title: Implementation and Operational Research: Reconstructing the PMTCT Cascade Using Cross-sectional Household Survey Data: The PEARL Study.
abstract: BACKGROUND
  Given the ambitious targets to reduce pediatric AIDS worldwide, ongoing assessment of programs to prevent mother-to-child HIV transmission (PMTCT) is critical. The concept of a "PMTCT cascade" has been used widely to identify bottlenecks in program implementation; however, most efforts to reconstruct the cascade have relied on facility-based approaches that may limit external validity.
  
  
  METHODS
  We analyzed data from the PEARL household survey, which measured PMTCT effectiveness in 26 communities across Zambia, South Africa, Cote d'Ivoire, and Cameroon. We recruited women who reported a delivery in the past 2 years. Among mothers confirmed to be HIV infected at the time of survey, we reconstructed the PMTCT cascade with self-reported participant information. We also analyzed data about the child's vital status; for those still alive, HIV testing was performed by DNA polymerase chain reaction testing.
  
  
  RESULTS
  Of the 976 eligible women, only 355 (36%) completed every step of the PMTCT cascade. Among the 621 mother-child pairs who did not, 22 (4%) reported never seeking antenatal care, 103 (17%) were not tested for HIV during pregnancy, 395 (64%) reported testing but never received their HIV-positive result, 48 (8%) did not receive maternal antiretroviral prophylaxis, and 53 (9%) did not receive infant antiretroviral prophylaxis. The lowest prevalence of infant HIV infection or death was observed in those completing the cascade (10%, 95% confidence interval: 7% to 12%).
  
  
  CONCLUSIONS
  Future efforts to measure population PMTCT impact should incorporate dimensions explored in the PEARL study-including HIV testing of HIV-exposed children in household surveys-to better understand program effectiveness.
authors.affiliation: *University of North Carolina at Chapel Hill, Chapel Hill, NC; †Centre for Infectious Disease Research in Zambia, Lusaka, Zambia; ‡Cameroon Baptist Health Convention Health Board, Bamenda, Cameroon; §University of Cape Town, Cape Town, South Africa; ‖INSERM, Centre INSERM U897, Bordeaux, France; ¶University of Bordeaux, ISPED, Centre INSERM U897, Bordeaux, France; #Programme PAC-CI, Abidjan, Cote d'Ivoire; **Zambian Ministry of Health, Lusaka, Zambia; and ††World Health Organization, Geneva, Switzerland.
authors.forename: Benjamin H
authors.initials: BH
authors.lastname: Chi
authors.forename: Pius M
authors.initials: PM
authors.lastname: Tih
authors.forename: Arianna
authors.initials: A
authors.lastname: Zanolini
authors.forename: Kathryn
authors.initials: K
authors.lastname: Stinson
authors.forename: Didier K
authors.initials: DK
authors.lastname: Ekouevi
authors.forename: David
authors.initials: D
authors.lastname: Coetzee
authors.forename: Thomas K
authors.initials: TK
authors.lastname: Welty
authors.forename: Maximillian
authors.initials: M
authors.lastname: Bweupe
authors.forename: Nathan
authors.initials: N
authors.lastname: Shaffer
authors.forename: Francois
authors.initials: F
authors.lastname: Dabis
authors.forename: Elizabeth M
authors.initials: EM
authors.lastname: Stringer
authors.forename: Jeffrey S A
authors.initials: JS
authors.lastname: Stringer
mesh_terms: D000328:Adult; D000349:Africa; D002675:Child, Preschool; D003140:Communicable Disease Control / Q000379:methods* / Q000458:organization & administration; D003430:Cross-Sectional Studies; D005191:Family Characteristics; D005260:Female; D015658:HIV Infections / Q000517:prevention & control* / Q000635:transmission*; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D018445:Infectious Disease Transmission, Vertical / Q000517:prevention & control*; D008297:Male; D011247:Pregnancy; D055815:Young Adult