title: Integrating prevention of mother-to-child HIV transmission programs to improve uptake: a systematic review.
abstract: BACKGROUND
  We performed a systematic review to assess the effect of integrated perinatal prevention of mother-to-child transmission of HIV interventions compared to non- or partially integrated services on the uptake in low- and middle-income countries.
  
  
  METHODS
  We searched for experimental, quasi-experimental and controlled observational studies in any language from 21 databases and grey literature sources.
  
  
  RESULTS
  Out of 28 654 citations retrieved, five studies met our inclusion criteria. A cluster randomized controlled trial reported higher probability of nevirapine uptake at the labor wards implementing HIV testing and structured nevirapine adherence assessment (RRR 1.37, bootstrapped 95% CI, 1.04-1.77). A stepped wedge design study showed marked improvement in antiretroviral therapy (ART) enrolment (44.4% versus 25.3%, p<0.001) and initiation (32.9% versus 14.4%, p<0.001) in integrated care, but the median gestational age of ART initiation (27.1 versus 27.7 weeks, p = 0.4), ART duration (10.8 versus 10.0 weeks, p = 0.3) or 90 days ART retention (87.8% versus 91.3%, p = 0.3) did not differ significantly. A cohort study reported no significant difference either in the ART coverage (55% versus 48% versus 47%, p = 0.29) or eight weeks of ART duration before the delivery (50% versus 42% versus 52%; p = 0.96) between integrated, proximal and distal partially integrated care. Two before and after studies assessed the impact of integration on HIV testing uptake in antenatal care. The first study reported that significantly more women received information on PMTCT (92% versus 77%, p<0.001), were tested (76% versus 62%, p<0.001) and learned their HIV status (66% versus 55%, p<0.001) after integration. The second study also reported significant increase in HIV testing uptake after integration (98.8% versus 52.6%, p<0.001).
  
  
  CONCLUSIONS
  Limited, non-generalizable evidence supports the effectiveness of integrated PMTCT programs. More research measuring coverage and other relevant outcomes is urgently needed to inform the design of services delivering PMTCT programs.
authors.affiliation: Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, United Kingdom.
authors.forename: Lorainne
authors.initials: L
authors.lastname: Tudor Car
authors.forename: Michelle H M M T
authors.initials: MH
authors.lastname: Van Velthoven
authors.forename: Serena
authors.initials: S
authors.lastname: Brusamento
authors.forename: Hoda
authors.initials: H
authors.lastname: Elmoniry
authors.forename: Josip
authors.initials: J
authors.lastname: Car
authors.forename: Azeem
authors.initials: A
authors.lastname: Majeed
authors.forename: Peter
authors.initials: P
authors.lastname: Tugwell
authors.forename: Vivian
authors.initials: V
authors.lastname: Welch
authors.forename: Ana
authors.initials: A
authors.lastname: Marusic
authors.forename: Rifat
authors.initials: R
authors.lastname: Atun
mesh_terms: D003140:Communicable Disease Control / Q000379:methods*; D003906:Developing Countries; D005260:Female; D015658:HIV Infections / Q000517:prevention & control / Q000635:transmission*; D006801:Humans; D018445:Infectious Disease Transmission, Vertical / Q000517:prevention & control*; D011247:Pregnancy; D011251:Pregnancy Complications, Infectious; D011314:Preventive Health Services / Q000379:methods*; D015397:Program Evaluation / Q000706:statistics & numerical data*