https://orcid.org/0000-0001-6435-8405
Figures
Abstract
Background
Prevention of mother-to-child transmission (PMTCT) of HIV service is conceptualized as a series of cascades that begins with all pregnant women and ends with the detection of a final HIV status in HIV-exposed infants (HEIs). A low rate of cascade completion by mothers’ results in an increased risk of HIV transmission to their infants. Therefore, this review aimed to understand the uptake and determinants of key PMTCT services cascades in East Africa.
Methods
We searched CINAHL, EMBASE, MEDLINE, Scopus, and AIM databases using a predetermined search strategy to identify studies published from January 2012 through to March 2022 on the uptake and determinants of PMTCT of HIV services. The quality of the included studies was assessed using the Mixed Methods Appraisal Tool. A random-effects model was used to obtain pooled estimates of (i) maternal HIV testing (ii) maternal ART initiation, (iii) infant ARV prophylaxis and (iv) early infant diagnosis (EID). Factors from quantitative studies were reviewed using a coding template based on the domains of the Andersen model (i.e., environmental, predisposing, enabling and need factors) and qualitative studies were reviewed using a thematic synthesis approach.
Results
The searches yielded 2231 articles and we systematically reduced to 52 included studies. Forty quantitative, eight qualitative, and four mixed methods papers were located containing evidence on the uptake and determinants of PMTCT services. The pooled proportions of maternal HIV test and ART uptake in East Africa were 82.6% (95% CI: 75.6–88.0%) and 88.3% (95% CI: 78.5–93.9%). Similarly, the pooled estimates of infant ARV prophylaxis and EID uptake were 84.9% (95% CI: 80.7–88.3%) and 68.7% (95% CI: 57.6–78.0) respectively. Key factors identified were the place of residence, stigma, the age of women, the educational status of both parents, marital status, socioeconomic status, Knowledge about HIV/PMTCT, access to healthcare facilities, attitudes/perceived benefits towards PMTCT services, prior use of maternal and child health (MCH) services, and healthcare-related factors like resource scarcity and insufficient follow-up supervision.
Conclusion
Most of the identified factors were modifiable and should be considered when formulating policies and planning interventions. Hence, promoting women’s education and economic empowerment, strengthening staff supervision, improving access to and integration with MCH services, and actively involving the community to reduce stigma are suggested. Engaging community health workers and expert mothers can also help to share the workload of healthcare providers because of the human resource shortage.
Citation: Astawesegn FH, Mannan H, Stulz V, Conroy E (2024) Understanding the uptake and determinants of prevention of mother-to-child transmission of HIV services in East Africa: Mixed methods systematic review and meta-analysis. PLoS ONE 19(4): e0300606. https://doi.org/10.1371/journal.pone.0300606
Editor: Hamufare Dumisani Dumisani Mugauri, University of Zimbabwe Faculty of Medicine: University of Zimbabwe College of Health Sciences, ZIMBABWE
Received: February 27, 2023; Accepted: February 28, 2024; Published: April 18, 2024
Copyright: © 2024 Astawesegn et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: All relevant data are within the paper and its Supporting information files.
Funding: The author(s) received no specific funding for this work.
Competing interests: The authors have declared that no competing interests exist.
Abbreviations: AIDS, Acquired Immune Deficiency Syndrome; ANC, Antenatal care; AOR, Adjusted Odds Ratio; ART, Antiretroviral therapy; ARV, Antiretrovirals; CI, Confidence Interval; DBS, Dry blood spot; EID, Early Infant HIV Diagnosis; HCWs, Health Care Workers; HEIs, HIV Exposed Infants; HIV, Human Immunodeficiency Virus; MCH, Maternal and child health; MMAT, Mixed Methods Appraisal Tool; MTCT, Mother-To-Child Transmission of HIV; PITC, Provider Initiated HIV Testing and Counselling; PMTCT, Prevention of mother-to-child transmission of HIV; SES, socioeconomic status; SSA, Sub-Saharan Africa; UNAIDS, The United Nations Programme on HIV and AIDS
Background
The provision of PMTCT services plays a crucial role in the global fight against new HIV infections and to ensure an HIV/AIDS-free generation. For the last two decades, the implementation of the PMTCT program has substantially decreased the number of HIV-infected babies born to HIV-positive mothers worldwide. This progress has been achieved through the implementation of improved HIV diagnosis, care, and treatment services [1] with technical and financial support from international health organizations such as the world health organization (WHO) [2] and integration of maternal, newborn and child health services [3,4].
Despite considerable progress in the PMTCT program, HIV remains a disease of public health importance in sub-Saharan Africa (SSA) [5] where more than two-thirds of the world’s HIV-infected children live [6]. The current global efforts in the fight against human immunodeficiency virus (HIV) have been focused on the virtual elimination of child HIV infection for resource-limited settings with targets of MTCT rate < 5% in breastfeeding countries and < 2% in non-breastfeeding countries [7–10]. Hence, World Health Organization endorsed lifelong antiretroviral therapy for pregnant and breastfeeding women diagnosed with HIV infection and provision of nevirapine to all HIV-exposed infants for 4–6 weeks (Option B+ approach) to prevent mother-to-child HIV transmission [11].
Effectively implemented PMTCT service can reduce the risk of vertical HIV transmission from 15–45% to less than 1% [12–14]. If PMTCT programs are going to be effective, HIV-infected pregnant women must be able to navigate through complex and sequential steps called the PMTCT cascade. It refers to the sequence of steps a mother with HIV takes from diagnosis through receiving appropriate care/treatment for themselves and their newborns [15–17]. It begins with all pregnant women and ends with exposed infants’ HIV testing [17], and includes (but is not limited to) (1) maternal/prenatal HIV testing, (2) initiating antiretroviral therapy (ART) treatment for women identified as HIV positive as early as possible during pregnancy, birth, and breastfeeding, (3) ARV prophylaxis for HIV-exposed infants (HEI) within hours of birth; and (4) early infant HIV diagnosis (EID)/testing of infants at six weeks [18]. Thus, successful navigation of pregnant women along the PMTCT cascade is crucial and at each step, 95% uptake is required to effectively reduce MTCT of HIV and virtually eliminate MTCT by 2030 [5,11].
However, mother-to-child transmission (MTCT) of HIV has remained a challenge because of the cumulative dropout rate of women and their infants at each step along these cascades [19–21]. A review done in SSA showed that 94% of pregnant women were tested for HIV, 70% of those who were HIV-positive initiated ARV/ART, and 64% of the HEIs were tested for HIV at six weeks/ had an early diagnosis [22]. Health systems are challenged to support women’s transfer along these various stages of care resulting in cumulative losses of pregnant women from the PMTCT program, with an increased risk of HIV transmission to their infants [23].
Studies worldwide have reported factors that have an association with maternal HIV test and ART services uptake, including place of residence [24–26], education level [24,26–28], maternal age [26,27], knowledge of HIV/AIDS and PMTCT [27,29,30], SES [24,26,31,32], lack of privacy and confidentiality [33], women’s decision-making capacity [29,34,35], prenatal care [26,31], fear of disclosure and stigma [30,36–39]. Likewise, factors such as distance from a health facility [40], partner/family support [39], denial of HIV status [41], shortages of resources [41,42], lack of knowledge [43], feelings of guilt [43], children of known HIV positive fathers [44] and maternal receipt of ART/HAART [40,43,45] have also been reported to affect infant ARV prophylaxis and EID services uptake.
In East Africa, the uptake, and determinants of key PMTCT services cascades have not been collectively and systematically analysed and remain poorly understood. Therefore, this mixed-methods systematic review and meta-analysis aims to understand the uptake and determinants of (i) maternal HIV testing among pregnant/postpartum women, (ii) ART initiation among HIV-infected pregnant/postpartum women, (iii) initiation of ARV prophylaxis for HEIs, and (iv) EID/HIV test at six weeks of age/ in East Africa. With the current global aim of ending the HIV epidemic by 2030, providing such vital information would help policymakers design better strategies and implement targeted interventions in East Africa.
Methods
This mixed-method systematic review and meta-analysis was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines [46] [S1 Table].
Inclusion criteria
This review considered quantitative, qualitative, and mixed methods studies. Studies with a quantitative study design (such as prospective cohort, retrospective cohort, case-control, or cross-sectional study) and a qualitative design (such as phenomenology, and grounded theory) were considered in the study. For the quantitative component of the review, the exposures of interest were factors that were associated with the key PMTCT cascade uptake. An exposure factor was identified when a study reported a statistically significant association between the exposure (independent) and the outcome (dependent) variable. In the qualitative component of the review, our interests were mothers’ and providers’ experiences and/or perceptions of the factors that affect PMTCT cascade uptake. Only studies conducted in East African countries (Burundi, Djibouti, Eritrea, Ethiopia, Kenya, Mauritius, Mayotte, Malawi, Mozambique, Réunion, Rwanda, Somalia, Sudan, South Sudan, United Republic of Tanzania, Uganda, Zambia, Zimbabwe, Madagascar, Seychelles, and Comoros) were taken into consideration [47,48]. Studies involving pregnant, postnatal, and breastfeeding mothers and/or providers of PMTCT services from East Africa were considered. Only full-text available studies, published in English, and published in a peer-reviewed journal from 01/01/2012 to 30/05/2022 were considered (this reflects the period after which option B+ strategy was introduced in East Africa by Malawi, the first country to do so [11,49]).
Information sources and search strategies
Searches were performed in five databases PubMed, Scopus, EMBASE, African Index Medicus (AIM), and CINAHL. The search strategy used four search concepts including the following keywords: Search #1: “pregnant women", “HIV positive mother”, "PMTCT mother", "Lactating mother", "Breast Feeding", "breastfeeding mother", "HIV exposed infant", "HIV exposed child”. Search #2: "option b+", "b plus", "lifelong antiretroviral therapy", "universal antiretroviral therapy", PMTCT, "prevention mother-to-child transmission", "prevention mother to child transmission", "elimination of mother-to-child transmission", "elimination of mother to child transmission", "prevention of vertical Transmission", "prevention of parent to child transmission", "highly active Antiretroviral Therapy", HAART, "antiretroviral therap*", ART, "Triple Therapy", ARV, "antiretroviral", "anti-retroviral", "HIV test*", "opt-out HIV test*", "counselling and testing", VCT, "early infant diagnosis", "infant testing", "infant HIV testing". Search #3: uptake, utilization, factor*, correlates, determinant*, predicator*, facilitator*, barrier*. Search #4: "East Africa*", Burundi*, Djibouti*, Eritrea*, Ethiopia*, Kenya*, Mauritius*, Mayotte*, Malawi*, Mozambique*, Reunion*, Rwanda*, Somalia*, Sudan*, "South Sudan*", Tanzania*, Uganda*, Zambia*, Zimbabwe*, Madagascar*, Seychelles*, Comoros*. The four search concepts, their synonyms, and truncations by the use of the asterisk ‘*’ where appropriate were combined using the Boolean operators ‘OR’, within concepts, and ‘AND’ to combine concepts to develop the final search strategy. The detailed search strategy can be found in S2 Table.
Study selection and data extraction
All identified citations were collected and uploaded into the reference management software EndNote version X9, and duplicates were removed. Articles were further screened based on titles and abstracts followed by full-text assessment by two independent reviewers (F.H and T.Y). Any disagreements between the reviewers at each stage of the selection process were resolved through discussion. Using a structured table, the following information was extracted from each eligible article: (i) country; (ii) year of study; (iii) year of publication; (iv) study setting, (v) specific details about the participants (pregnant women, postpartum women, HEIs and PMTCT service providers); (vi) study methods/design (vii) sample size (viii) aim of the study and (ix) uptake and significant determinants or the phenomena of interest relevant to the review objective for qualitative studies.
Assessment of methodological quality
The Mixed Methods Appraisal Tool (MMAT) version 2018 was used to evaluate the methodological quality of studies that met the inclusion criteria [50]. This tool has been utilized by various studies [51–53] and is designed to enable systematic reviewers to evaluate the methodological quality of different study designs (quantitative, qualitative, and mixed methods). The studies were categorized into three (high, moderate, and low) based on the number of criteria out of seven that were met (quality scores). Studies that scored 6 or more were considered high quality, studies that scored 3 to 5 were considered moderate quality, and studies that scored 2 or less were deemed low quality. Quality scores for each study are presented in S3 Table.
Data analysis and synthesis
Firstly, we used the I2 test statistic and its corresponding p-value to verify the heterogeneity among the studies that were included. A p-value of less than 0.05 was used as a threshold to determine whether or not heterogeneity was present [54]. We also used Egger’s and Begg’s tests, as well as a funnel plot, to evaluate publication bias among the studies. Funnel plots are scatter plots that illustrate the effect size estimates (on the x-axis) versus the standard errors of the effect size (on the y-axis), with the estimated average effect size represented by a vertical line. Then, a random effects model was used to estimate the pooled proportion of HIV testing, ART initiation, infant prophylaxis, and EID uptake, due to the heterogeneity observed between studies (p < 0.01%). Additionally, for each cascade, subgroup analysis was performed by year of publication, study settings and countries, using the random effects model.
Secondly, The JBI method for conducting a mixed-method systematic review (MMSR) was used to examine the factors that influenced the uptake of PMTCT cascades [55]. This method involves conducting a separate analysis of quantitative and qualitative data, and then integrating the findings from both forms of evidence. Because of wide variations in the measurement of variables that affect PMTCT service uptake, it was not practical to conduct a meta-analysis to assess the effect of each factor. Hence, we performed narrative synthesis after tabulating individual studies based on their unique characteristics. The quantitative data synthesis was guided by Andersen’s behavioural model i.e. community factors including health facility factors, predisposing factors, enabling factors and need factors including prior use services [56]. Therefore, significant factors across studies were matched to the appropriate category in the Andersen behavioural model. In this review, meta-analyses were carried out using R software version 4.2.1 to estimate PMTCT services uptake in East Africa.
Result
Study identification
A total of 2231 potentially relevant articles were retrieved from the literature search, with 1146 articles remaining after the deletion of duplicates. After title and abstract screening, 171 references were remained and included in the full-text screening. Finally, 52 studies were deemed eligible and included in this study (forty quantitative and eight qualitative and four mixed method articles) as illustrated with the PRISMA flow chart [Fig 1].
Characteristics of included studies on prevention of mother-to-child transmission of HIV (PMTCT) services cascade
The studies published between January 2012 and March 2022 were carried out in a range of East African countries; namely, Burundi [57], Comoros [57], Ethiopia [25,45,57–74], Kenya [57,75–78], Malawi [25,45,57–74,79], Mozambique [57,76–78,80], Rwanda [57], South Sudan [81], Tanzania [82,83], Uganda [39,57,84–87], Zambia [57,88–90], and Zimbabwe [57,91–96]. Studies conducted among eligible pregnant/postpartum women, infants and service providers were included in the analysis. Almost all the studies (44/52) were facility-based [23,25,39,45,58–62,64–74,76–89,91–93,95–101]. Furthermore, the study design varied across studies: cross-sectional studies (n = 28); prospective cohort (n = 2); retrospective cohort (n = 6), retrospective chart review (n = 4), qualitative studies (n = 8) and mixed methods studies (n = 4). The mixed methods studies included a mix of surveys, interviews, and focus groups. The study characteristics are summarized in Table 1.
Uptake of PMTCT of HIV services in East Africa
The pooled uptake for maternal HIV test, maternal ARV use, infant ARV prophylaxis and EID for the PMTCT of HIV in East Africa were estimated using a random effects model. Accordingly, the forest plots showed that the pooled uptake estimate was 82.69%; 95% CI: 75.62–88.03% for maternal HIV test [Fig 2]; 88.33% (95% CI: 78.59–93.98%) for maternal ART [Fig 3]; 84.98% (95% CI: 80.78–88.39%) for infant ARV prophylaxis [Fig 4] and 68.77% (95% CI: 57.63–78.09%) for EID [Fig 5].
Subgroup analysis
In this review, subgroup analysis was conducted for the country, study setting and year of publication. Accordingly, Malawi (98.8%) and Uganda (95.7%) had the highest proportion of women tested for HIV, while South Sudan (72%) and Ethiopia (75.5%) had the lowest proportion of women tested for HIV. The highest proportion of women who initiated ART was found in Mozambique (97.66%) followed by Malawi (95.76%), whereas the lowest proportion of women who initiated ART was found in Zambia (68.8%) followed by Zimbabwe (78.7%). Of the eight countries that had data on infant prophylaxis and EID uptake, Zimbabwe had the highest infant prophylaxis (91.9%) and EID uptake (85.6%).
Moreover, consistent maternal HIV testing was found across years, however, the highest (93.78%) and the lowest (73.7%) proportion of maternal ART uptake was found between the year 2012–2014 and 2015–2017 respectively. In all PMTCT cascades, studies that were conducted in the community had lower rates (77.9%, 95% CI: 69.7–84.3% for maternal HIV testing; 63.7%, 95% CI: 53.6–72.8% for maternal ART uptake, 62.8%, 95% CI: 60.1–65.3% for infant ARV prophylaxis) than studies that were conducted in the health facilities (84.7%, 95% CI:72.9–91.9% for maternal HIV testing, 91%, 95% CI:82.6–95.6% for maternal ART uptake, 86.8%,95% CI: 82.9–89.9% for infant ARV prophylaxis use) [S4 Table].
Publication bias
To examine publication bias, we visually inspected the funnel plot shown in S1 Fig. A symmetric funnel plot indicates the absence of publication bias; that is, studies are evenly distributed on either side of the average effect size, regardless of the size of the study’s sample. However, as shown in S1 Fig, the plots A to C are asymmetric. To test whether this asymmetry was statistically significant, we conducted Egger’s regression test, which was significant for infant ARV prophylaxis uptake (z = 1.5725, p = 0.001) but not for maternal HIV testing, maternal ARV uptake and EID (z = 0.4437, p = 0.6572 for maternal HIV testing, z = 1.3556, p = 0.1752 for maternal ARV uptake, z = -0.5671, p = 0.5706 for EID). Our further sensitivity analysis (i.e., trim-and-fill analysis) for infant prophylaxis did not reveal a significant influence on pooled uptake.
Reported factors associated with PMTCT of HIV services uptake in East Africa
Quantitative synthesis.
Table 2 shows the factors that the quantitative studies have found to be statistically significantly associated with maternal HIV test, maternal ARV, infant ARV prophylaxis, and EID uptake. Factors from quantitative studies were organized into four categories according to Andersen’s behavioural model: community and health care factor, predisposing factors, enabling factors, need and prior health service use factors [Table 2].
Community and health care factors: Six studies [25,57,58,63,66,103] showed the presence of an association between place residence and maternal HIV testing. However, two studies on maternal HIV testing [65,75] and three studies on EID [62,91,92] revealed the absence of statistical association with place of residence. Women who lived in a community where there was no/low stigmatized attitude toward people living with HIV/AIDS [25,58] were more likely to be HIV tested than those who lived in a community that stigmatized HIV-positive patients [63,75]. Two studies explicitly indicated an association between the quality of available HIV testing services and maternal HIV test uptake [65,95].
Predisposing factors: Eight studies reported the presence of an association [25,57,59,63,64,66,95,103] and three studies [65,70,75] reported the absence of an association between educational level and maternal HIV testing. Of the eight studies that showed the presence of association, seven studies reported more educated women were found to be HIV tested than non-educated women [25,57,59,63,64,95,103]. Similarly, for women who have educated partners [57,103] and exposure to media [57,103] the odds of HIV testing were higher. Furthermore, a study conducted in Tanzania showed the presence of a correlation between children’s age and marital status with EID [92].
Enabling factors: Factors under the enabling category included socioeconomic factors (for example, employment, higher monthly income and wealth index) [25,57–59,63,66,95,103], access to the PMTCT services [57,59,92], knowledge/awareness about HIV/PMTCT/MTCT [25,57,63–65,75,92], and presence of support groups [84]. Studies showed that higher SES was positively associated with HIV testing. For example, having a higher wealth or monthly income was positively related to taking HIV testing multiple times [57,63,103]. Moreover, occupation or employment was found to be correlated with maternal HIV testing in four studies [58,66,95,103]. Nevertheless, three studies indicated that there was no significant association between occupation or employment and maternal HIV testing [57,63,64]. Similarly, comprehensive knowledge about PMTCT is significantly associated with a higher rate of HIV testing [25,57,63,64,75]. Only one Ugandan study reported associations between social support and infant ARV prophylaxis uptake [84] and infants from mothers who are currently in a social support group were more likely to be HIV tested than their counterparts (AOR = 2.50) [84]. Nevertheless, women who have lower access to PMTCT services were less likely to use both maternal HIV testing and EID [57,59,92].
Need factors and prior health services use: Women who did not want to have more children were less likely to utilize maternal HIV testing [103]. However, women who had symptoms of sexually transmitted infections [95] and more ANC visits [64,65,95] were found to be more likely to use the HIV test service. Women who were on ART during pregnancy or at the time of the HIV PCR test and infants who had ARV prophylaxis at birth were positively associated with EID [45,76]. Likewise, factors such as ANC follow-up [62], birth at a government health facility [45], and maternal ART adherence [89] were found to be positively correlated with EID. However, having an HIV-positive child resulted in lower odds of EID service uptake [92].
Qualitative synthesis.
Qualitative studies and qualitative aspects of mixed methods studies were thematically analysed. Themes such as health care factors, access to services, partner-related factors, acceptance and disclosure of HIV status, stigma and misconception, knowledge and couples’ differences in HIV status, disease progression, fear related to ART and good health were generated [Table 3].
Health care factors: Most women and providers believed that health system factors were the most common challenges across PMTCT cascades. This review illustrated how lack of privacy [94,96–98], shortage of staff and HIV test kits [98], negative attitude/behaviour of health workers [39,84], lack of age-specific service [39], long waiting times [39] and lack of supervision [97] were often responsible for low PMTCT services uptake.
Lack of privacy and counselling were crucial factors, particularly during maternal HIV testing and ART initiation [94,96,98], Furthermore, the shortage of healthcare workers (HCWs) in comparison to the number of clients and the irregular availability of HIV test kits were both reported as a challenge [39]. Providers also commonly reported that lack of follow-up supervision for nurses working in the ART clinics, antenatal clinics (ANCs) and maternity wards, as well as for laboratory and health surveillance assistants who provide EID and treatment services as a challenge [97]. Likewise, the absence of a reliable transport system for dried blood spot (DBS) [97] to perform DNA PCR tests for EID at central reference laboratories was also identified as a challenge. It requires specimen transport over long distances from health centres to the central labs where samples are analysed. The long waiting time between DBS sample collection and the processing of results meant there were repeated facility visits by women and associated unnecessary transport costs. This created frustration and worry in women about the health of their children [97].
A range of healthcare-related motivators was described such as free treatment/services, peer support, client motivation emotional support in health facilities, implementation of SMS and a good referral system.
Access to facilities/services: Long distances to the health facility [39,98] and financial constraints [39,80] were reported by women as a barrier to accessing maternal HIV testing and ART initiation. However, a study conducted in Uganda reported that having access to free treatment and services was a strong motivator for the uptake of PMTCT services [39].
Partner-related factors: Domestic violence by a partner, lack of partner support, and blame when using ART [39,80,84,85,88,98,101] were reported by women. Women feared domestic violence and were not happy to disclose their HIV status and initiate treatment [85,98]. Likewise, women were usually frustrated with the continuity of their relationship if their partners knew they were HIV positive and on ART [85,88,98,101].
Stigma and misconceptions: Five qualitative studies with a focus on HIV testing and ART uptake among pregnant women suggested that HIV-related stigma and misconceptions prevented them from service use [39,80,85,86,98]. Women experience stigma when they are seen testing for HIV and taking ARV medication. In addition, the embodied misconception of HIV such as traditional health beliefs and practices [80,86] as well as religious views [80,85,98] towards HIV played a negative role in the uptake of HIV testing and ART.
Knowledge and couples’ difference in HIV status: women lacking comprehensive knowledge about HIV and the benefits of ART were identified as a barrier [39,86,96]. Moreover, in couples where women are infected with HIV but their male partners are HIV-negative, the women often experience emotional and psychological distress [88]. This emotional and psychological distress delayed their acceptance and initiation of ART. Therefore, when women are in this situation, counselling support is needed to encourage them to disclose their HIV-positive status to their HIV-uninfected partners and utilize ART services.
Disease progression: women who acquire HIV does not show sign and symptoms at the early stage of infection and are usually asymptomatic or clinically healthy at the time of diagnosis [80,101]. Hence, when women show no symptoms of AIDS, they perceive themselves as healthy and may not accept their HIV-positive status and start ART promptly to prevent vertical transmission.
Fear related to ART: Our review also observed that women do not initiate ART because of the fear they have towards ART drugs; such as fear of potential ART side effects (3 studies) [39,80,86], fear of lifelong commitment to taking ART (4 studies) [39,85,86,101], and fear of its size (1 studies) [85]. The studies conducted in Uganda, [39,85,86] and Malawi [101] reported that most mothers were fearful of taking ART daily for their entire life which deters them from starting the treatment. Furthermore, women perceived that if they were not adherent after treatment had started, they would die earlier, so they did not want to start treatment at all since they were not sure that they would be adherent [85].
Good health: Women’s desire to be healthy [85,86,100] and an interest to protect their unborn children from acquiring HIV infection [39,85,86,88,100] were identified as strong motivators to initiate ART. These studies indicated that the interest of women to be healthy and to have an HIV-free child inspired them to initiate ART uptake because mothers who are highly concerned about their unborn child are more likely to utilize the services hoping that the child would be found negative in the end.
Discussion
This systematic review analysed the uptake and determinants of PMTCT of HIV services in East Africa. Accordingly, the overall pooled proportion was 82.69% for maternal HIV testing; 88.33% for maternal ART uptake; 84.98% for infant ARV prophylaxis; and 68.77% for EID in East Africa. The finding was found to be promising, however, much work remains to be done to achieve the UNAID’s target by 2030 [8]. Besides, in comparison with the other PMTCT cascades, lower EID uptake was observed. This could be due to its complexity as it requires molecular techniques to detect viral nucleic acid rather than serological methods [42]. In resource-constrained settings, performing DBS sample analysis at central reference laboratories is challenging, as it necessitates skilled personnel and complex lab equipment. Moreover, the transportation of specimens over long distances adds to the difficulty, leading to extended turnaround times for test results to be at health facilities [42,105].
The findings of the sub-group analysis showed variation in the level of uptake from country to country. This could be due to differences in socioeconomic characteristics, considerable variation in the timing of PMTCT policies adoption and the extent to which policies are implemented within health facilities [49] along with availability and quality of the service between countries [106–108]. Besides, in comparison with community-based studies higher uptake was observed in facility-based studies as facility settings studies are expected to involve women who have access to health services with ongoing PMTCT services and awareness programs.
The quantitative component of the review pointed to a wide range of community and health care factors (such as place of residence/geographical location, stigma, quality of PMTCT services), and predisposing factors (such as maternal age, child age, education status, religion, marital status, parity, ethnicity, and perceived benefits/ self-efficacy of PMTCT). Along with enabling factors (such as wealth, distance to a health facility, employment status and income) and need factors and prior health services use (such as ANC follow-up, ART adherence, child HIV status, desire to have a child, and STIs symptoms). Some of the factors identified through quantitative studies were consistent with the synthesized findings obtained from the qualitative studies. These included lack of access to facilities/services, disclosure of HIV status, lack of age-specific service, stigma, and lack of knowledge about PMTCT services. The qualitative findings also pointed to additional factors not identified by the quantitative studies. These included the shortage of resources, lack of follow-up supervision, lack of privacy and confidentiality, fear related to ART, being asymptomatic and being a discordant couple.
Amongst the community factors, residence was associated with maternal HIV testing [25,57,58,63,66,103]. However, its effect was inconsistent in that Alemu et al. [25], Astawesegn et al. [57], Yaya et al. [103] and Ejigu et al. [63] found urban residents were more likely to be HIV tested, whilst Abtew et al. [58] and Gebresillassie et al. [66] revealed rural residents were more likely to be HIV tested. The finding of increased maternal HIV testing among urban mothers may be due to the availability of more healthcare centres, and a shorter distance to these centres in urban areas in comparison with rural areas [109,110]. Whereas, the opposite finding may reflect the belief of women from rural areas that their doctor/nurse will react negatively to their refusal-thus they do not opt out of HIV testing unless adequately informed about the opt-out policy by healthcare professionals [111].
This review also identified stigma and discrimination as the most prominent barrier deterring women from HIV test uptake. Social stigmatization may result in difficulty to attend regular clinic visits and further reduces women’s opportunities for a social support system that facilitates disclosure of their HIV status and the subsequent decision to take PMTCT services. Therefore, efforts should be directed at community education about HIV to change communities’ views about HIV from a fearsome death sentence to a manageable chronic condition [112].
Likewise, among the predisposing factors, never-married, widowed, or divorced women were less likely to take both maternal and infant HIV test services in comparison to their married counterparts [63,75,92]. This may be linked to the lack of psychosocial and financial support that husbands may provide [113]. Moreover, being widowed/divorced/separated women is socially unacceptable in most developing communities [113,114] and therefore women may fear discrimination and feel ashamed of receiving PMTCT services [113].
There is an interplay between higher educational attainment for women and their husbands/partners and higher SES (employment, income, and wealth index status) in influencing maternal HIV test uptake [25,57,59,63,66,95,103]. This is because, the more educated women are, the greater their level of employment and financial independence and the better informed they are about the importance of PMTCT services [115]. A similar effect of SES on maternal and child health service use has been documented in other studies [116,117]. The more a community is advantaged socioeconomically, the higher the likelihood of women in that community utilizing health services [118,119]. This finding highlights the need to promote universal primary education and improve women’s SES.
The present review demonstrated that knowledge and awareness about HIV and PMTCT were significantly associated with maternal HIV testing [25,57,63–65,75] and EID [92]. Individuals’ knowledge and awareness of health issues influenced their: perceived need, perceived services benefit and recognition of the healthcare service centres which provided health services. Therefore, repeated PMTCT messages through media to improve women’s knowledge and motivate them to use PMTCT services for themselves and their children, especially in developing countries is recommended [120]. Whereas, long travelling distances to access health facilities providing PMTCT services were associated with lower odds of PMTCT services utilization [57,59,92], because, during pregnancy, walking or travelling long distances is very difficult and may discourage women from using the services in addition to travel-related costs.
Regarding the association between need factors and prior health services use with PMTCT service uptake, there was clear evidence for a positive association between these factors. In line with studies conducted in Ghana [121], ANC follow-up and facility delivery were found to be important factors associated with PMTCT service uptake [62,64,65,84,95]. ANC follow-up and facility delivery create an opportunity for early screening and enrolment of mothers and their newborns into the PMTCT service [19]. Furthermore, studies demonstrated that a child who has used ARV prophylaxis [45,76] or was born from a mother who took ART/HAART [76] had higher odds of testing for HIV at six weeks. Women on ART and infants on ARV prophylaxis are more likely to access EID services because of good awareness of their HIV status, more frequent medical visits, and increased opportunities for providers to identify HEIs. Therefore, attendance and integration of maternal and child health (MCH) services (e.g., ANC) with the PMTCT program is an important strategy to eliminate HIV infection among children [75].
Concerning findings from the qualitative component, healthcare factors (such as shortage of resources, lack of privacy and confidentiality, and lack of follow-up supervision) were identified as a barrier. For example, staff shortages may mean that healthcare providers are unable to provide services to all women in need, which can be experienced directly by women as neglected. Poor infrastructure may also create stressful working environments, which may predispose healthcare providers to behave poorly towards women [94,98]. Similarly, the absence of follow-up supervision was also identified by HCWs as a challenge in EID service delivery. If HCWs are not supervised and trained, they may not have the necessary skills or knowledge of current treatment protocols or referral procedures for providing EID. Hence, ensuring closer supervision of health workers and provision of the needed work inputs and training could improve the utilization of PMTCT services. Furthermore, consistent with a previous systematic review [122], fear related to ART, and being asymptomatic have been also associated with lower ART initiation. Several factors were identified as facilitators or motivators including same-day ART initiation, support/counselling/motivation by health workers or peer educators, free treatment/services, mother’s wish to be healthy or to have an HIV-free child, application of SMS system, good referrals and coordinating systems. It is important to note that even though same-day ART initiation is an important factor to increase ART initiation it has been reported to result in poor adherence and treatment discontinuation [122] because women may not have adequate time to think and make an informed decision before initiating ART.
This systematic review has several strengths. Firstly, we used a comprehensive approach to capture all possible articles on this review question. Secondly, we have included articles conducted with quantitative, qualitative, and mixed-methods study designs, without restricting any study design/method. The use of both quant and qualitative evidence is the best approach to inform policies [55]. Thirdly, we explored whether there were differences in the level of uptake and factors across key PMTCT cascades. As a limitation, firstly, we used a narrative synthesis of factors associated with PMTCT cascades due to wide variations in the measurement of variables among studies. Secondly, we did not search for grey literature, we did not consider publications in other languages apart from English.
Conclusion
In conclusion, the pooled uptake of the PMTCT service cascade was promising in East Africa, but this finding should be interpreted with caution mainly because of the high between-study variability. Ensuring women and their children are enrolled and retained across the PMTCT cascade is recommended. The most identified factors associated with the service uptake were residence, educational status of parents, SES, stigma towards HIV-positive women, marital status, knowledge on PMTCT, intimate partner violence, attitudes/perceived benefits towards PMTCT services, lack of access to PMTCT service and healthcare-related factors like resource scarcity and insufficient follow-up supervision. These factors are modifiable by deliberately focusing on addressing them systematically, both at the policy and service delivery levels. Therefore, it is advisable to promote women’s education and economic empowerment while reducing stigma through active community involvement. Additionally, strengthening staff supervision and improving access to PMTCT services, integrating with maternal and child health care are recommended. Engaging community health workers and expert mothers can also help to share the workload of healthcare providers because of human resource shortages.
Acknowledgments
The authors would like to thank Mr Tesfaye Yitna from Wolaita Sodo University, School of Nursing for his assistance in the study selection.
References
- 1. Edmonds A, Yotebieng M, Lusiama J, Matumona Y, Kitetele F, Napravnik S, et al. The Effect of Highly Active Antiretroviral Therapy on the Survival of HIV-Infected Children in a Resource-Deprived Setting: A Cohort Study. Plos Med. 2011;8(6).
- 2.
Global Health Policy. The Global HIV/AIDS Epidemic 2022 [cited 2023 February 25]. https://www.kff.org/global-health-policy/fact-sheet/the-global-hivaids-epidemic/
- 3. Chi BH, Bolton-Moore C, Holmes CB. Prevention of mother-to-child HIV transmission within the continuum of maternal, newborn, and child health services. Current Opinion in HIV and AIDS. 2013;8(5):498. pmid:23872611
- 4. Kiragu K, Collins L, Von Zinkernagel D, Mushavi A. Integrating PMTCT into maternal, newborn, and child health and related services: experiences from the global plan priority countries. JAIDS Journal of Acquired Immune Deficiency Syndromes. 2017;75:S36–S42. pmid:28398995
- 5.
(UNAIDS) JUNPoHA. GLOBAL PLAN TOWARDS THE ELIMINATION OF NEW HIV INFECTIONS AMONG CHILDREN BY 2015 AND KEEPING THEIR MOTHERS ALIVE. 2011.
- 6.
The Joint United Nations Programme on HIV/AIDS (UNAIDS). UNAIDS DATA.. UNAIDS; 2019 [cited 2022 May 2]. https://www.unaids.org/sites/default/files/media_asset/2019-UNAIDS-data_en.pdf.
- 7. Neary J, Langat A, Singa B, Kinuthia J, Itindi J, Nyaboe E, et al. Higher prevalence of stunting and poor growth outcomes in HIV-exposed uninfected than HIV-unexposed infants in Kenya. Aids. 2022;36(4):605–10. pmid:34750290
- 8.
The Joint United Nations Programme on HIV/AIDS. The United Nations Programme. On the fast-track to an AIDS-free generation. The incredible journey of the global plan towards the elimination of new HIV infections among children by 2015 and keeping their mothers alive 2016 [cited 2021 May 26]. https://www.unaids.org/sites/default/files/media_asset/GlobalPlan2016_en.pdf
- 9.
World Health Organization. Global guidance on criteria and processes for validation: Elimination of mother-to-child transmission of HIV and Syphilis, Second edition Geneva, Switzerland WHO; 2017 [cited 2021 January 2]. https://apps.who.int/iris/bitstream/handle/10665/259517/9789241513272-eng.pdf?sequence=1
- 10.
UNICEF, UNAIDS, WHO.. Key considerations for programming and prioritization. going the ‘LAST MILE’ to EMTCT:: A road map for ending the HIV epidemic in children 2020 [cited 2021 January 2]. http://www.childrenandaids.org/sites/default/files/2020-02/Last-Mile-To-EMTCT_WhitePaper_UNICEF2020.pdf
- 11.
World Health Organization. Programmatic update: use of antiretroviral drugs for treating pregnant women and preventing HIV infection in infants: executive summary. 2012 [cited 2022 April 14]. https://apps.who.int/iris/bitstream/handle/10665/70892/WHO_HIV_2012.6_eng.pdf?sequence=2&isAllowed=y
- 12.
World Health Organization. Prevention of mother-to-child transmission (PMTCT) 2018 [cited 2020 January 25]. https://www.who.int/gho/hiv/epidemic_response/PMTCT_text/en/
- 13.
Center for Disease Control and Prevention. Prevent mother to child transmission CDC; 2020 [cited 2021 May 2]. https://www.cdc.gov/hiv/basics/hiv-prevention/mother-to-child.html
- 14. D’Ippolito M, Read JS, Korelitz J, Joao EC, Mussi-Pinhata M, Rocha N, et al. Missed opportunities for prevention of mother-to-child transmission of human immunodeficiency virus type 1 in Latin America and the Caribbean: the NISDI perinatal study. Pediatr Infect Dis J. 2007;26(7):649–53. pmid:17596813
- 15.
The Joint United Nations Programme on HIV/AIDS (UNAIDS). Global HIV/AIDS response epidemic update and health sector progress towards universal access 2011 [cited 2020 January 25]. https://www.unaids.org/sites/default/files/media_asset/20111130_UA_Report_en_1.pdf.
- 16.
The Joint United Nations Programme on HIV/AIDS (UNAIDS). UNAIDS and PEPFAR announce dramatic reductions in new HIV infections among children in the 21 countries most affected by HIV in Africa 2016 [cited 2021 January 21]. https://www.unaids.org/sites/default/files/20160608_PR_GlobalPlan_en.pdf.
- 17. Hamilton E, Bossiky B, Ditekemena J, Esiru G, Fwamba F, Goga AE, et al. Using the PMTCT cascade to accelerate achievement of the global plan goals. Journal of acquired immune deficiency syndromes (1999). 2017;75(1):S27. pmid:28398994
- 18. Suthar AB, Hoos D, Beqiri A, Lorenz-Dehne K, McClure C, Duncombe C. Integrating antiretroviral therapy into antenatal care and maternal and child health settings: a systematic review and meta-analysis. B World Health Organ. 2013;91(1):46–56. pmid:23397350
- 19. Turan JM, Steinfeld RL, Onono M, Bukusi EA, Woods M, Shade SB, et al. The Study of HIV and Antenatal Care Integration in Pregnancy in Kenya: Design, Methods, and Baseline Results of a Cluster-Randomized Controlled Trial. PLoS One. 2012;7(9) (no pagination).
- 20.
Oladokun R, Awolude O, Brown B, Adesina O, Oladokun A, Roberts A, et al. Service uptake and performance of the prevention of mother-to-child transmission (PMTCT) programme in Ibadan, Nigeria. 2010.
- 21. Dionne-Odom J, Welty TK, Westfall AO, Chi BH, Ekouevi DK, Kasaro M, et al. Factors associated with PMTCT cascade completion in four African countries. AIDS research and treatment. 2016;2016. pmid:27872760
- 22. Wettstein C, Mugglin C, Egger M, Blaser N, Vizcaya LS, Estill J, et al. Missed opportunities to prevent mother-to-child-transmission: Systematic review and meta-analysis. Aids. 2012;26(18):2361–73. pmid:22948267
- 23. Van Lettow M, Landes M, Van Oosterhout J, Schouten E, Phiri H, Nkhoma E, et al. Prevention of mother-to-child transmission of HIV: a cross-sectional study in Malawi. B World Health Organ. 2018;96(4):256. pmid:29695882
- 24. Ajayi A, Awopegba O, Owolabi E, Ajala A. Coverage of HIV testing among pregnant women in Nigeria: progress, challenges and opportunities. Journal of public health (Oxford, England). 2021;43(1):e77–e84. pmid:31786595
- 25. Alemu YM, Ambaw F, Wilder-Smith A. Utilization of HIV testing services among pregnant mothers in low income primary care settings in northern Ethiopia: a cross sectional study. BMC Pregnancy & Childbirth. 2017;17:1–8. pmid:28646888
- 26. Morales JA, Hamahuwa M, Moyo N, Mutanga JN, Schue JL, Maunga S, et al. Factors associated with antiretroviral therapy use among pregnant women in rural and urban settings in Southern Province, Zambia: 2016–2019. Tropical Medicine & International Health. 2022;27(10):902–12. pmid:36127148
- 27. Valle S, Pezzotti P, Floridia M, Pellegrini MG, Bernardi S, Puro V, et al. Percentage and determinants of missed HIV testing in pregnancy: a survey of women delivering in the Lazio region, Italy. AIDS care. 2014;26(7):899–906. pmid:24279737
- 28. Barigye H, Levin J, Maher D, Tindiwegi G, Atuhumuza E, Nakibinge S, et al. Operational evaluation of a service for prevention of mother‐to‐child transmission of HIV in rural Uganda: barriers to uptake of single‐dose nevirapine and the role of birth reporting. Tropical medicine & international health. 2010;15(10):1163–71. pmid:20667051
- 29. Malaju MT, Alene GD. Assessment of utilization of provider-initiated HIV testing and counseling as an intervention for prevention of mother to child transmission of HIV and associated factors among pregnant women in Gondar town, North West Ethiopia. BMC Public Health. 2012;12:226. pmid:22440018
- 30. Vieira N, Rasmussen DN, Oliveira I, Gomes A, Aaby P, Wejse C, et al. Awareness, attitudes and perceptions regarding HIV and PMTCT amongst pregnant women in Guinea-Bissau- a qualitative study. BMC women’s health. 2017;17(1):71. pmid:28870180
- 31. Liao C, Golden WC, Anderson JR, Coleman JS. Missed opportunities for repeat HIV testing in pregnancy: implications for elimination of mother-to-child transmission in the United States. AIDS Patient Care STDS. 2017;31(1):20–6. pmid:27936863
- 32. Gebremedhin T, Alamneh TS, Hagos A, Desalegn B, Worku N. A multilevel analysis of determinants of PMTCT service utilisation among women during the antepartum, intrapartum and postpartum period in Ethiopia. BMC Pregnancy Childbirth. 2021;21(1):1–10.
- 33. Madhivanan P, Krupp K, Kulkarni V, Kulkarni S, Vaidya N, Shaheen R, et al. HIV testing among pregnant women living with HIV in India: are private healthcare providers routinely violating women’s human rights? BMC international health and human rights. 2014;14(1):1–9. pmid:24656059
- 34. Seidu A-A, Oduro JK, Ahinkorah BO, Budu E, Appiah F, Baatiema L, et al. Women’s healthcare decision-making capacity and HIV testing in sub-Saharan Africa: a multi-country analysis of demographic and health surveys. BMC Public Health. 2020;20(1):1–11.
- 35. Ford CE, Coetzee D, Winston J, Chibwesha CJ, Ekouevi DK, Welty TK, et al. Maternal decision-making and uptake of health services for the prevention of mother-to-child HIV transmission: a secondary analysis. Matern Child Health J. 2019;23(1):30–8. pmid:30022401
- 36. Stinson K, Myer L. Barriers to initiating antiretroviral therapy during pregnancy: a qualitative study of women attending services in Cape Town, South Africa. African Journal of AIDS research. 2012;11(1):65–73. pmid:25870899
- 37. Abtew S, Awoke W, Asrat A. Acceptability of provider-initiated HIV testing as an intervention for prevention of mother to child transmission of HIV and associated factors among pregnant women attending at Public Health Facilities in Assosa town, Northwest Ethiopia. BMC research notes. 2015;8:661. pmid:26553035
- 38. Kohler PK, Ondenge K, Mills LA, Okanda J, Kinuthia J, Olilo G, et al. Shame, guilt, and stress: Community perceptions of barriers to engaging in prevention of mother to child transmission (PMTCT) programs in western Kenya. AIDS Patient Care STDS. 2014;28(12):643–51. pmid:25361205
- 39. Mustapha M, Musiime V, Bakeera-Kitaka S, Rujumba J, Nabukeera-Barungi N. Utilization of “prevention of mother-to-child transmission” of HIV services by adolescent and young mothers in Mulago Hospital, Uganda. BMC infectious diseases. 2018;18(1):1–11.
- 40. Cook RE, Ciampa PJ, Sidat M, Blevins M, Burlison J, Davidson MA, et al. Predictors of successful early infant diagnosis of HIV in a rural district hospital in Zambezia, Mozambique. Journal of acquired immune deficiency syndromes (1999). 2011;56(4):e104.
- 41. Ankrah AK, Dako-Gyeke P. Factors influencing the delivery and uptake of early infant diagnosis of HIV services in Greater Accra, Ghana: A qualitative study. PLoS One. 2021;16(2):e0246876. pmid:33596241
- 42. Mofenson LM, Cohn J, Sacks E. Challenges in the Early Infant HIV Diagnosis and Treatment Cascade. JAIDS Journal of Acquired Immune Deficiency Syndromes. 2020;84:S1–S4. pmid:32520908
- 43. Adeniyi VO, Thomson E, Goon DT, Ajayi IA. Disclosure, stigma of HIV positive child and access to early infant diagnosis in the rural communities of OR Tambo District, South Africa: a qualitative exploration of maternal perspective. BMC pediatrics. 2015;15(1):1–10.
- 44. Shargie MB, Eek F, Abaychew A. Prophylactic treatment uptake and compliance with recommended follow up among HIV exposed infants: a retrospective study in Addis Ababa, Ethiopia. BMC research notes. 2011;4(1):1–8. pmid:22201727
- 45. Kebede B, Gebeyehu A, Jain S, Sun S, Haubrich R. Delay in early infant diagnosis and high loss to follow-up among infant born to HIV-infected women in Ethiopia. World Journal of AIDS. 2014;4(04):402.
- 46. Moher D, Liberati A, Tetzlaff J, Altman DG, Group P. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Int J Surg. 2010;8(5):336–41. pmid:20171303
- 47.
United Nations Department of Economic and social afairs statistical division. Standard country or area codes for statistical use (M49) 2020 [cited 2020 December 6]. https://unstats.un.org/unsd/methodology/m49/
- 48.
United Nation. World Population Review 2020 [cited 2020 December 6]. https://worldpopulationreview.com/country-rankings/east-african-countries
- 49. Impact of an innovative approach to prevent mother-to-child transmission of HIV—Malawi, July 2011-September 2012. MMWR Morb Mortal Wkly Rep. 2013;62(8):148–51. pmid:23446514
- 50. Pace R, Pluye P, Bartlett G, Macaulay AC, Salsberg J, Jagosh J, et al. Testing the reliability and efficiency of the pilot Mixed Methods Appraisal Tool (MMAT) for systematic mixed studies review. Int J Nurs Stud. 2012;49(1):47–53. pmid:21835406
- 51. Allen B, Canuto K, Evans JR, Lewis E, Gwynn J, Radford K, et al. Facilitators and Barriers to Physical Activity and Sport Participation Experienced by Aboriginal and Torres Strait Islander Adults: A Mixed Method Review. Int J Environ Res Public Health. 2021;18(18). pmid:34574816
- 52. Laher Z, Robertson N, Harrad-Hyde F, Jones CR. Prevalence, Predictors, and Experience of Moral Suffering in Nursing and Care Home Staff during the COVID-19 Pandemic: A Mixed-Methods Systematic Review. Int J Environ Res Public Health. 2022;19(15):9593. pmid:35954948
- 53. Mey A, Plummer D, Dukie S, Rogers GD, O’Sullivan M, Domberelli A. Motivations and barriers to treatment uptake and adherence among people living with HIV in Australia: a mixed-methods systematic review. Aids Behav. 2017;21(2):352–85. pmid:27826734
- 54. Thorlund K, Imberger G, Johnston BC, Walsh M, Awad T, Thabane L, et al. Evolution of heterogeneity (I2) estimates and their 95% confidence intervals in large meta-analyses. PLoS One. 2012;7(7):e39471. pmid:22848355
- 55. Stern C, Lizarondo L, Carrier J, Godfrey C, Rieger K, Salmond S, et al. Methodological guidance for the conduct of mixed methods systematic reviews. JBI Evid Implement. 2021;19(2):120–9. pmid:34061049
- 56. Andersen RM. Revisiting the behavioral model and access to medical care: does it matter? J Health Soc Behav. 1995;36(1):1–10. pmid:7738325
- 57. Astawesegn FH, Stulz V, Agho KE, Mannan H, Conroy E, Ogbo FA. Prenatal HIV Test Uptake and Its Associated Factors for Prevention of Mother to Child Transmission of HIV in East Africa. Int J Environ Res Public Health. 2021;18(10). pmid:34065689
- 58. Abtew S, Awoke W, Asrat A. Acceptability of provider-initiated HIV testing as an intervention for prevention of mother to child transmission of HIV and associated factors among pregnant women attending at Public Health Facilities in Assosa town, Northwest Ethiopia. BMC research notes. 2015;8(1):1–8. pmid:26553035
- 59. Akal CG, Afework DT. Status of Prevention of Mother-to-Child Transmission (PMTCT) Services Utilization and Factors Affecting PMTCT Service Uptake by Pregnant Women Attending Antenatal Care Clinic in Selected Health Facilities of Afar Regional State, Ethiopia. J Environ Public Health. 2018;2018 (no pagination). pmid:30651741
- 60. Berhan Z, Abebe F, Gedefaw M, Tesfa M, Assefa M, Tafere Y. Risk of HIV and associated factors among infants born to HIV positive women in Amhara region, Ethiopia: a facility based retrospective study. BMC research notes. 2014;7:876. pmid:25475398
- 61. Desta ML, Saravanan M, Hilekiros H, Kahsay AG, Mohamed NF, Gezahegn AA, et al. HIV prevalence and risk factors in infants born to HIV positive mothers, measured by dried blood spot real-time PCR assay in Tigray, Northern Ethiopia. BMC pediatrics. 2019;19(1):1–8.
- 62. Ebuy H, Bekele A, Redae G. HIV testing, test results and factors influencing among infants born to HIV positive mothers in public hospitals of Mekelle City, North Ethiopia: a cross-sectional study. BMC Infectious Diseases. 2020;20(1):1–10. pmid:31964397
- 63. Ejigu Y, Tadesse B. HIV testing during pregnancy for prevention of mother-to-child transmission of HIV in Ethiopia. PLoS One. 2018;13(8):e0201886. pmid:30092104
- 64. Gebeyehu NA, Wassie AY, Gelaw KA. Acceptance of HIV testing and associated factors among pregnant women attending antenatal care in Gunino health center, Southern Ethiopia 2019: an institutional based cross-sectional study. HIV/AIDS (Auckland, NZ). 2019;11:333.
- 65. Gebremedhin KB, Tian B, Tang C, Zhang X, Yisma E, Wang H. Factors associated with acceptance of provider-initiated HIV testing and counseling among pregnant women in Ethiopia. Patient preference and adherence. 2018;12:183. pmid:29416320
- 66. Gebresillassie BM, Emiru YK, Erku DA, Mersha AG, Mekuria AB, Ayele AA, et al. Utilization of Provider-Initiated HIV Testing and Counseling as an Intervention for PMTCT Services Among Pregnant Women Attending Antenatal Clinic in a Teaching Hospital in Ethiopia. Front Public Health. 2019;7.
- 67. Moges NA, Kassa GM, Boneya DJ. Rate of HIV transmission and associated factors among HIV-exposed infants in selected health facilities of East and West Gojjam Zones, Northwest Ethiopia; retrospective cohort study. BMC Infectious Diseases. 2017;17:1–10.
- 68. Tadewos K, Adimasu M, Tachbele E. Mother-to-Child Transmission of HIV and Associated Factors Among Exposed Infants in Pastoralist Health Facilities, South Omo Zone, Ethiopia, 2020–A Retrospective Cross-Sectional Study. HIV/AIDS (Auckland, NZ). 2021;13:1015. pmid:34916853
- 69. Tsehay AK. Factors associated with HIV-positive sero-status among exposed infants attending care at health facilities in Bahir Dar administration, Ethiopia: Evidence from medical records. Cogent Medicine. 2019;6(1) (no pagination).
- 70. Workagegn F, Kiros G, Abebe L. Predictors of HIV-test utilization in PMTCT among antenatal care attendees in government health centers: Institution-based cross-sectional study using health belief model in Addis Ababa, Ethiopia, 2013. HIV/AIDS—Research and Palliative Care. 2015;7:215–22. pmid:26203282
- 71. Wudineh F, Damtew B. Mother-to-child transmission of HIV infection and its determinants among exposed infants on care and follow-up in Dire Dawa City, Eastern Ethiopia. AIDS research and treatment. 2016;2016. pmid:26989507
- 72. Zegeye B, Lemma G, Balcha A, Taderegew MM. Prevention of Mother-to-Child HIV Transmission Service Utilization among Pregnant Women in Northeast Ethiopia: A Cross-Sectional Survey. Scientifica. 2020;2020. pmid:33204577
- 73. Olana T, Bacha T, Worku W, Tadesse BT. Early infant diagnosis of HIV infection using DNA-PCR at a referral center: an 8 years retrospective analysis. AIDS research and therapy. 2016;13(1):1–7.
- 74. Deressa W, Seme A, Asefa A, Teshome G, Enqusellassie F. Utilization of PMTCT services and associated factors among pregnant women attending antenatal clinics in Addis Ababa, Ethiopia. BMC Pregnancy Childbirth. 2014;14(1):1–13. pmid:25234199
- 75. Haider MR, Kingori C, Gebre HS. Factors associated with HIV testing among women during pregnancy in Kenya: evidence from the Kenya Demographic and Health Survey 2014. AIDS Care. 2022;34(2):193–200. pmid:33576689
- 76. Gaitho D, Kinoti F, Mwaniki L, Kemunto D, Ogoti V, Njigua C, et al. Factors associated with the timely uptake of initial HIV virologic test among HIV-exposed infants attending clinics within a faith-based HIV program in Kenya; a cross-sectional study. BMC Public Health. 2021;21(1):1–7.
- 77. Makau G, Okwara F, Oyore J. Determinants of early infant diagnosis and treatment of HIV among exposed infants in informal settlements in Nairobi, Kenya. East Cent Afr Med J. 2015;2:74–9.
- 78. Ongaki D, Obonyo M, Nyanga N, Ransom J. Factors Affecting Uptake of PMTCT Services, Lodwar County Referral Hospital, Turkana County, Kenya, 2015 to 2016. Journal of the International Association of Providers of AIDS Care. 2019;18(no pagination). pmid:30931683
- 79. Ng’ambi WF, Merzouki FA, Estill J, Orel E, Chimpandule T, Nyirenda R, et al. Factors associated with the risk of HIV infection among HIV-exposed infants in Malawi: 2013–2020. BMJ paediatrics open. 2022;6(1). pmid:36053628
- 80. Buleza Lamucene O, Bernales M, Irarrázabal Vargas L, Ferrer Lagunas L. Perceptions of barriers and facilitators to implement programs for prevention of mother-to-child transmission of HIV-Mozambique. Revista da Escola de Enfermagem da USP. 2022;56.
- 81. Thidor GTY, August F. Prevention of mother-to-child transmission of HIV: knowledge, attitudes and practice among pregnant women at Juba Teaching Hospital. South Sudan med j. 2019;12(1):12–6.
- 82. Ahoua L, Tiendrebeogo T, Arikawa S, Lahuerta M, Aly D, Journot V, et al. PMTCT care cascade and factors associated with attrition in the first four years after Option B+ implementation in Mozambique. Tropical Medicine & International Health. 2020;25(2):222–35. pmid:31667997
- 83. Lain MG, Chicumbe S, de Araujo AR, Karajeanes E, Couto A, Giaquinto C, et al. Correlates of loss to follow-up and missed diagnosis among HIV-exposed infants throughout the breastfeeding period in southern Mozambique. PLoS One. 2020;15(8):e0237993. pmid:32822388
- 84. Bergmann J, Wanyenze R, Makumbi F, Naigino R, Kiene S, Stockman J. Maternal Influences on Access to and Use of Infant ARVs and HIV Health Services in Uganda. AIDS & Behavior. 2017;21(9):2693–702.
- 85. Buregyeya E, Naigino R, Mukose A, Makumbi F, Esiru G, Arinaitwe J, et al. Facilitators and barriers to uptake and adherence to lifelong antiretroviral therapy among HIV infected pregnant women in Uganda: a qualitative study. BMC Pregnancy & Childbirth. 2017;17:1–9. pmid:28320347
- 86. Mukose AD, Bastiaens H, Makumbi F, Buregyeya E, Naigino R, Musinguzi J, et al. What influences uptake and early adherence to Option B+ (lifelong antiretroviral therapy among HIV positive pregnant and breastfeeding women) in Central Uganda? A mixed methods study. PLoS ONE. 2021;16(5 May) (no pagination). pmid:33951109
- 87. Wanyenze RK, Goggin K, Finocchario-Kessler S, Beyeza-Kashesya J, Mindry D, Birungi J, et al. Utilization of prevention of mother-to-child transmission (PMTCT) services among pregnant women in HIV care in Uganda: a 24-month cohort of women from pre-conception to post-delivery. BMC research notes. 2018;11(1):187. pmid:29566724
- 88. Kanguya T, Koyuncu A, Sharma A, Kusanathan T, Mubanga M, Chi BH, et al. Identifying barriers to ART initiation and adherence: An exploratory qualitative study on PMTCT in Zambia. PLoS ONE. 2022;17(1 January 2022) (no pagination). pmid:35025923
- 89. Hampanda KM, Nimz AM, Abuogi LL. Barriers to uptake of early infant HIV testing in Zambia: the role of intimate partner violence and HIV status disclosure within couples. AIDS research and therapy. 2017;14(1):1–9.
- 90. Ford C, Chibwesha CJ, Winston J, Jacobs C, Lubeya MK, Musonda P, et al. Women’s decision-making and uptake of services to prevent mother-to-child HIV transmission in Zambia. AIDS care. 2018;30(4):426–34. pmid:28971710
- 91. Augustine N, Philip O, Kumar AM, Simukai Z, Owen M, Dumisani MH, et al. Gaps in the care cascade among human immunodeficiency virus-exposed infants born in 2017 in Mashonaland East Province of Zimbabwe. Journal of Global Infectious Diseases. 2021;13(2):72. pmid:34194173
- 92. Bwana VM, Mfinanga SG, Simulundu E, Mboera LE, Michelo C. Accessibility of early infant diagnostic services by under-5 years and HIV exposed children in Muheza District, north-East Tanzania. Front Public Health. 2018;6:139. pmid:29868546
- 93. Gamell A, Luwanda LB, Kalinjuma AV, Samson L, Ntamatungiro AJ, Weisser M, et al. Prevention of mother-to-child transmission of HIV Option B+ cascade in rural Tanzania: The One Stop Clinic model. PLoS One. 2017;12(7) (no pagination). pmid:28704472
- 94. Konje ET, Magoma MTN, Hatfield J, Kuhn S, Sauve RS, Dewey DM. Missed opportunities in antenatal care for improving the health of pregnant women and newborns in Geita district, Northwest Tanzania. BMC Pregnancy Childbirth. 2018;18(1):1–13.
- 95. Nungu SI, Mghamba JM, Rumisha SF, Semali IA. Uptake and determinants for HIV postpartum re-testing among mothers with prenatal negative status in Njombe region, Tanzania. BMC Infectious Diseases. 2019;19(1) (no pagination). pmid:31072332
- 96. Oshosen M, Knettel BA, Knippler E, Relf M, Mmbaga BT, Watt MH. “She just told me not to cry”: A qualitative study of experiences of HIV Testing and Counseling (HTC) among pregnant women living with HIV in Tanzania. AIDS and Behavior. 2021;25(1):104–12. pmid:32572712
- 97. Bobrow EA, Yemaneberhan AG, Phiri M, Katirayi L, Ahimbisibwe A, Chimbwandira F, et al. Barriers, facilitators and recommendations for the early infant diagnosis and treatment (EIDT) cascade: A qualitative study in Malawi. SAJCH South African Journal of Child Health. 2016;10(2):116–20.
- 98. Cataldo F, Chiwaula L, Nkhata M, van Lettow M, Kasende F, Rosenberg NE, et al. Exploring the experiences of women and health care workers in the context of PMTCT Option B Plus in Malawi. Journal of acquired immune deficiency syndromes (1999). 2017;74(5):517. pmid:28045712
- 99. Dzangare J, Takarinda KC, Harries AD, Tayler-Smith K, Mhangara M, Apollo TM, et al. HIV testing uptake and retention in care of HIV-infected pregnant and breastfeeding women initiated on ’Option B+’ in rural Zimbabwe. Tropical Medicine and International Health. 2016;21(2):202–9. pmid:26555353
- 100. Chadambuka A, Katirayi L, Muchedzi A, Tumbare E, Musarandega R, Mahomva AI, et al. Acceptability of lifelong treatment among HIV-positive pregnant and breastfeeding women (Option B+) in selected health facilities in Zimbabwe: a qualitative study. BMC Public Health. 2018;18(1):1–8.
- 101. Kim MH, Zhou A, Mazenga A, Ahmed S, Markham C, Zomba G, et al. Why did I stop? Barriers and facilitators to uptake and adherence to ART in Option B+ HIV care in Lilongwe, Malawi. PLoS One. 2016;11(2):e0149527. pmid:26901563
- 102. Semali I, Damian DJ, Saronga HP, Malamsha D. Factors associated with HIV testing and receiving results during antenatal care in Tanzania. African Population Studies. 2014:1035–45.
- 103. Yaya S, Oladimeji O, Oladimeji KE, Bishwajit G. Determinants of prenatal care use and HIV testing during pregnancy: a population-based, cross-sectional study of 7080 women of reproductive age in Mozambique. BMC Pregnancy Childbirth. 2019;19(1):1–10.
- 104. McCoy SI, Buzdugan R, Padian NS, Musarandega R, Engelsman B, Martz TE, et al. Uptake of services and behaviors in the prevention of mother-to-child HIV transmission (PMTCT) cascade in Zimbabwe. Journal of acquired immune deficiency syndromes (1999). 2015;69(2):e74.
- 105. Adebimpe WO. Challenges facing early infant diagnosis of HIV among infants in resource poor settings. African J Reprod Health. 2013;17(1):122–9. pmid:24069741
- 106.
United Nations Programme on HIV/AIDS. Policy statement: UNAIDS/WHO POLICY STATEMENT ON HIV TESTING: UNAIDS; 2004 [http://data.unaids.org/una-docs/hivtestingpolicy_en.pdf.
- 107.
Open Society Initiative For East Africa. HIV/AIDS, Human Rights, and Legal Services in Uganda: A Country Assessment 2008 [cited 2021 February 22]. https://www.refworld.org/pdfid/4cdcead32.pdf.
- 108. Kasenga F, Byass P, Emmelin M, Hurtig AK. The implications of policy changes on the uptake of a PMTCT programme in rural Malawi: first three years of experience. Glob Health Action. 2009;2. pmid:20027274
- 109. Gunn JK, Asaolu IO, Center KE, Gibson SJ, Wightman P, Ezeanolue EE, et al. Antenatal care and uptake of HIV testing among pregnant women in sub-Saharan Africa: a cross-sectional study. J Int Aids Soc. 2016;19(1):20605. pmid:26787516
- 110. Creek T, Ntumy R, Mazhani L, Moore J, Smith M, Han G, et al. Factors associated with low early uptake of a national program to prevent mother to child transmission of HIV (PMTCT): results of a survey of mothers and providers, Botswana, 2003. Aids Behav. 2009;13(2):356–64. pmid:17985228
- 111. Rennie S, Behets F. Desperately seeking targets: the ethics of routine HIV testing in low-income countries. B World Health Organ. 2006;84:52–7. pmid:16501715
- 112. Castro A, Farmer P. Understanding and addressing AIDS-related stigma: from anthropological theory to clinical practice in Haiti. Am J Public Health. 2005;95(1):53–9. pmid:15623859
- 113. Mohammadi F, Kohan S, Mostafavi F, Gholami A. The stigma of reproductive health services utilization by unmarried women. Iranian Red Crescent Medical Journal. 2016;18(3). pmid:27247794
- 114. Newton-Levinson A, Winskell K, Abdela B, Rubardt M, Stephenson R. ‘People insult her as a sexy woman’: sexuality, stigma and vulnerability among widowed and divorced women in Oromiya, Ethiopia. Culture, health & sexuality. 2014;16(8):916–30.
- 115. Bekele YA, Fekadu GA. Factors associated with HIV testing among young females; further analysis of the 2016 Ethiopian demographic and health survey data. PLoS One. 2020;15(2):e0228783. pmid:32045460
- 116. Novignon J, Ofori B, Tabiri KG, Pulok MH. Socioeconomic inequalities in maternal health care utilization in Ghana. Int J Equity Health. 2019;18(1):141. pmid:31488160
- 117. Makinen M, Waters H, Rauch M, Almagambetova N, Bitran R, Gilson L, et al. Inequalities in health care use and expenditures: empirical data from eight developing countries and countries in transition. B World Health Organ. 2000;78(1):55–65. pmid:10686733
- 118. Alam N, Hajizadeh M, Dumont A, Fournier P. Inequalities in maternal health care utilization in sub-Saharan African countries: a multiyear and multi-country analysis. PLoS One. 2015;10(4):e0120922. pmid:25853423
- 119. Goli S, Nawal D, Rammohan A, Sekher TV, Singh D. DECOMPOSING THE SOCIOECONOMIC INEQUALITY IN UTILIZATION OF MATERNAL HEALTH CARE SERVICES IN SELECTED COUNTRIES OF SOUTH ASIA AND SUB-SAHARAN AFRICA. Journal of biosocial science. 2018;50(6):749–69. pmid:29081310
- 120. Awopegba OE, Kalu A, Ahinkorah BO, Seidu A-A, Ajayi AI. Prenatal care coverage and correlates of HIV testing in sub-Saharan Africa: Insight from demographic and health surveys of 16 countries. PLoS One. 2020;15(11):e0242001. pmid:33166351
- 121. Sambah F, Baatiema L, Appiah F, Ameyaw EK, Budu E, Ahinkorah BO, et al. Educational attainment and HIV testing and counselling service utilisation during antenatal care in Ghana: analysis of demographic and health surveys. PLoS One. 2020;15(1):e0227576. pmid:31940331
- 122. Munkhondya TEM, Smyth RM, Lavender T. Facilitators and barriers to retention in care under universal antiretroviral therapy (Option B+) for the Prevention of Mother to Child Transmission of HIV (PMTCT): A narrative review. International Journal of Africa Nursing Sciences. 2021;15:100372.