title: Structural Level Differences in the Mother-to-Child HIV Transmission Rate in South Africa: A Multilevel Assessment of Individual-, Health Facility-, and Provincial-Level Predictors of Infant HIV Transmission.
abstract: In 2010, South Africa reported an early mother-to-child transmission (MTCT) rate of 3.5% at 4-8 weeks postpartum. Provincial early MTCT rates ranged from 1.4% [95% confidence interval (CI): 0.1 to 3.4] to 5.9% (95% CI: 3.8 to 8.0). We sought to determine reasons for these geographic differences in MTCT rates.
  
  
  
  This study used multilevel modeling using 2010 South African prevention of mother-to-child transmission (PMTCT) evaluation (SAPMTCTE) data from 530 facilities. Interview data and blood samples of infants were collected from 3085 mother-infant pairs at 4-8 weeks postpartum. Facility-level data on human resources, referral systems, linkages to care, and record keeping were collected through facility staff interviews. Provincial level data were gathered from publicly available data (eg, health professionals per 10,000 population) or aggregated at province-level from the SAPMTCTE (PMTCT maternal-infant antiretroviral (ARV) coverage). Variance partition coefficients and odds ratios (for provincial facility- and individual-level factors influencing MTCT) from multilevel modeling are reported.
  
  
  
  The provincial- (5.0%) and facility-level (1.4%) variance partition coefficients showed no substantive geographic variation in early MTCT. In multivariable analysis accounting for the multilevel nature of the data, the following were associated with early MTCT: individual-level-low maternal-infant ARV uptake [adjusted odds ratio (AOR) = 2.5, 95% CI: 1.7 to 3.5], mixed breastfeeding (AOR = 1.9, 95% CI: 1.3 to 2.9) and maternal age <20 years (AOR 1.8, 95% CI: 1.1 to 3.0); facility-level-insufficient (≤2) health care-personnel for HIV-testing services (AOR = 1.8, 95% CI: 1.1 to 3.0); provincial-level PMTCT ARV (maternal-infant) coverage lower than 80% (AOR = 1.4, 95% CI: 1.1 to 1.9), and number of health professionals per 10,000 population (AOR = 0.99, 95% CI: 0.98 to 0.99).
  
  
  
  There was no substantial province-/facility-level MTCT difference. This could be due to good overall performance in reducing early MTCT. Disparities in human resource allocation (including allocation of insufficient health care personnel for testing and care at facility level) and PMTCT coverage influenced overall PMTCT programme performance. These are long-standing systemic problems that impact quality of care.
authors.affiliation: *Health Systems Research Unit, South African Medical Research Council, Cape Town; †US Centers for Disease Control and Prevention, Center for Global Health, Division of Global HIV/AIDS, Pretoria, South Africa; ‡School of Public Health, University of the Western Cape, Cape Town, South Africa; §UNICEF, Knowledge Management and Implementation Research Unit, New York, NY; ‖Biostatistics Unit, South African Medical Research Council, Cape Town; ¶School of Public Health and Family Medicine, University of Cape Town, South Africa; #US Centers for Disease Control and Prevention, Center for Global Health, Division of Global HIV/AIDS, Atlanta, Georgia, US; **School of Public Health, University of the Witwatersrand, Johannesburg, South Africa; ††Centre for HIV and STI, 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; §§National Department of Health, Pretoria, South Africa; ‖‖Department of Paediatrics, University of Pretoria, Pretoria, South Africa; and ***Health Systems Research Unit, South African Medical Research Council, Pretoria.
authors.forename: Selamawit A
authors.initials: SA
authors.lastname: Woldesenbet
authors.forename: Debra J
authors.initials: DJ
authors.lastname: Jackson
authors.forename: C J
authors.initials: CJ
authors.lastname: Lombard
authors.forename: Thu-Ha
authors.initials: TH
authors.lastname: Dinh
authors.forename: Vundli
authors.initials: V
authors.lastname: Ramokolo
authors.forename: Tanya
authors.initials: T
authors.lastname: Doherty
authors.forename: Gayle G
authors.initials: GG
authors.lastname: Sherman
authors.forename: Yogan
authors.initials: Y
authors.lastname: Pillay
authors.forename: Ameena E
authors.initials: AE
authors.lastname: Goga
mesh_terms: D000328:Adult; D005260:Female; D015658:HIV Infections / Q000453:epidemiology / Q000635:transmission*; D006268:Health Facilities; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D018445:Infectious Disease Transmission, Vertical; D007407:Interviews as Topic; D008297:Male; D011787:Quality of Health Care; D018570:Risk Assessment; D013019:South Africa / Q000453:epidemiology; D019371:Topography, Medical; D055815:Young Adult