult and pediatric HIV services.
PMTCT integration has been long supported by policy recommendations, but justifications for such an approach, while compelling, have been based on a limited body of evidence to date. Early studies have shown improvement in uptake when PMTCT is provided alongside routine MNCH services, but these positive results are yet to be confirmed in the setting of increased ART demand. A better understanding of health systems efficiencies generated by PMTCT service integration is also urgently needed, to provide important empirical data to support long-held assumptions. Ultimately, the success of integrated programs will be heavily dependent upon upfront health systems investments and meaningful community engagement to increase institutional healthcare. Properly coordinated and effectively managed, the integration of PMTCT within the MNCH framework can broaden the reach of HIV prevention, care, and treatment initiatives, while raising the quality of healthcare across the entire service platform.
Conflicts of interest
The authors declare no conflicts of interest. This work has not been submitted or published elsewhere.
REFERENCES AND RECOMMENDED READING
Papers of particular interest, published within the annual period of review, have been highlighted as:
▪ of special interest
▪▪ of outstanding interest
Additional references related to this topic can also be found in the Current World Literature section in this issue (pp. 518–519).
1. Joint United Nations Programme on HIV/AID, Joint United Nations Programme on HIV/AIDSA progress report on the Global plan towards the elimination of new HIV infections among children by 2015 and keeping their mothers alive. 2012; http://http://www.unaids.org
/en/media/unaids/contentassets/documents/unaidspublication/2012/JC2385_ProgressReportGlobalPlan_en.pdf. [Accessed April 10, 2013].
2. Chi BH, Adler MR, Bolu O, et al. Progress, challenges, and new opportunities for the prevention of mother-to-child transmission of HIV under the US President's Emergency Plan for AIDS Relief. J Acquir Immune Defic Syndr 2012; 60 (Suppl 3):S78–S87.
3. Chi BH, Stringer JS, Moodley D. Antiretroviral drug regimens to prevent mother-to-child transmission of HIV: a review of scientific, program, and policy advances for Sub-Saharan Africa. Curr HIV/AIDS Rep 2013; 10:124–133.
4. Joint United Nations Programme on HIV/AIDS, Joint United Nations Programme on HIV/AIDSZambia Country Report: Monitoring the Declaration of Commitment on HIV and AIDS and the Universal Access. 2012; http://http://www.unaids.org
/en/dataanalysis/knowyourresponse/countryprogressreports/2012countries/ce_ZM_Narrative_Report.pdf. [Accessed 10 April 2013].
5. Stringer EM, Chi BH, Chintu N, et al. Monitoring effectiveness of programmes to prevent mother-to-child HIV transmission in lower-income countries. Bull World Health Organ 2008; 86:57–62.
6. Stringer EM, Ekouevi DK, Coetzee D, et al. Coverage of nevirapine-based services to prevent mother-to-child HIV transmission in 4 African countries. JAMA 2010; 304:293–302.
7. Wettstein C, Mugglin C, Egger M, et al. Missed opportunities to prevent mother-to-child-transmission: systematic review and meta-analysis. AIDS 2012; 26:2361–2373.
8▪. Barker PM, Mate K. Eliminating mother-to-child HIV transmission will require major improvements in maternal and child health services. Health affairs 2012; 31:1489–1497.
This modeling study demonstrated the large relative contribution of healthcare access in PMTCT program impact at the population level.
9. Barker PM, Mphatswe W, Rollins N. Antiretroviral drugs in the cupboard are not enough: the impact of health systems’ performance on mother-to-child transmission of HIV. J Acquir Immune Defic Syndr 2011; 56:e45–e48.
10. Joint United Nations Programme on HIV/AIDS, The President's Emergency Plan for AIDS Relief (PEPFAR)PEPFAR guidance on integrating prevention of mother to child transmission of HIV, maternal, neonatal, and child health and pediatric HIV services. 2011; http://http://www.pepfar.gov
/documents/organization/158963.pdf. [Accessed on 16 April 2013].
11. World Health OrganizationTechnical consultation on the integration of HIV interventions into maternal, newborn, and child health services. 5–7 April 2006; Geneva, Switzerland:World Health Organization, http://whqlibdoc.who.int/hq/2008/WHO_MPS_08.05_eng.pdf. [Accessed April 16, 2013].
12. AIDSTAR-OneIntegrating prevention of mother-to-child transmission of HIV interventions with maternal, newborn, and child health services: technical brief; 2012. http://http://www.aidstar-one.com
/sites/default/files/AIDSTAR-One_TB_Integrating PMTCT with MNCH_0.pdf. [Accessed 16 April 2013]
13. Duncombe C, Ball A, Passarelli C, Hirnschall G. Treatment 2.0: catalyzing the next phase of treatment, care and support. Curr Opin HIV AIDS 2013; 8:4–11.
14. Schouten EJ, Jahn A, Midiani D, et al. Prevention of mother-to-child transmission of HIV and the health-related Millennium Development Goals: time for a public health approach. Lancet 2011; 378:282–284.
15. Tudor Car L, Van Velthoven MH, Brusamento S, et al. Integrating prevention of mother-to-child HIV transmission programs to improve uptake: a systematic review. PLoS One 2012; 7:e35268.
16. Suthar AB, Hoos D, Beqiri A, et al. Integrating antiretroviral therapy into antenatal care and maternal and child health settings: a systematic review and meta-analysis. Bull World Health Organ 2013; 91:46–56.
17▪. Uebel KE, Lombard C, Joubert G, et al. Integration of HIV care into primary care in South Africa: Effect on survival of patients needing antiretroviral treatment. J Acquir Immune Defic Syndr 2013; 63:e94–e100.
From the adult HIV treatment literature, this study demonstrated an association between increased service integration at the clinical care site and improved patient survival.
18. Uebel KE, Joubert G, Wouters E, et al. Integrating HIV care into primary care services: quantifying progress of an intervention in South Africa. PLoS One 2013; 8:e54266.
19. Topp SM, Chipukuma JM, Giganti M, et al. Strengthening health systems at facility-level: feasibility of integrating antiretroviral therapy into primary healthcare services in Lusaka, Zambia. PLoS One 2010; 5:e11522.
20. Deo S, Topp SM, Garcia A, et al. Modeling the impact of integrating HIV and outpatient health services on patient waiting times in an urban health clinic in Zambia. PLoS One 2012; 7:e35479.
21. Lambdin BH, Micek MA, Sherr K, et al. Integration of HIV care and treatment in primary healthcare centers and patient retention in central Mozambique: A Retrospective Cohort Study. J Acquir Immune Defic Syndr 2013; 62:e146–e152.
22. Topp SM, Chipukuma JM, Chiko MM, et al. Integrating HIV treatment with primary care outpatient services: opportunities and challenges from a scaled-up model in Zambia. Health Policy Plan 2012.
23. Gounder CR, Chaisson RE. A diagonal approach to building primary healthcare systems in resource-limited settings: women-centred integration of HIV/AIDS, tuberculosis, malaria, MCH and NCD initiatives. Trop Med Int Health 2012.
24. Leeper SC, Reddi A. United States global health policy: HIV/AIDS, maternal and child health, and The President's Emergency Plan for AIDS Relief (PEPFAR). AIDS 2010; 24:2145–2149.
25. Killam WP, Tambatamba BC, Chintu N, et al. Antiretroviral therapy in antenatal care to increase treatment initiation in HIV-infected pregnant women: a stepped-wedge evaluation. AIDS 2010; 24:85–91.
26▪▪. 2013; Myer L, Manuelli V, Abrams E, et al. Optimization of ART initiation in pregnancy through linke of services vs. integration of ART into antenatal care [Abstract 83]. 20th Conference on Retroviruses and Opportunistic Infections, Atlanta, GA
This before-after study from South Africa showed the comparative advantage of integrated PMTCT-antenatal care service integration over a strategy of enhanced program linkages.
27. Turan JM, Steinfeld RL, Onono M, et al. The study of HIV and antenatal care integration in pregnancy in Kenya: design, methods, and baseline results of a cluster-randomized controlled trial. PLoS One 2012; 7:e44181.
28▪▪. Turan JM, Bukusi E, Onono M, et al. Effects of integration on the PMTCT cascade. 2012; http://integrationforimpact.org/wp-content/uploads/2012/10/Abstract-11.pdf. [Accessed 18 April 2013]
Preliminary results from this large cluster-randomized trial showed the positive impact PMTCT-antenatal care service integration had on the timely triage and initiation of ART among HIV-infected pregnant women.
29. Vo BN, Cohen CR, Smith RM, et al. Patient satisfaction with integrated HIV and antenatal care services in rural Kenya. AIDS Care 2012; 24:1442–1447.
30. Winestone LE, Bukusi EA, Cohen CR, et al. Acceptability and feasibility of integration of HIV care services into antenatal clinics in rural Kenya: a qualitative provider interview study. Global public health 2012; 7:149–163.
31. World Health Organization, World Health OrganizationTowards the elimination of mother-to-child transmission of HIV: report of a WHO technical consultation. 2012; http://whqlibdoc.who.int/publications/2011/9789241501910_eng.pdf. [Accessed April 2, 2012].
32. 2010; Mujaranji GG, Patel D, Gerema G, et al. Integrating follow-up of HIV-exposed infants into routine EPI services in a changing policy environment in Zimbabwe: yes we can and why we should [Abstract THPE0578]. PC 18th International AIDS Conference, Vienna, Austria.
33▪▪. Goodson JL, Finkbeiner T, Davis N L, et al. Evaluation of using routine infant immunization visits to identify and follow-up HIV-exposed Infants and their mothers in Tanzania. J Acquir Immune Defic Syndr 2013; 63:e9–e15.
This study demonstrated the relative benefits and risks for an integrated service delivery approach within immunization clinics. The inclusion of immunization rates as a secondary outcome highlighted the potential for adverse impact when services are integrated.
34. 2012; Molisho M, Michaelis A, Shelley K, et al. Increasing retention in care for prevention of MTCT in Machinga District, Malawi through an integrated service delivery model: the Mother-Infant Pair (MIP) clinic [Abstract TUPE763]. 19th International AIDS Conference, Washington, D.C.
35. 2012; Walakira M, Sripipatana T, Mirembe Kunya B, et al. The challenge of translating policy into practice: the impact of revised prevention of mother-to-child transmission of HIV guideline implementation on uptake of infant antiretroviral prophylaxis in southwestern Uganda [Abstract MOPE609]. 19th International AIDS Conference, Washington, D.C.
36▪. Gartland MG, Chintu NT, Li MS, et al. Field effectiveness of combination antiretroviral prophylaxis for the prevention of mother-to-child HIV transmission in rural Zambia. AIDS 2013.
This cohort study from Zambia demonstrated significant losses to follow-up at 12 months among mothers receiving universal combination treatment or prophylaxis through an integrated PMTCT-MNCH platform.
37▪▪. Chimbwandria F, Mhango E, Makombe S, et al. Impact of an innovative approach to prevent mother to child transmission of HIV – Malawi, July 2011–September 2012. MMWR 2013; 62:148–151.
This report described the early program outcomes for Malawi's roll-out of the Option B+ strategy for PMTCT, including uptake and retention.
38. Rollins N, Mzolo S, Moodley T, et al. Universal HIV testing of infants at immunization clinics: an acceptable and feasible approach for early infant diagnosis in high HIV prevalence settings. AIDS 2009; 23:1851–1857.
39▪▪. McCollum ED, Johnson DC, Chasela CS, et al. Superior uptake and outcomes of early infant diagnosis of HIV services at an immunization clinic versus an ‘under-five’ general pediatric clinic in Malawi. J Acquir Immune Defic Syndr 2012; 60:e107–e110.
This comparative study examined the feasibility and uptake of maternal HIV testing at two infant care venues: immunization clinic and pediatric outpatient (i.e., ‘under 5’) clinics.
40. Mahy M, Stover J, Kiragu K, et al. What will it take to achieve virtual elimination of mother-to-child transmission of HIV? An assessment of current progress and future needs. Sex Transm Infect 2010; 86 (Suppl 2):ii48–ii55.
41. Ciaranello AL, Perez F, Keatinge J, et al. What will it take to eliminate pediatric HIV? Reaching WHO target rates of mother-to-child HIV transmission in Zimbabwe: a model-based analysis. PLoS Med 2012; 9:e1001156.
42. Webster PD, Sibanyoni M, Malekutu D, et al. Using quality improvement to accelerate highly active antiretroviral treatment coverage in South Africa. BMJ Qual Saf 2012; 21:315–324.
43. Youngleson MS, Nkurunziza P, Jennings K, et al. Improving a mother to child HIV transmission programme through health system redesign: quality improvement, protocol adjustment and resource addition. PLoS One 2010; 5:e13891.
44. Dillabaugh LL, Lewis Kulzer J, Owuor K, et al. Towards elimination of mother-to-child transmission of HIV: the impact of a rapid results initiative in Nyanza Province, Kenya. AIDS Res Treat 2012; 2012:602120.
45▪. Nachega JB, Uthman OA, Anderson J, et al. Adherence to antiretroviral therapy during and after pregnancy in low-income, middle-income, and high-income countries: a systematic review and meta-analysis. AIDS 2012; 26:2039–2052.
This meta-analysis demonstrated suboptimal adherence levels among women receiving antiretroviral drug regimens, particularly following delivery.
46. Clouse K, Pettifor A, Shearer K, et al. Loss to follow-up before and after delivery among women testing HIV positive during pregnancy in Johannesburg, South Africa. Trop Med Int Health 2013; 18:451–460.
47. Ciampa PJ, Burlison JR, Blevins M, et al. Improving retention in the early infant diagnosis of HIV program in rural Mozambique by better service integration. J Acquir Immune Defic Syndr 2011; 58:115–119.
48. Aluisio A, Richardson BA, Bosire R, et al. Male antenatal attendance and HIV testing are associated with decreased infant HIV infection and increased HIV-free survival. J Acquir Immune Defic Syndr 2011; 56:76–82.