title: Missed Opportunities along the Prevention of Mother-to-Child Transmission Services Cascade in South Africa: Uptake, Determinants, and Attributable Risk (the SAPMTCTE).
abstract: OBJECTIVE
  We examined uptake of prevention of mother-to-child HIV transmission (PMTCT) services, predictors of missed opportunities, and infant HIV transmission attributable to missed opportunities along the PMTCT cascade across South Africa.
  
  
  METHODS
  A cross-sectional survey was conducted among 4-8 week old infants receiving first immunisations in 580 nationally representative public health facilities in 2010. This included maternal interviews and testing infants' dried blood spots for HIV. A weighted analysis was performed to assess uptake of antenatal and perinatal PMTCT services along the PMTCT cascade (namely: maternal HIV testing, CD4 count test/result, and receiving maternal and infant antiretroviral treatment) and predictors of dropout. The population attributable fraction associated with dropouts at each service point are estimated.
  
  
  RESULTS
  Of 9,803 mothers included, 31.7% were HIV-positive as identified by reactive infant antibody tests. Of these 80.4% received some form of maternal and infant antiretroviral treatment. More than a third (34.9%) of mothers dropped out from one or more steps in the PMTCT service cascade. In a multivariable analysis, the following characteristics were associated with increased dropout from the PMTCT cascade: adolescent (<20 years) mothers, low socioeconomic score, low education level, primiparous mothers, delayed first antenatal visit, homebirth, and non-disclosure of HIV status. Adolescent mothers were twice (adjusted odds ratio: 2.2, 95% confidence interval: 1.5-3.3) as likely to be unaware of their HIV-positive status and had a significantly higher rate (85.2%) of unplanned pregnancies compared to adults aged ≥20 years (55.5%, p = 0.0001). A third (33.8%) of infant HIV infections were attributable to dropout in one or more steps in the cascade.
  
  
  CONCLUSIONS
  A third of transmissions attributable to missed opportunities of PMTCT services can be prevented by optimizing the uptake of PMTCT services. Identified risk factors for low PMTCT service uptake should be addressed through health facility and community-level interventions, including raising awareness, promoting women education, adolescent focused interventions, and strengthening linkages/referral-system between communities and health facilities.
authors.affiliation: Health Systems Research Unit, Medical Research Council, Cape Town, South Africa.
authors.forename: Selamawit
authors.initials: S
authors.lastname: Woldesenbet
authors.affiliation: School of Public Health, University of the Western Cape, Cape Town, South Africa; United Nations Children's Fund, New York, United States of America.
authors.forename: Debra
authors.initials: D
authors.lastname: Jackson
authors.affiliation: Health Systems Research Unit, Medical Research Council, Cape Town, South Africa.
authors.forename: Carl
authors.initials: C
authors.lastname: Lombard
authors.affiliation: Centers for Disease Control and Prevention, Center for Global Health, Division of Global HIV/AIDS, Atlanta, Georgia, United States of America.
authors.forename: Thu-Ha
authors.initials: TH
authors.lastname: Dinh
authors.affiliation: National Institute for Communicable Diseases of the National Health Laboratory Services, Johannesburg, South Africa; Division of Virology and Communicable Diseases, Faculty of Health Science, University of the Witwatersrand, Johannesburg, South Africa.
authors.forename: Adrian
authors.initials: A
authors.lastname: Puren
authors.affiliation: National Institute for Communicable Diseases of the National Health Laboratory Services, Johannesburg, South Africa; Department of Paediatrics and Child Health, Faculty of Health Sciences, University of the Witwatersrand, 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: Vundli
authors.initials: V
authors.lastname: Ramokolo
authors.affiliation: Health Systems Research Unit, Medical Research Council, Cape Town, South Africa; School of Public Health, University of the Western Cape, Cape Town, South Africa; School of Public Health, University of the Witwatersrand, Johannesburg, South Africa.
authors.forename: Tanya
authors.initials: T
authors.lastname: Doherty
authors.affiliation: Centers for Disease Control and Prevention, Center for Global Health, Division of Global HIV/AIDS, Pretoria, South Africa.
authors.forename: Mary
authors.initials: M
authors.lastname: Mogashoa
authors.affiliation: United Nations Children's Fund, Pretoria, South Africa.
authors.forename: Sanjana
authors.initials: S
authors.lastname: Bhardwaj
authors.affiliation: School of Public Health, University of the Western Cape, Cape Town, South Africa; United Nations Children's Fund, New York, United States of America.
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
authors.affiliation: Department of Paediatrics and Child Health, University of Pretoria, Pretoria, South Africa; Health Systems Research Unit, Medical Research Council, Pretoria, South Africa.
authors.forename: Ameena
authors.initials: A
authors.lastname: Goga
mesh_terms: D015492:AIDS Serodiagnosis / Q000706:statistics & numerical data; D000293:Adolescent; D000328:Adult; D019380:Anti-HIV Agents / Q000627:therapeutic use; D018791:CD4 Lymphocyte Count / Q000706:statistics & numerical data; D003430:Cross-Sectional Studies; D003906:Developing Countries; D005260:Female; D015658:HIV Infections / Q000151:congenital / Q000175:diagnosis / Q000188:drug therapy / Q000453:epidemiology / Q000517:prevention & control* / Q000635:transmission; D006700:Home Childbirth / Q000706:statistics & numerical data; D006801:Humans; D007231:Infant, Newborn; D018445:Infectious Disease Transmission, Vertical / Q000517:prevention & control*; D008423:Maternal Age; D008427:Maternal Health Services / Q000458:organization & administration / Q000706:statistics & numerical data*; D019829:Nevirapine / Q000627:therapeutic use; D010298:Parity; D010352:Patient Dropouts; D011247:Pregnancy; D011251:Pregnancy Complications, Infectious / Q000175:diagnosis / Q000188:drug therapy / Q000453:epidemiology; D011253:Pregnancy in Adolescence; D011295:Prenatal Care / Q000706:statistics & numerical data*; D012307:Risk Factors; D012959:Socioeconomic Factors; D013019:South Africa / Q000453:epidemiology; D015215:Zidovudine / Q000627:therapeutic use
chemical_list: D019380:Anti-HIV Agents; D015215:Zidovudine; D019829:Nevirapine