Missed opportunities to prevent mother-to-child-transmission: systematic review and meta-analysis

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Objectives:To determine magnitude and reasons of loss to program and poor antiretroviral prophylaxis coverage in prevention of mother-to-child transmission (PMTCT) programs in sub-Saharan Africa.Design:Systematic review and meta-analysis.Methods:We searched PubMed and Embase databases for PMTCT studies in sub-Saharan Africa published between January 2002 and March 2012. Outcomes were the percentage of pregnant women tested for HIV, initiating antiretroviral prophylaxis, having a CD4 cell count measured, and initiating antiretroviral combination therapy (cART) if eligible. In children outcomes were early infant diagnosis for HIV, and cART initiation. We combined data using random-effects meta-analysis and identified predictors of uptake of interventions.Results:Forty-four studies from 15 countries including 75 172 HIV-infected pregnant women were analyzed. HIV-testing uptake at antenatal care services was 94% [95% confidence intervals (CIs) 92–95%] for opt-out and 58% (95% CI 40–75%) for opt-in testing. Coverage with any antiretroviral prophylaxis was 70% (95% CI 64–76%) and 62% (95% CI 50–73%) of pregnant women eligible for cART received treatment. Sixty-four percent (95% CI 48–81%) of HIV exposed infants had early diagnosis performed and 55% (95% CI 36–74%) were tested between 12 and 18 months. Uptake of PMTCT interventions was improved if cART was provided at the antenatal clinic and if the male partner was involved.Conclusion:In sub-Saharan Africa, uptake of PMTCT interventions and early infant diagnosis is unsatisfactory. An integrated family-centered approach seems to improve retention.

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