title: Population-level effectiveness of PMTCT Option A on early mother-to-child (MTCT) transmission of HIV in South Africa: implications for eliminating MTCT.
abstract: Eliminating mother-to-child transmission of HIV (EMTCT), defined as ≤50 infant HIV infections per 100 000 live births, is a global priority. Since 2011 policies to prevent mother-to-child transmission of HIV (PMTCT) shifted from maternal antiretroviral (ARV) treatment or prophylaxis contingent on CD4 cell count to lifelong maternal ARV treatment (cART). We sought to measure progress with early (4-8 weeks postpartum) MTCT prevention and elimination, 2011-2013, at national and sub-national levels in South Africa, a high antenatal HIV prevalence setting ( ≈ 29%), where early MTCT was 3.5% in 2010.
  
  
  
  Two surveys were conducted (August 2011-March 2012 and October 2012-May 2013), in 580 health facilities, randomly selected after two-stage probability proportional to size sampling of facilities (the primary sampling unit), to provide valid national and sub-national-(provincial)-level estimates. Data collectors interviewed caregivers of eligible infants, reviewed patient-held charts, and collected infant dried blood spots (iDBS). Confirmed positive HIV enzyme immunoassay (EIA) and positive total HIV nucleic acid polymerase chain reaction (PCR) indicated infant HIV exposure or infection, respectively. Weighted survey analysis was conducted for each survey and for the pooled data.
  
  
  
  National data from 10 106 and 9120 participants were analyzed (2011-12 and 2012-13 surveys respectively). Infant HIV exposure was 32.2% (95% confidence interval (CI) 30.7-33.6%), in 2011-12 and 33.1% (95% CI 31.8-34.4%), provincial range of 22.1-43.6% in 2012-13. MTCT was 2.7% (95% CI 2.1%-3.2%) in 2011-12 and 2.6% (95% CI 2.0-3.2%), provincial range of 1.9-5.4% in 2012-13. HIV-infected ARV-exposed mothers had significantly lower unadjusted early MTCT (2.0% [2011-12: 1.6-2.5%; 2012-13:1.5-2.6%]) compared to HIV-infected ARV-naive mothers [10.2% in 2011-12 (6.5-13.8%); 9.2% in 2012-13 (5.6-12.7%)]. Pooled analyses demonstrated significantly lower early MTCT among exclusive breastfeeding (EBF) mothers receiving >10 weeks ARV prophylaxis or cART compared with EBF and no ARVs: (2.2% [95% CI 1.25-3.09%] vs 12.2% [95% CI 4.7-19.6%], respectively); among HIV-infected ARV-exposed mothers, 24.9% (95% CI 23.5-26.3%) initiated cART during or before the first trimester, and their early MTCT was 1.2% (95% CI 0.6-1.7%). Extrapolating these data, assuming 32% EIA positivity and 2.6% or 1.2% MTCT, 832 and 384 infants per 100 000 live births were HIV infected, respectively.
  
  
  
  Although we demonstrate sustained national-level PMTCT impact in a high HIV prevalence setting, results are far-removed from EMTCT targets. Reducing maternal HIV prevalence and treating all maternal HIV infection early are critical for further progress.
authors.affiliation: Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa; Department of Paediatrics, University of Pretoria, Pretoria, South Africa.
authors.forename: Ameena E
authors.initials: AE
authors.lastname: Goga
authors.affiliation: Centers for Disease Control and Prevention, Center for Global Health, Division of Global HIV and Tuberculosis, Atlanta, GA, USA.
authors.forename: Thu-Ha
authors.initials: TH
authors.lastname: Dinh
authors.affiliation: School of Public Health, University of the Western Cape, Cape Town, South Africa; UNICEF, New York, NY, USA.
authors.forename: Debra J
authors.initials: DJ
authors.lastname: Jackson
authors.affiliation: Biostatistics Unit, South African Medical Research Council, Cape Town, South Africa; School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa.
authors.forename: Carl J
authors.initials: CJ
authors.lastname: Lombard
authors.affiliation: Centre for HIV and STI, National Institute of Communicable Diseases, Johannesburg, South Africa; Division of Virology and Communicable Diseases, School of Pathology, University of the Witwatersrand Medical School, Johannesburg, South Africa.
authors.forename: Adrian
authors.initials: A
authors.lastname: Puren
authors.affiliation: Centre for HIV and STI, National Institute of Communicable Diseases, Johannesburg, South Africa; Department of Paediatrics and Child Health, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa.
authors.forename: Gayle
authors.initials: G
authors.lastname: Sherman
authors.affiliation: Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa.
authors.forename: Vundli
authors.initials: V
authors.lastname: Ramokolo
authors.affiliation: Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa.
authors.forename: Selamawit
authors.initials: S
authors.lastname: Woldesenbet
authors.affiliation: Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa; School of Public Health, University of the Western Cape, Cape Town, South Africa; Wits School of Public Health, University of the Witwatersrand, Parktown, South Africa.
authors.forename: Tanya
authors.initials: T
authors.lastname: Doherty
authors.affiliation: Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa.
authors.forename: Nobuntu
authors.initials: N
authors.lastname: Noveve
authors.affiliation: Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa.
authors.forename: Vuyolwethu
authors.initials: V
authors.lastname: Magasana
authors.affiliation: Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa.
authors.forename: Yagespari
authors.initials: Y
authors.lastname: Singh
authors.affiliation: Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa.
authors.forename: Trisha
authors.initials: T
authors.lastname: Ramraj
authors.affiliation: UNICEF, Pretoria, South Africa.
authors.forename: Sanjana
authors.initials: S
authors.lastname: Bhardwaj
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; D018791:CD4 Lymphocyte Count; D005260:Female; D015658:HIV Infections / Q000188:drug therapy / Q000635:transmission*; D006306:Health Surveys; D006801:Humans; D007223:Infant; D018445:Infectious Disease Transmission, Vertical / Q000517:prevention & control*; D009035:Mothers; D049590:Postpartum Period; D011247:Pregnancy; D011251:Pregnancy Complications, Infectious; D015995:Prevalence; D013019:South Africa
chemical_list: D019380:Anti-HIV Agents