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Antiretroviral Drugs in the Cupboard are Not Enough: The Impact of Health Systems' Performance on Mother-to-Child Transmission of HIV

Barker, Pierre M MBChB, MD*†; Mphatswe, Wendy MBChB, MPH; Rollins, Nigel MB, MD‡§

JAIDS Journal of Acquired Immune Deficiency Syndromes: February 1st, 2011 - Volume 56 - Issue 2 - p e45-e48
doi: 10.1097/QAI.0b013e3181fdbf20
Implementation and Operational Research: Epidemiology and Prevention

Objective: To model the effect of health systems performance on rates of mother-to-child HIV transmission.

Methods: We modeled the effect of variation in performance of the multiple steps of different prevention of mother-to-child transmission (PMTCT) protocols using hypothetical and reported data.

Setting: Data from a PMTCT program in a large province in South Africa was used to compare model predictions with reported outcomes for mother-to-child HIV transmission.

Main Outcome Measure: Perinatal HIV transmission was predicted for infants of 6 weeks of age.

Results: HIV-infected pregnant women who fulfill eligibility criteria are initiated on lifelong antiretroviral treatment, whereas noneligible HIV-infected women and their infants receive single-dose nevirapine in a health system functioning at reported performance levels, and the overall vertical transmission rate would be 19.5%. Adding azidothymidine for women not eligible for lifelong treatment would further decrease the overall transmission rates only marginally to 17%. If the same steps were accomplished at 95% reliability, then the overall transmission rates would be 9.4% and 4.1%, respectively.

Conclusions: Introduction of more effective combination antiretroviral interventions will yield only marginal reductions in childhood HIV infections and mortality unless health systems achieve high levels of performance at each step of the PMTCT pathway. Investment in and support for the mechanisms of delivering and sustaining PMTCT interventions at scale are required if gains in maternal and child survival are to be realized in countries highly affected by HIV.

From the *Institute for Healthcare Improvement, Cambridge, MA; †Department of Pediatrics, University of North Carolina, Chapel Hill, NC; ‡Department of Child Health, University of KwaZulu-Natal, Durban, South Africa; and §Department of Adolescent Health and Development, World Health Organization, Geneva, Switzerland.

Received for publication August 15, 2010; accepted September 21, 2010.

All authors have contributed to the development of the models and writing of the manuscript.

The data for the models were obtained through literature review. Data for the South African health system performance was obtained from the South African District Health Information System.

The model was presented at a WHO internal technical consultation in October 2009.

N. Rollins is a staff member of the World Health Organization.

The authors alone are responsible for the views expressed in this publication and they do not necessarily represent the decisions, policy, or views of the World Health Organization.

The authors have no funding to disclose.

Correspondence to: Nigel Rollins, MB, MD, Department of Child and Adolescent Health and Development, World Health Organization, Avenue Appia 20, 1211 Geneva, Switzerland (e-mail:

© 2011 Lippincott Williams & Wilkins, Inc.