Secondary Logo

Journal Logo


Missed opportunities to prevent mother-to-child-transmission

systematic review and meta-analysis

Wettstein, Celinaa; Mugglin, Catrinaa; Egger, Matthiasa,b; Blaser, Nelloa; Vizcaya, Luisa S.a; Estill, Jannea; Bender, Nicolea; Davies, Mary-Annb; Wandeler, Gillesa,c,*; Keiser, Oliviaa,* for the IeDEA Southern Africa Collaboration

Author Information
doi: 10.1097/QAD.0b013e328359ab0c



In 2009, approximately 130 000 children were newly infected with HIV in sub-Saharan Africa, over 90% of them by vertical transmission [1,2]. If HIV-infected infants are left undiagnosed and untreated, about half of them die before the age of two [2]. Mother-to-child transmission, which occurs in 20–45% of HIV-infected pregnant women without antiretroviral prophylaxis, can be lowered to 5% or less with adequate interventions [2]. Early infant diagnosis (EID) and treatment after delivery dramatically reduce infant mortality [3]. However, loss to follow-up of mothers and their infants from prevention of mother-to-child transmission (PMTCT) programs limits the impact of these interventions.

PMTCT interventions can be seen as a series of consecutive steps (Fig. 1). When pregnant women first present at an antenatal care unit, they are tested for HIV. If positive, they are counseled for PMTCT and provided with antiretroviral medication. They are also assessed for eligibility for lifelong combination antiretroviral therapy (cART) and if they are eligible, therapy is initiated. With the option B+ approach for PMTCT, this last step is unnecessary as all pregnant women start cART [4]. EID of HIV by polymerase chain reaction (PCR) is performed on infants if their mothers return with them for postnatal follow-up, preferably at around 6 weeks after delivery. In infants who test negative at EID or if no EID is available, the final HIV status is determined after weaning. Finally, cART is initiated in HIV-infected infants.

Fig. 1
Fig. 1:
Steps of the prevention of mother-to-child-transmission cascade.Bold arrows represent steps with risk of attrition. ANC, antenatal care; ARVs, antiretroviral drugs; cART, lifelong combination ART.

At each step of the PMTCT cascade, pregnant women and their infants may be lost to follow-up and not benefit from important healthcare interventions. The magnitude and reasons for program attrition in sub-Saharan Africa remain poorly understood. We performed a systematic review and meta-analysis to evaluate the uptake of HIV testing and antiretroviral treatment in pregnant women and their children.


Data sources

We searched Pubmed and Embase databases on 5 March 2012, limiting the search to publications in the English language and studies published since 2002 (i.e. when the scale-up of ART programs in sub-Saharan Africa began) [5]. We used free text words as well as Medical Subjects Headings in Pubmed and Emtree-terms in Embase. We combined the following search terms and their variations: HIV, PMTCT, infection of newborn, pregnancy, prenatal care, postnatal care, antiretroviral agents, eligibility, referral process and loss to follow-up. We examined the references of all included studies. Further details on the search strategy are given in the web appendix,

Study selection

We included all studies on pregnant women (with either unknown or positive HIV status) and their HIV-exposed infants who attended PMTCT programs in sub-Saharan Africa. We selected studies that reported the number of participants who were given access to at least one of the following interventions: initiation of antiretroviral prophylaxis for HIV-positive pregnant women; assessment and initiation of lifelong cART; or HIV testing in infants. We excluded qualitative studies, randomized controlled trials, modeling studies, studies where uptake of interventions was assessed by interview, and cost-effectiveness studies. Abstracts were screened according to a list of inclusion and exclusion criteria. Two reviewers independently assessed the eligibility of articles. Discrepancies were resolved by consensus.

Data extraction

Data extraction was performed in duplicate by eight reviewers using a standardized extraction sheet. The following data were extracted: characteristics of programs (setting, location, country) and participants (age, gestational age at first antenatal care visit), eligibility criteria for cART initiation and the number of participants completing the following steps: first, HIV-testing of pregnant women; second, initiation of antiretroviral prophylaxis for mothers; third, CD4 cell count testing; fourth, initiation of cART in eligible women; fifth, HIV diagnosis of the exposed infants around 6 weeks by PCR and between 12 and 18 months by PCR or antibody test; and sixth, cART initiation in infected infants (Fig. 1). Eligibility was defined according to the program threshold in use at the time of the study. We also extracted predictors of successful uptake of each step and recorded positive or negative associations with the outcomes studied. Discrepancies were resolved by consensus.

Statistical analysis

We assessed the percentage of participants who completed each of the steps, and estimated the underlying mean percentage by combining studies in random-effect meta-analysis. Calculations were done on the logit scale with results back-transformed to percentages. Results were heterogeneous with I2 values consistently above 90% and P values from tests of heterogeneity less than 0.001. We therefore, calculated approximate prediction intervals (PrI) based on the whole random effects distribution as well as traditional 95% confidence intervals (CI) around the mean of the distribution. PrI predict the likely underlying mean percentages in new studies and are the most sensible way to summarize the results of heterogeneous studies [6]. The percentage of women tested for HIV in programs with opt-in and opt-out strategies were compared in a random-effects metaregression model. To calculate overall PMTCT coverage, all regimens (single dose nevirapine at birth, dual and triple antiretroviral prophylaxis, as well as cART prescribed for life) were considered. For the meta-analysis on testing between 12 and 18 months postpartum, only infants from programs without PCR-testing or with negative early PCR test result were included. Data were analyzed using STATA version 12 (StataCorp, College Station, Texas, USA).


Study and patient characteristics

We identified 146 potentially eligible full text articles out of 2370 identified studies based on titles and abstracts. Fifty-six publications met our inclusion criteria but a further 12 articles were excluded because they reported on the same populations and time periods as other articles. A total of 44 studies including 75 172 HIV-positive women were included. Details on the selection process are provided in the web appendix (Figure S1, The studies originated from 15 countries in sub-Saharan Africa (web appendix Figure S2, The number of patients in each publication ranged from 22 to 14 815 (Table 1) [7,8]. Eight studies reported on the gestational age at presentation to antenatal care [9–16]. The majority of women were in the late second or third trimester (web appendix Table S1, Many studies provided information on HIV testing (N = 27) or antiretroviral prophylaxis without cART-eligibility assessment (N = 23). Eligibility for cART was assessed in 14 programs, and 12 studies reported on cART-initiation in eligible women. Thirteen studies reported on uptake of EID, eight on HIV testing between 12 and 18 months postpartum and one study reported on treatment initiation in infected infants (Fig. 1).

Table 1-a
Table 1-a:
Characteristics of included studies.
Table 1-b
Table 1-b:
Characteristics of included studies.

HIV testing of pregnant women

In sites where provider initiated (opt-out) testing was performed, the combined estimate of women tested for HIV, based on nine studies, was 93.7%, with 95% CI of 92.4–95.0% and only slightly wider PrI of 88.7–98.6%. The combined estimate for opt-in testing, based on seven studies, was 57.6%, with a 95% CI of 40.0–75.1% and a PrI of 0–100% (Fig. 2). The results from the two testing strategies were clearly different (P < 0.001 from metaregression). Predictors of successful HIV testing were reported in six publications [10,17–21] and included cART provision at the antenatal clinic [21] and being accompanied by a male partner [20] (web appendix Table S2,

Fig. 2
Fig. 2:
Meta-analyses of uptake of HIV testing in pregnant women by testing strategy.Top panel: Uptake of opt-out HIV testing. Bottom panel: Uptake of opt-in HIV testing. ANC, antenatal care.

Antiretroviral prophylaxis for prevention of mother-to-child transmission

The combined estimate of the percentage of HIV-positive women receiving any type of prophylaxis, based on 34 studies, was 70.3%, with 95% CI and PrI of 64.3–76.3% and 33.7–100%, respectively, (Fig. 3, web appendix Figure S3, In 19 of these programs, the only PMTCT intervention consisted of single dose nevirapine (sdNVP) at birth. In three studies, women initiated lifelong cART if eligible and received sdNVP otherwise. Dual or triple ART prophylaxis was available in nine studies, with an estimate of mean coverage of 58.6% and 95% CI and PrI of 41.0–76.2% and 0–100%, respectively (Fig. 3, web appendix Figure S4, In six of these nine studies, some women received sdNVP even though dual or triple ART was available. The reason for this was that the women received sdNVP at their first visit but never returned for an assessment of ART eligibility [15,22]. In three of the 34 studies the antiretroviral regimen was not specified. Information on predictors of sdNVP uptake was available in six studies [10,13,17,19,20,23]. Uptake was better when the male partner was involved [20] and when women delivered at the healthcare facility [19] (web appendix Table S2,

Fig. 3
Fig. 3:
Coverage with antiretroviral drugs for prevention of mother-to-child-transmission (PMTCT).Estimates are pooled estimates from meta-analyses providing data on the whole time period of each graph. HIV+, HIV positive; cART, antiretroviral combination therapy.

Eligibility assessment and combination antiretroviral therapy initiation

Ten studies reported on uptake of assessments of cART eligibility based on CD4 cell counts and subsequent cART initiation. In these studies, a CD4 cell count was determined in 67.6% of HIV-infected pregnant women (95% CI 37.5–97.8%; PrI 0–100%). An estimated 22.3% of women who had a CD4 cell count were eligible for cART (95% CI 17.2–27.4%; PrI 3.0–41.6%) and an estimated 61.1% of these women initiated treatment (95% CI 47.7–74.5%; PrI 10.4–100%) (Fig. 3, web appendix Figure S5, Results were similar when including all studies with information on any one of these steps (web appendix Figure S6, the estimated percentage of HIV-positive women with a CD4 cell count, based on 14 studies, was 68.1% (95% CI 44.6–91.7%; PrI 0–100%). Among these 22.6% of women were eligible for cART (95% CI 17.8–27.5%; PrI 3.9–41.4%, based on 11 studies) and 61.5% of eligible women initiated cART (95% CI 49.8–73.2%; PrI 16.2–100, 11 studies). Six studies assessed whether women with CD4 cell measurements returned to collect the results: an estimated 72.6% (95% CI 62.5–82.7%; PrI 35.5–100%) returned to the clinic.

Four studies reported on predictors for having a CD4 cell count recorded [8,13,18,24]. A CD4 count was more likely to be recorded if the measurement was ordered on the same day as testing for HIV was done [8], if the result was available rapidly [8], if the test was done in urban areas [8], if the women was employed [18], or if the gestational age at the first visit was below 20 weeks [18]. Five studies reported on predictors for cART initiation in eligible women [8,13,18,21,24,25]. Women were more likely to start cART if it was provided at the antenatal clinic [8,24], if they were older [25], had more children [25], or presented earlier in pregnancy [21] (web appendix Table S2,

Linkage between prevention of mother-to-child transmission services, infant HIV diagnosis and antiretroviral combination therapy initiation

The mean percentage of infants tested for HIV by PCR around 6 weeks based on 12 studies was 64.4% with 95% CI and PrI of 47.5–81.2% and 0–100%, respectively (Fig. 4, web appendix Table S3, Predictors for EID were reported in three studies [26–28]. These showed positive associations between uptake of testing and proximity to the clinic [26], large family size [26], early HIV diagnosis of the mother [27], or having received antiretroviral prophylaxis for PMTCT [27] (web appendix Table S2, The combined estimate of the percentage of infants tested between 12 and 18 months postpartum based on seven studies was 55.2% with 95% CI 36.4–74.1% and PrI 0.0–100.0% (Fig. 4, web appendix Table S3, Only one study followed the HIV-infected children until cART initiation: 29.5% of infected infants could be traced to an ART clinic and of these about half initiated cART [29].

Fig. 4
Fig. 4:
Uptake of early infant diagnosis by polymerase chain reaction (PCR) around 6 weeks postpartum and infant testing between 12 and 18 months postpartum if the program did not provide early infant diagnosis by PCR or the child was HIV negative at PCR testing.


Our meta-analysis included over 75 000 pregnant women from 15 countries in sub-Saharan Africa who had been enrolled in 44 studies of one or several steps of the PMTCT cascade. The results of the different studies were heterogeneous, and in some instances very heterogeneous, with maximally wide PrIs. Provider-initiated (opt-out) HIV testing of pregnant women resulted in much higher coverage than patient-initiated (opt-in) testing, with an estimated 94% of women being tested with the first approach compared to 58% with the second. The uptake of antiretroviral prophylaxis for mothers was unsatisfactory, and the percentage of cART-eligible patients who received the recommended treatment low. Overall, 70% of pregnant women received some form of antiretroviral prophylaxis, 64% of HIV-exposed infants accessed EID by PCR around 6 weeks postpartum and 55% were tested between 12 and 18 months.

The risk of mother-to-child HIV transmission can be dramatically reduced by preventive measures including antiretroviral prophylaxis for the mother and the child [2]. According to a recent WHO update, the use of cART during pregnancy is preferable to mono or dual therapy [4]. Our analysis showed that some women received sdNVP at their first visit and were then lost before dual or triple prophylaxis or cART could be initiated. In other cases it was unknown why the optimal regimen had not been provided even though it was available. Significantly, about one-third of patients did not receive any type of antiretroviral prophylaxis, and 40% of cART eligible women did not initiate treatment. This finding is in line with recent systematic reviews on retention in HIV care, which reported that between 38 and 88% of pregnant women [30], and 32 and 37% of eligible patients from the general HIV-infected population never started cART [31,32]. An important difference between pregnant women and the general HIV-infected population is that a substantially lower proportion of pregnant women were eligible for cART at first presentation (23 and 40% [31], respectively). This shows that with systematic HIV testing during pregnancy, HIV infection can be diagnosed earlier, providing opportunities to initiate cART before patients present with advanced disease.

In a previous review Hensen et al.[33] compared HIV-testing uptake before and after implementation of the opt-out strategy and found a substantial increase in uptake, from 10 to 66%. In our analysis, which included studies with either opt-in or opt-out testing, we found that the mean uptake was 94% with the opt-out strategy. The consistency of results across programs was striking and in contrast to the pronounced heterogeneity of results with the opt-in strategy. In general, pregnant women may be reluctant to be tested for many reasons, including structural and sociocultural barriers [34,35]. However, the provision of universal opt-out HIV-testing in antenatal care clinics might remove some of the fears related to patient-initiated testing, as it ‘normalizes’ the testing process and integrates it into routine clinical care. As a consequence, women might be less afraid of being stigmatized and judged by their peers. The studies included in this analysis showed enhanced uptake of testing if patients were accompanied by their male partner [20]. Finally, programmatic issues such as staff shortages or the unavailability of test kits might also limit HIV testing uptake [36].

In our meta-analysis, about two-thirds of the HIV-exposed infants returned for EID and even less for HIV testing between 12 and 18 months postpartum. We analyzed coverage of HIV infant testing in programs in which mothers were informed about the importance of testing their child. Preventing transmission from mothers who seroconvert while breastfeeding, or who are not attending an antenatal care clinic, is probably even more difficult than in women who attended an antenatal care clinic during pregnancy [37]. Several strategies aimed at increasing the uptake of infant testing have been evaluated [38]. For example, Rollins et al.[39] showed that universal HIV-testing of infants at immunization clinics was acceptable and feasible in rural South Africa, with 90% of women agreeing to have their infant tested. WHO and most national guidelines recommend universal treatment of all HIV-infected children under 2 years of age. It is therefore important to develop effective strategies for testing children for HIV in infancy.

In order to increase the uptake of PMTCT interventions, our understanding of the individual and program-level factors that limit access to care must improve. Although few studies analyzed barriers to pre-ART care, integration of cART provision into routine antenatal services and reducing the number of visits seems promising. An example of this was the improved uptake of cART when the CD4 cell count was done on the same day as testing for HIV [8]. Better uptake was also associated with the provision of cART at the same place as PMTCT services [8,21,24], or if the distance to the clinic was short [8,13]. In general, however, there is a lack of data on the effectiveness of integrating PMTCT programs with other health services. This is illustrated by a Cochrane review on this topic [40], which found only one study that matched the inclusion criteria. The involvement of the male partner may also increase the chance of successful interventions [20]. In a study from Côte d’Ivoire, a family centered approach (i.e. provision of cART to partner and children and improved access to contraception) helped to achieve coverage of over 90% from CD4 measurement to EID.

Our review provides a unique overview on the uptake of diagnostic and interventional steps throughout the PMTCT cascade in sub-Saharan Africa. The studies included in this review represent a wide range of urban, semi-urban and rural healthcare settings from many regions of sub-Saharan Africa. There are, however, several limitations. As noted previously, there were important differences between studies, which led to heterogenous results and wide PrIs. Furthermore, the studies were conducted over 8 years, a period in which HIV testing, treatment and prevention strategies evolved substantially. For example, the studies evaluating opt-out HIV-testing were performed later than those with opt-in strategies, possibly leading to bias due to an increase in the level of HIV awareness and quality of care over time. Most of the studies did not trace patients lost to follow-up or assess predictors for losses to program. They could thus not contribute to a better understanding of the reasons for attrition. In the context of initiation of lifelong cART in eligible women, we did not consider different CD4 cell count thresholds for starting cART, and studies did not report whether eligibility was based on CD4 cell count or stage of disease. Finally, none of the studies evaluated the option B+ approach and only one study reported on cART initiation in HIV-infected infants.


In order to reach the UNAIDS goal of eliminating paediatric HIV infections by 2015 [41], the coverage of PMTCT and cART need to be improved. Even though provider-initiated HIV-testing shows promising results, large gaps in antiretroviral prophylaxis, cART initiation, and infant testing remain. In order to improve retention in care of HIV-infected mothers and prevent new HIV-infections in children, a better understanding of the major barriers is of paramount importance. Further research on the major reasons for the failure of PMTCT programs in sub-Saharan Africa is urgently needed.


We thank Kali Tal for editorial help and Marcel Zwahlen for statistical support.

C.W., C.M., O.K. analyzed the data. C.W., G.W., O.K. wrote the article. C.W., M.E., O.K. conceived and designed the systematic review. C.W., C.M., N.B., L.S., J.E., N.B., G.W., O.K. performed data extraction. M.E., M.D. revised the article.

The study was supported by the National Institute of Allergy and Infectious Diseases (NIAID), Grant 5U01-AI069924–05, a PROSPER fellowship grant to O.K. funded by the Swiss National Science Foundation (Grant 32333B_131629) and PhD fellowships to J.E. and N.B. from the Swiss School of Public Health and the Swiss National Science Foundation.

Conflicts of interest

The authors have no conflicts of interest to declare.


1. UNAIDS. Global report, fact sheet, sub-Saharan Africa. 2010. http:// [Accessed 3 September 2012].
2. WHO. PMTCT Strategic Vision 2010-2015: Preventing mother-to-child transmission of HIV to reach the UNGASS and Millenium Development Goals (2010). http:// [Accessed 3 September 2012].
3. Violari A, Cotton MF, Gibb DM, Babiker AG, Steyn J, Madhi SA, et al. Early antiretroviral therapy and mortality among HIV-infected infants. N Engl J Med 2008; 359:2233–2244.
4. WHO. Programmatic update, use of antiretroviral drugs for treating pregnant women and preventing HIV infection in infants, executive summary (2012). [Accessed 3 September 2012].
5. WHO. Prevention of mother-to-child transmission (PMTCT), Briefing note (2007). http:// [Accessed 3 September 2012].
6. Higgins JP, Thompson SG, Spiegelhalter DJ. A re-evaluation of random-effects meta-analysis. J R Stat Soc Ser A Stat Soc 2009; 172:137–159.
7. Kouam L, Nsangou I, Mbanya D, Nkam M, Kongnyuy EJ, Ngassa P, et al. Prevention of mother-to-child transmission of HIV in Cameroon: experiences from the University Teaching Hospital in Yaounde (Cameroon). Zentralbl Gynakol 2006; 128:82–86.
8. Mandala J, Torpey K, Kasonde P, Kabaso M, Dirks R, Suzuki C, et al. Prevention of mother-to-child transmission of HIV in Zambia: implementing efficacious ARV regimens in primary health centers. BMC Public Health 2009; 9:314.
9. Azcoaga-Lorenzo A, Ferreyra C, Alvarez A, Palma PP, Velilla E, del Amo J. Effectiveness of a PMTCT programme in rural Western Kenya. AIDS Care 2011; 23:274–280.
10. Barigye H, Levin J, Maher D, Tindiwegi G, Atuhumuza E, Nakibinge S, et al. Operational evaluation of a service for prevention of mother-to-child transmission of HIV in rural Uganda: barriers to uptake of single-dose nevirapine and the role of birth reporting. Trop Med Int Health 2010; 15:1163–1171.
11. Colvin M, Chopra M, Doherty T, Jackson D, Levin J, Willumsen J, et al. Operational effectiveness of single-dose nevirapine in preventing mother-to-child transmission of HIV. Bull World Health Organ 2007; 85:466–473.
12. Kirere Mathe M, Sondag-Thull D, Lepage P. Feasibility of prevention of perinatal HIV infection by nevirapine in rural areas of the northeast Democratic Republic of Congo, 2002–2004. J Med Virol 2008; 80:772–776.
13. Moodley D, Srikewal J, Msweli L, Maharaj NR. A bird's eye view of PMTCT coverage at two regional hospitals and their referral clinics in a resource-limited setting. S Afr Med J 2011; 101:122–125.
14. Msuya SE, Mbizvo E, Uriyo J, Stray-Pedersen B, Sam NE, Hussain A. Predictors of failure to return for HIV test results among pregnant women in Moshi, Tanzania. J Acquir Immune Defic Syndr 2006; 43:85–90.
15. Namukwaya Z, Mudiope P, Kekitiinwa A, Musoke P, Matovu J, Kayma S, et al. The impact of maternal highly active antiretroviral therapy and short-course combination antiretrovirals for prevention of mother-to-child transmission on early infant infection rates at the Mulago national referral hospital in Kampala, Uganda, January 2007 to May 2009. J Acquir Immune Defic Syndr 2011; 56:69–75.
16. Rutta E, Gongo R, Mwansasu A, Mutasingwa D, Rwegasira V, Kishumbu S, et al. Prevention of mother-to-child transmission of HIV in a refugee camp setting in Tanzania. Global Public Health 2008; 3:62–76.
17. Balcha TT, Lecerof SS, Jeppsson AR. Strategic challenges of PMTCT program implementation in Ethiopia. J Int Assoc Physic AIDS Care 2011; 10:187–192.
18. Chen JY, Ogwu AC, Svab P, Lockman S, Moffat HJ, Gaolathe T, et al. Antiretroviral treatment initiation among HIV-infected pregnant women with low CD4(+) cell counts in Gaborone, Botswana. J Acquir Immune Defic Syndr 2010; 54:102–106.
19. Mirkuzie AH, Hinderaker SG, Sisay MM, Moland KM, Morkve O. Current status of medication adherence and infant follow up in the prevention of mother to child HIV transmission programme in Addis Ababa: a cohort study.J Int AIDS Soc 2011; 14:50.
20. Peltzer K, Mosala T, Dana P, Fomundam H. Follow-up survey of women who have undergone a prevention of mother-to-child transmission program in a resource-poor setting in South Africa. J Assoc Nurs AIDS Care 2008; 19:450–460.
21. Stinson K, Boulle A, Coetzee D, Abrams EJ, Myer L. Initiation of highly active antiretroviral therapy among pregnant women in Cape Town, South Africa. Trop Med Int Health 2010; 15:825–832.
22. Chi BH, Chintu N, Lee A, Stringer EM, Sinkala M, Stringer JS. Expanded services for the prevention of mother-to-child HIV transmission: field acceptability of a pilot program in Lusaka, Zambia. J Acquir Immune Defic Syndr 2007; 45:125–127.
23. Stringer JS, Sinkala M, Maclean CC, Levy J, Kankasa C, Degroot A, et al. Effectiveness of a city-wide program to prevent mother-to-child HIV transmission in Lusaka, Zambia. AIDS 2005; 19:1309–1315.
24. Tsague L, Tsiouris FO, Carter RJ, Mugisha V, Tene G, Nyankesha E, et al. Comparing two service delivery models for the prevention of mother-to-child transmission (PMTCT) of HIV during transition from single-dose nevirapine to multidrug antiretroviral regimens. BMC Public Health 2010; 10:753.
25. Kumwenda J, Matchere F, Mataya R, Chen S, Mipando L, Li Q, et al. Coverage of highly active antiretroviral therapy among postpartum women in Malawi. Int J STD AIDS 2011; 22:368–372.
26. Ciampa PJ, Burlison JR, Blevins M, Sidat M, Moon TD, Rothman RL, 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.
27. Tejiokem MC, Faye A, Penda IC, Guemkam G, Ateba Ndongo F, Chewa G, et al.Feasibility of early infant diagnosis of HIV in resource-limited settings: The ANRS 12140-PEDIACAM study in cameroon. PLoS ONE 2011; 6:e21840.
28. Geddes R, Giddy J, Butler LM, van Wyk E, Crankshaw T, Esterhuizen TM, et al. Dual and triple therapy to prevent mother-to-child transmission of HIV in a resource-limited setting: lessons from a South African programme. S Afr Med J 2011; 101:651–654.
29. Braun M, Kabue MM, McCollum ED, Ahmed S, Kim M, Aertker L, et al. Inadequate coordination of maternal and infant HIV services detrimentally affects early infant diagnosis outcomes in lilongwe, Malawi. J Acquir Immune Defic Syndr 2011; 56:e122–e128.
30. Ferguson L, Grant AD, Watson-Jones D, Kahawita T, Ong’ech JO, Ross DA. Linking women who test HIV-positive in pregnancy-related services to long-term HIV care and treatment services: a systematic review.Trop Med Int Health 2012; 17:564–580.
31. Mugglin C, Wandeler G, Bender N, Egger M, Gsponer T, Keiser O. Loss to programme between HIV diagnosis and initiation of antiretroviral therapy in sub-Saharan Africa: Systematic review and meta-analysis. Trop Med Int Health (in press).
32. Rosen S, Fox MP. Retention in HIV care between testing and treatment in sub-Saharan Africa: a systematic review. PLoS Med 2011; 8:e1001056.
33. Hensen B, Baggaley R, Wong VJ, Grabbe KL, Shaffer N, Lo YR, et al.Universal voluntary HIV testing in antenatal care settings: a review of the contribution of provider-initiated testing & counselling.Trop Med Int Health 2012; 17:59–70.
34. Gruskin S, Ahmed S, Ferguson L. Provider-initiated HIV testing and counseling in health facilities--what does this mean for the health and human rights of pregnant women?. Dev World Bioeth 2008; 8:23–32.
35. Oosterhoff P, Hardon AP, Nguyen TA, Pham NY, Wright P. Dealing with a positive result: routine HIV testing of pregnant women in Vietnam. AIDS Care 2008; 20:654–659.
36. Doherty T, Chopra M, Nsibande D, Mngoma D. Improving the coverage of the PMTCT programme through a participatory quality improvement intervention in South Africa.BMC Public Health 2009; 9:406.
37. Johnson LF, Stinson K, Newell ML, Bland RM, Moultrie H, Davies MA, et al. The Contribution of Maternal HIV Seroconversion During Late Pregnancy and Breastfeeding to Mother-to-Child Transmission of HIV. J Acquir Immune Defic Syndr 2012; 59:417–425.
38. Ciaranello AL, Park JE, Ramirez-Avila L, Freedberg KA, Walensky RP, Leroy V. Early infant HIV-1 diagnosis programs in resource-limited settings: opportunities for improved outcomes and more cost-effective interventions. BMC Med 2011; 9:59.
39. Rollins N, Mzolo S, Moodley T, Esterhuizen T, van Rooyen H. 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.
40. Tudor Car L, van-Velthoven MH, Brusamento S, Elmoniry H, Car J, Majeed A, et al.Integrating prevention of mother-to-child HIV transmission (PMTCT) programmes with other health services for preventing HIV infection and improving HIV outcomes in developing countries.Cochrane Database Syst Rev 2011:CD008741.
41. UNAIDS 2011–2015 strategy. Getting to zero (2010). http:// [Accessed 3 September 2012].
42. Behets F, Mutombo GM, Edmonds A, Dulli L, Belting MT, Kapinga M, et al. Reducing vertical HIV transmission in Kinshasa, Democratic Republic of Congo: trends in HIV prevalence and service delivery. AIDS Care 2009; 21:583–590.
43. Chama C, Gashau W, Oguche S. The value of highly active antiretroviral therapy in the prevention of mother-to-child transmission of HIV. J Obstet Gynaecol 2007; 27:134–137.
44. Chama CM, Bello M, Ajayi BA, Zarma S, Gashau W. The use of highly active antiretroviral therapy for the prevention of mother-to-child transmission of the human immunodeficiency virus in Nigeria. J Obstet Gynaecol 2010; 30:362–366.
45. Chandisarewa W, Stranix-Chibanda L, Chirapa E, Miller A, Simoyi M, Mahomva A, et al. Routine offer of antenatal HIV testing (’opt-out’ approach) to prevent mother-to-child transmission of HIV in urban Zimbabwe. Bull World Health Organ 2007; 85:843–850.
46. Creek TL, Ntumy R, Seipone K, Smith M, Mogodi M, Smit M, et al. Successful introduction of routine opt-out HIV testing in antenatal care in Botswana. J Acquir Immune Defic Syndr 2007; 45:102–107.
47. Ekouevi DK, Rouet F, Becquet R, Inwoley A, Viho I, Tonwe-Gold B, et al. Immune status and uptake of antiretroviral interventions to prevent mother-to-child transmission of HIV-1 in Africa. J Acquir Immune Defic Syndr 2004; 36:755–757.
48. Homsy J, Kalamya JN, Obonyo J, Ojwang J, Mugumya R, Opio C, et al. Routine intrapartum HIV counseling and testing for prevention of mother-to-child transmission of HIV in a rural Ugandan hospital. J Acquir Immune Defic Syndr 2006; 42:149–154.
49. Kasenga F, Byass P, Emmelin M, Hurtig AK. The implications of policy changes on the uptake of a PMTCT programme in rural Malawi: first three years of experience.Glob Health Action 2009; 2. doi: 10.3402/gha.v2i0.1883.
    50. Manzi M, Zachariah R, Teck R, Buhendwa L, Kazima J, Bakali E, et al. High acceptability of voluntary counselling and HIV-testing but unacceptable loss to follow up in a prevention of mother-to-child HIV transmission programme in rural Malawi: scaling-up requires a different way of acting. Trop Med Int Health 2005; 10:1242–1250.
    51. Oladokun RE, Awolude O, Brown BJ, Adesina O, Oladokun A, Roberts A, et al. Service uptake and performance of the prevention of mother-to-child transmission (PMTCT) programme in Ibadan, Nigeria. Afr J Med Med Sci 2010; 39:81–87.
    52. Orie EF, Songca PP, Moodley J. An audit of PMTCT services at a regional hospital in South Africa. S Afr Fam Pract 2009; 51:492–495.
      53. Shetty AK, Marangwanda C, Stranix-Chibanda L, Chandisarewa W, Chirapa E, Mahomva A, et al.The feasibility of preventing mother-to-child transmission of HIV using peer counselors in Zimbabwe.AIDS Res Ther 2008; 5:17.
        54. Wanyu B, Diom E, Mitchell P, Tih PM, Meyer DJ. Birth attendants trained in ‘Prevention of Mother-To-Child HIV Transmission’ provide care in rural Cameroon, Africa. J Midwifery Womens Health 2007; 52:334–341.
        55. Zvandasara P, Magwali T, Mulambo JT, Sithole J. Acceptance of HIV screening in an antenatal population at a referral teaching hospital in Zimbabwe: a substudy of an operational research in prevention of mother to child HIV vertical transmission. Cent Afr J Med 2006; 52:31–35.
        56. Tukur J, Galadanci H, Adeleke SI, Mukhtar-Yola M. Outcome of delivery among HIV positive mothers at Aminu Kano Teaching Hospital, Kano. Niger J Med 2007; 16:34–37.
        57. Cook RE, Ciampa PJ, Sidat M, Blevins M, Burlison J, Davidson MA, et al. Predictors of successful early infant diagnosis of HIV in a rural district hospital in Zambezia, Mozambique. J Acquir Immune Defic Syndr 2011; 56:e104–e109.
        58. Kiptoo M, Mpoke S, Ng’ang’a Z, Mueke J, Okoth F, Songok E. Survey on prevalence and risk factors on HIV-1 among pregnant women in North-Rift, Kenya: a hospital based cross-sectional study conducted between 2005 and 2006. BMC Int Health Hum Rights 2009; 9:10.
        59. Tonwe-Gold B, Ekouevi DK, Viho I, Amani-Bosse C, Toure S, Coffie PA, et al. Antiretroviral treatment and prevention of peripartum and postnatal HIV transmission in West Africa: evaluation of a two-tiered approach. PLoS Med 2007; 4:e257.
        60. Van Der Merwe K, Chersich MF, Technau K, Umurungi Y, Conradie F, Coovadia A. Integration of antiretroviral treatment within antenatal care in Gauteng Province, South Africa. J Acquir Immune Defic Syndr 2006; 43:577–581.
        61. Marazzi MC, Liotta G, Nielsen-Saines K, Haswell J, Magid NA, Buonomo E, et al. Extended antenatal antiretroviral use correlates with improved infant outcomes throughout the first year of life. AIDS 2010; 24:2819–2826.

        early infant diagnosis; linkage to care; loss to follow-up; mortality; prevention of mother-to-child transmission; preantiretroviral therapy; prophylaxis

        Supplemental Digital Content

        © 2012 Lippincott Williams & Wilkins, Inc.