title: First population-level effectiveness evaluation of a national programme to prevent HIV transmission from mother to child, South Africa.
abstract: BACKGROUND
  There is a paucity of data on the national population-level effectiveness of preventing mother-to-child transmission (PMTCT) programmes in high-HIV-prevalence, resource-limited settings. We assessed national PMTCT impact in South Africa (SA), 2010.
  
  
  METHODS
  A facility-based survey was conducted using a stratified multistage, cluster sampling design. A nationally representative sample of 10 178 infants aged 4-8 weeks was recruited from 565 clinics. Data collection included caregiver interviews, record reviews and infant dried blood spots to identify HIV-exposed infants (HEI) and HIV-infected infants. During analysis, self-reported antiretroviral (ARV) use was categorised: 1a: triple ARV treatment; 1b: azidothymidine >10 weeks; 2a: azidothymidine ≤10 weeks; 2b: incomplete ARV prophylaxis; 3a: no antenatal ARV and 3b: missing ARV information. Findings were adjusted for non-response, survey design and weighted for live-birth distributions.
  
  
  RESULTS
  Nationally, 32% of live infants were HEI; early mother-to-child transmission (MTCT) was 3.5% (95% CI 2.9% to 4.1%). In total 29.4% HEI were born to mothers on triple ARV treatment (category 1a) 55.6% on prophylaxis (1b, 2a, 2b), 9.5% received no antenatal ARV (3a) and 5.5% had missing ARV information (3b). Controlling for other factors groups, 1b and 2a had similar MTCT to 1a (Ref; adjusted OR (AOR) for 1b, 0.98, 0.52 to 1.83; and 2a, 1.31, 0.69 to 2.48). MTCT was higher in group 2b (AOR 3.68, 1.69 to 7.97). Within group 3a, early MTCT was highest among breastfeeding mothers 11.50% (4.67% to 18.33%) for exclusive breast feeding, 11.90% (7.45% to 16.35%) for mixed breast feeding, and 3.45% (0.53% to 6.35%) for no breast feeding). Antiretroviral therapy or >10 weeks prophylaxis negated this difference (MTCT 3.94%, 1.98% to 5.90%; 2.07%, 0.55% to 3.60% and 2.11%, 1.28% to 2.95%, respectively).
  
  
  CONCLUSIONS
  SA, a high-HIV-prevalence middle income country achieved <5% MTCT by 4-8 weeks post partum. The long-term impact on PMTCT on HIV-free survival needs urgent assessment.
authors.affiliation: Health Systems Research Unit, Medical Research Council, Cape Town, South Africa Department of Paediatrics and Child Health, Kalafong Hospital, University of Pretoria, Hatfield, Pretoria, South Africa.
authors.forename: Ameena E
authors.initials: AE
authors.lastname: Goga
authors.affiliation: Division of Global HIV/AIDS, Centers for Disease Control and Prevention, Center for Global Health, Atlanta, Georgia, USA.
authors.forename: Thu-Ha
authors.initials: TH
authors.lastname: Dinh
authors.affiliation: School of Public Health, University of the Western Cape, Bellville, South Africa UNICEF New York, New York, USA.
authors.forename: Debra J
authors.initials: DJ
authors.lastname: Jackson
authors.affiliation: Biostatistics Unit, Medical Research Council, Cape Town, South Africa School of Public Health and Family Medicine, Cape Town, South Africa.
authors.forename: Carl
authors.initials: C
authors.lastname: Lombard
authors.affiliation: Division of HIV/AID Prevention, Centers for Disease Control and Prevention, National Center for HIV, Hepatitis, STD, and Tuberculosis Prevention, Atlanta, Georgia, USA.
authors.forename: Kevin P
authors.identifier: http://orcid.org/0000-0002-7562-7647
authors.initials: KP
authors.lastname: Delaney
authors.affiliation: Division of National Health Laboratory Services, National institute of Communicable Diseases, Sandringham, Johannesburg, South Africa.
authors.forename: Adrian
authors.initials: A
authors.lastname: Puren
authors.affiliation: Division of National Health Laboratory Services, National institute of Communicable Diseases, Sandringham, Johannesburg, South Africa Department of Paediatrics and Child Health, Faculty of Health Sciences, University of Witwatersrand, Parktown, Johannesburg, South Africa.
authors.forename: Gayle
authors.initials: G
authors.lastname: Sherman
authors.affiliation: Health Systems Research Unit, Medical Research Council, Cape Town, South Africa.
authors.forename: Selamawit
authors.initials: S
authors.lastname: Woldesenbet
authors.affiliation: Health Systems Research Unit, Medical Research Council, Cape Town, South Africa.
authors.forename: Vundli
authors.initials: V
authors.lastname: Ramokolo
authors.affiliation: Affiliated with UNICEF South Africa at the time of the study. Currently affiliated to Elma Philanthropies, New York USA, Pretoria, South Africa.
authors.forename: Siobhan
authors.initials: S
authors.lastname: Crowley
authors.affiliation: Health Systems Research Unit, Medical Research Council, Cape Town, South Africa School of Public Health, University of the Western Cape, Bellville, South Africa School of Public Health, University of the Witwatersrand, Johannesburg South Africa.
authors.forename: Tanya
authors.initials: T
authors.lastname: Doherty
authors.affiliation: UNICEF New York, New York, USA.
authors.forename: Mickey
authors.initials: M
authors.lastname: Chopra
authors.affiliation: World Health Organization, Geneva, Switzerland.
authors.forename: Nathan
authors.initials: N
authors.lastname: Shaffer
authors.affiliation: National Department of Health, Pretoria, South Africa.
authors.forename: Yogan
authors.initials: Y
authors.lastname: Pillay
mesh_terms: D019380:Anti-HIV Agents / Q000627:therapeutic use*; D001942:Breast Feeding / Q000009:adverse effects* / Q000706:statistics & numerical data; D005260:Female; D015658:HIV Infections / Q000453:epidemiology / Q000517:prevention & control* / Q000635:transmission; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D018445:Infectious Disease Transmission, Vertical / Q000517:prevention & control* / Q000706:statistics & numerical data; D009035:Mothers; D009313:National Health Programs / Q000458:organization & administration / Q000706:statistics & numerical data*; D017063:Outcome Assessment, Health Care / Q000379:methods; D011247:Pregnancy; D011251:Pregnancy Complications, Infectious / Q000188:drug therapy*; D015995:Prevalence; D013019:South Africa / Q000453:epidemiology
chemical_list: D019380:Anti-HIV Agents
keywords: CHILD HEALTH; HIV; PERINATAL EPIDEMIOLOGY; PUBLIC HEALTH; SURVEILLANCE