title: Barriers and facilitating factors to the uptake of antiretroviral drugs for prevention of mother-to-child transmission of HIV in sub-Saharan Africa: a systematic review.
abstract: OBJECTIVE
  To investigate and synthesize reasons for low access, initiation and adherence to antiretroviral drugs by mothers and exposed babies for prevention of mother-to-child transmission (PMTCT) of HIV in sub-Saharan Africa.
  
  
  METHODS
  A systematic literature review was conducted. Four databases were searched (Medline, Embase, Global Health and Web of Science) for studies conducted in sub-Saharan Africa from January 2000 to September 2012. Quantitative and qualitative studies were included that met pre-defined criteria. Antiretroviral (ARV) prophylaxis (maternal/infant) and combination antiretroviral therapy (ART) usage/registration at HIV care and treatment during pregnancy were included as outcomes.
  
  
  RESULTS
  Of 574 references identified, 40 met the inclusion criteria. Four references were added after searching reference lists of included articles. Twenty studies were quantitative, 16 were qualitative and eight were mixed methods. Forty-one studies were conducted in Southern and East Africa, two in West Africa, none in Central Africa and one was multi-regional. The majority (n=25) were conducted before combination ART for PMTCT was emphasized in 2006. At the individual-level, poor knowledge of HIV/ART/vertical transmission, lower maternal educational level and psychological issues following HIV diagnosis were the key barriers identified. Stigma and fear of status disclosure to partners, family or community members (community-level factors) were the most frequently cited barriers overall and across time. The extent of partner/community support was another major factor impeding or facilitating the uptake of PMTCT ARVs, while cultural traditions including preferences for traditional healers and birth attendants were also common. Key health-systems issues included poor staff-client interactions, staff shortages, service accessibility and non-facility deliveries.
  
  
  CONCLUSIONS
  Long-standing health-systems issues (such as staffing and service accessibility) and community-level factors (particularly stigma, fear of disclosure and lack of partner support) have not changed over time and continue to plague PMTCT programmes more than 10 years after their introduction. The potential of PMTCT programmes to virtually eliminate vertical transmission of HIV will remain elusive unless these barriers are tackled. The prominence of community-level factors in this review points to the importance of community-driven approaches to improve uptake of PMTCT interventions, although packages of solutions addressing barriers at different levels will be important.
authors.affiliation: Department of Population Health, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom. annabelle.gourlay@lshtm.ac.uk
authors.forename: Annabelle
authors.initials: A
authors.lastname: Gourlay
authors.forename: Isolde
authors.initials: I
authors.lastname: Birdthistle
authors.forename: Gitau
authors.initials: G
authors.lastname: Mburu
authors.forename: Kate
authors.initials: K
authors.lastname: Iorpenda
authors.forename: Alison
authors.initials: A
authors.lastname: Wringe
mesh_terms: D017954:Africa South of the Sahara; D019380:Anti-HIV Agents / Q000627:therapeutic use*; D044966:Anti-Retroviral Agents / Q000627:therapeutic use*; D018890:Chemoprevention / Q000379:methods*; D005260:Female; D015658:HIV Infections / Q000188:drug therapy* / Q000517:prevention & control / Q000635:transmission*; D006297:Health Services Accessibility; D006801:Humans; D018445:Infectious Disease Transmission, Vertical / Q000517:prevention & control*; D010349:Patient Compliance; D011247:Pregnancy
chemical_list: D019380:Anti-HIV Agents; D044966:Anti-Retroviral Agents
keywords: Africa; HIV; barriers; prevention; review; vertical transmission