title: Operational effectiveness and 36 week HIV-free survival in the South African programme to prevent mother-to-child transmission of HIV-1.
abstract: OBJECTIVE
  Previous studies on the operational effectiveness of programmes to reduce transmission of HIV from mother-to-child (PMTCT) in Africa have generally been hospital-based pilot studies with short follow-up periods.
  
  
  METHODS
  Prospective cohort study to evaluate the routine operational effectiveness of the South African National PMTCT Programme, primarily measured by HIV-free survival at 36 weeks post-delivery. Three of eighteen pilot sites participating in the programme were selected as they reflected differences in circumstances, such as HIV prevalence, socioeconomic status and rural-urban location. A total of 665 HIV-positive mothers and their infants were followed.
  
  
  RESULTS
  HIV-free survival at 36 weeks varied significantly across sites with 84% in Paarl, 74% in Umlazi and 65% in Rietvlei (P = 0.0003). Maternal viral load was the single most important factor associated with HIV transmission or death [hazard ratio (HR), 1.54; 95% confidence interval (CI), 1.21-1.95]. Adjusting for health system variables (fewer than four antenatal visits and no antenatal syphilis test) explained the difference between Rietvlei and Paarl (crude HR, 2.27; 95% CI, 1.36-3.77; adjusted HR, 1.81; 95% CI, 0.93-3.50). Exposure to breastmilk feeding explained the difference between Umlazi and Paarl (crude HR, 1.74; 95% CI, 1.06-2.84; adjusted HR, 1.41; 95% CI, 0.81-2.48).
  
  
  CONCLUSIONS
  Ever breastfeeding and underlying inequities in healthcare quality within South Africa are predictors of PMTCT programme performance and will need to be addressed to optimize PMTCT effectiveness.
authors.affiliation: School of Public Health, University of the Western Cape, Bellville, South Africa. djackson@uwc.ac.za
authors.forename: Debra J
authors.initials: DJ
authors.lastname: Jackson
authors.forename: Mickey
authors.initials: M
authors.lastname: Chopra
authors.forename: Tanya M
authors.initials: TM
authors.lastname: Doherty
authors.forename: Mark Se
authors.initials: MS
authors.lastname: Colvin
authors.forename: Jonathan B
authors.initials: JB
authors.lastname: Levin
authors.forename: Juana F
authors.initials: JF
authors.lastname: Willumsen
authors.forename: Ameena E
authors.initials: AE
authors.lastname: Goga
authors.forename: Pravi
authors.initials: P
authors.lastname: Moodley
mesh_terms: D001942:Breast Feeding / Q000009:adverse effects; D004812:Epidemiologic Methods; D005260:Female; D015658:HIV Infections / Q000517:prevention & control* / Q000635:transmission* / Q000821:virology; D015497:HIV-1; D006801:Humans; D007223:Infant; D018445:Infectious Disease Transmission, Vertical / Q000517:prevention & control; D011247:Pregnancy; D011251:Pregnancy Complications, Infectious / Q000821:virology; D015397:Program Evaluation; D012959:Socioeconomic Factors; D013019:South Africa; D019562:Viral Load