Abstract
ObjectivesTo investigate and synthesize reasons for low access, initiation and adherence to antiretroviral drugs by mothers and exposed babies for prevention of mother-to-child transmission (PMTCT) of HIV in sub-Saharan Africa.MethodsA systematic literature review was conducted. Four databases were searched (Medline, Embase, Global Health and Web of Science) for studies conducted in sub-Saharan Africa from January 2000 to September 2012. Quantitative and qualitative studies were included that met pre-defined criteria. Antiretroviral (ARV) prophylaxis (maternal/infant) and combination antiretroviral therapy (ART) usage/registration at HIV care and treatment during pregnancy were included as outcomes.ResultsOf 574 references identified, 40 met the inclusion criteria. Four references were added after searching reference lists of included articles. Twenty studies were quantitative, 16 were qualitative and eight were mixed methods. Forty-one studies were conducted in Southern and East Africa, two in West Africa, none in Central Africa and one was multi-regional. The majority (n=25) were conducted before combination ART for PMTCT was emphasized in 2006. At the individual-level, poor knowledge of HIV/ART/vertical transmission, lower maternal educational level and psychological issues following HIV diagnosis were the key barriers identified. Stigma and fear of status disclosure to partners, family or community members (community-level factors) were the most frequently cited barriers overall and across time. The extent of partner/community support was another major factor impeding or facilitating the uptake of PMTCT ARVs, while cultural traditions including preferences for traditional healers and birth attendants were also common. Key health-systems issues included poor staff-client interactions, staff shortages, service accessibility and non-facility deliveries.ConclusionsLong-standing health-systems issues (such as staffing and service accessibility) and community-level factors (particularly stigma, fear of disclosure and lack of partner support) have not changed over time and continue to plague PMTCT programmes more than 10 years after their introduction. The potential of PMTCT programmes to virtually eliminate vertical transmission of HIV will remain elusive unless these barriers are tackled. The prominence of community-level factors in this review points to the importance of community-driven approaches to improve uptake of PMTCT interventions, although packages of solutions addressing barriers at different levels will be important.
Highlights
In 2008, 12 million women aged 15 years and over were estimated to be living with HIV in sub-Saharan Africa, and of the 330,000 new HIV infections among children globally in 2011, over 90% were in sub-Saharan Africa [1,2]
prevention of mother-to-child transmission (PMTCT) treatment guidelines have evolved considerably over time in sub-Saharan Africa, following the first recommendation for ARV drugs for PMTCT in 2000 (short-course prophylaxis starting late in pregnancy or during labour, including single-dose nevirapine (NVP) for mothers and infants) [7], and subsequent revisions in 2004 and 2006 which emphasized the importance of providing cART to pregnant women for their own health (cART for those with CD4 counts below 200 cells/mm3, or azidothymidine (AZT) prophylaxis starting from 28 weeks of pregnancy, single-dose NVP during labour and delivery, and infant prophylaxis for one week) [8,9]
The majority of studies were conducted during early phases of PMTCT programmes, before the introduction of cART for PMTCT, an increasing amount of literature has emerged recently
Summary
In 2008, 12 million women aged 15 years and over were estimated to be living with HIV in sub-Saharan Africa, and of the 330,000 new HIV infections among children (under 15) globally in 2011, over 90% were in sub-Saharan Africa [1,2]. In 2010, the World Health Organisation (WHO) published guidelines advising that all HIV-positive pregnant women with CD4 counts B350 cells/mm should initiate combination ART for their own health ( referred to as ‘‘cART’’) [1], some countries in sub-Saharan Africa still use lower CD4 count thresholds [4] Option B' (ARV therapy for all HIV-positive pregnant women continued for life) is expected to be formally recommended in 2013, with foreseen benefits including further simplification and operational simplicity, avoidance of stopping and starting ARV drugs, protection against vertical transmission in future pregnancies and protection against sexual transmission to sero-discordant partners [5]
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