Missed opportunities to prevent mother-to-child-transmission: systematic review and meta-analysis

Abstract

Objectives: To determine magnitude and reasons of loss to program and poor antiretroviral prophylaxis coverage in prevention of mother-to-child transmission (PMTCT) programs in sub-Saharan Africa.

Design: Systematic review and meta-analysis.

Methods: We searched PubMed and Embase databases for PMTCT studies in sub-Saharan Africa published between January 2002 and March 2012. Outcomes were the percentage of pregnant women tested for HIV, initiating antiretroviral prophylaxis, having a CD4 cell count measured, and initiating antiretroviral combination therapy (cART) if eligible. In children outcomes were early infant diagnosis for HIV, and cART initiation. We combined data using random-effects meta-analysis and identified predictors of uptake of interventions.

Results: Forty-four studies from 15 countries including 75,172 HIV-infected pregnant women were analyzed. HIV-testing uptake at antenatal care services was 94% [95% confidence intervals (CIs) 92-95%] for opt-out and 58% (95% CI 40-75%) for opt-in testing. Coverage with any antiretroviral prophylaxis was 70% (95% CI 64-76%) and 62% (95% CI 50-73%) of pregnant women eligible for cART received treatment. Sixty-four percent (95% CI 48-81%) of HIV exposed infants had early diagnosis performed and 55% (95% CI 36-74%) were tested between 12 and 18 months. Uptake of PMTCT interventions was improved if cART was provided at the antenatal clinic and if the male partner was involved.

Conclusion: In sub-Saharan Africa, uptake of PMTCT interventions and early infant diagnosis is unsatisfactory. An integrated family-centered approach seems to improve retention.

Figure 1. Steps of the prevention of mother-to-child-transmission cascade

Bold arrows represent steps with risk of attrition ANC=antenatal care, cART=lifelong combination ART, ARVs=antiretroviral drugs, PCR=polymerase chain reaction

Figure 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

Figure 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

Figure 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.