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Mother-to-child transmission (MTCT) is the main route of transmission for HIV among under 5 children in Brazil. National data indicate that missed opportunities for HIV prevention of MTCT are still common in antenatal care (ANC). We studied variables related to target process indicators in a cohort of HIV exposed children. We used data from 1996 to 2013 related to HIV exposed uninfected and HIV-infected children attended in an HIV reference hospital in Rio de Janeiro, Brazil. Data were collected from baseline questionnaires applied to all children followed-up in the hospital. Gestational and perinatal history were extracted from the mother's ANC card. Infants were categorized according to dates of first HIV care at the unit (1996-2000, 2001-2006 and 2007-2013). Distances between recorded addresses and the nearest maternity/hospital were measured by Euclidean distance, the shortest car route calculated in Google Maps and the route of the available bus line. Of the 599 children who fulfilled the inclusion criteria, 178 (29.7%) were HIV-infected. Approximately 70% of infants exposed to the virus from 1996-2000 were infected, dropping to 15.2% from 2001-2006 and rebounding to 30.1% from 2007-2013. Birth cohort was associated with ANC, and mothers from 2007-2013 had a lower chance of attending ANC (OR = 0.16; 95%CI 0.08-0.30). In addition, when the distance home-birthplace was higher than 9.5 km, there was a lower chance that the mother had attended ANC (OR = 0.35; 95%CI 0.18-0.68). Birth cohort was associated to HIV and ANC, and our data showed that a reduction of ANC might be related to rebound in HIV cases. There seems to have an association between larger distances from home to the birthplace and absence of ANC, which suggests that ANC was being performed in the tertiary units instead of in the primary care facilities as recommended.

Health worker experience and community support may be higher in high HIV prevalence regions than low prevalence regions, leading to improved prevention of mother-to-child HIV transmission (PMTCT) programs. We evaluated 6-week and 9-month infant HIV transmission risk (TR) in a high prevalence region and nationally. Population-proportionate-to-size sampling was used to select 141 clinics in Kenya, and mobile teams surveyed mother-infant pairs attending 6-week and 9-month immunizations. HIV DNA testing was performed on HIV-exposed infants. Among 2521 mother-infant pairs surveyed nationally, 2423 (94.7%) reported HIV testing in pregnancy or prior diagnosis, of whom 200 (7.4%) were HIV-infected and 188 infants underwent HIV testing. TR was 8.8% (4.0%-18.3%) in 6-week and 8.9% (3.2%-22.2%) in 9-month cohorts including mothers with HIV diagnosed postpartum, of which 53% of infant infections were due to previously undiagnosed mothers. Of 276 HIV-exposed infants in the Nyanza survey, TR was 1.4% (0.4%-5.3%) at 6-week and 5.1% (2.5%-9.9%) at 9-months. Overall TR was lower in Nyanza, high HIV region, than nationally (3.3% vs. 7.2%, P = 0.02). HIV non-disclosure to male partners and incomplete ARVs were associated with TR in both surveys [aOR = 12.8 (3.0-54.3); aOR = 5.6 (1.2-27.4); aOR = 4.5 (1.0-20.0), aOR = 2.5, (0.8-8.4), respectively]. TR was lower in a high HIV prevalence region which had better ARV completion and partner HIV disclosure, possibly due to programmatic efficiencies or community/peer/partner support. Most 9-month infections were among infants of mothers without prior HIV diagnosis. Strategies to detect incident or undiagnosed maternal infections will be important to achieve PMTCT.

Women's empowerment is associated with engagement in some areas of healthcare, but its role in prevention of mother-to-child HIV transmission (PMTCT) services has not been previously considered. In this secondary analysis, we investigated the association of women's decision-making and uptake of health services for PMTCT. Using data from population-based household surveys, we included women who reported delivery in the 2-year period prior to the survey and were HIV-infected. We measured a woman's self-reported role in decision-making in her own healthcare, making of large purchases, schooling of children, and healthcare for children. For each domain, respondents were categorized as having an "active" or "no active" role. We investigated associations between decision-making and specific steps along the PMTCT cascade: uptake of maternal antiretroviral drugs, uptake of infant HIV prophylaxis, and infant HIV testing. We calculated unadjusted and adjusted odds ratios via logistic regression. From March to December 2011, 344 HIV-infected mothers were surveyed and 276 completed the relevant survey questions. Of these, 190 (69%) took antiretroviral drugs during pregnancy; 175 (64%) of their HIV-exposed infants received antiretroviral prophylaxis; and 160 (58%) had their infant tested for HIV. There was no association between decision-making and maternal or infant antiretroviral drug use. We observed a significant association between decision-making and infant HIV testing in univariate analyses (OR 1.56-1.85; p 0.05); however, odds ratios for the decision-making indicators were no longer statistically significant predictors of infant HIV testing in multivariate analyses. In conclusion, women who reported an active role in decision-making trended toward a higher likelihood of uptake of infant testing in the PMTCT cascade. Larger studies are needed to evaluate the impact of empowerment initiatives on the PMTCT service utilization overall and infant testing in particular.

Involvement of male partners may increase adherence to and improve outcomes of programs to prevent mother-to-child HIV transmission (PMTCT). Greater understanding of factors impeding male voluntary HIV counseling and testing (VCT) is needed. A cross-sectional study was conducted in Tshwane, South Africa. Semi-structured interviews were completed with men whose partners had recently been pregnant. Of 124 men who participated, 94% believed male HIV testing was important, but 40% had never been tested. Of those tested, 32% were tested during the pregnancy, while 37% were tested afterward. Fifty-eight percent of men reported that their female partners had disclosed their test results during pregnancy. A man's likelihood of testing during pregnancy was associated with prior discussion of testing in PMTCT, knowing the female partner had tested, and her disclosure of the test result (all p0.05). In terms of increasing male-partner HIV testing rates, 74% of the men reported they would respond favorably to a written invitation for VCT from their partners. Based on themes that emerged during the interviews, six partner invitation cards to encourage male involvement in PMTCT were designed. Responses to the cards were elicited from 158 men and 409 women. One invitation card framed by the themes of fatherhood and the baby was selected by 41% of men and 31% of women as the most likely for women undergoing PMTCT to bring to their male partners and the most successful at encouraging men to be tested. In conclusion, this study found that a substantial proportion of men whose partners were recently pregnant had never been tested themselves; of those who had tested, most had done so only after the pregnancy. Encouraging partner communication and clinic attendance using an invitation card could facilitate increased male testing and participation in PMTCT.

For almost a decade, single-dose nevirapine (sdNVP) has been proven to be a safe and effective drug for the prevention of mother-to-child transmission (PMTCT) of HIV. With the advent of the use of more efficacious combination therapy strategy in reducing mother-to-child transmission, sdNVP has been relegated as a lower tier intervention. Availability of infrastructural capacity coupled with the practical reality that very few women attend an antenatal clinic more than once makes universal implementation of combination therapy a challenge. This retrospective review examined PMTCT programmatic indicators following the introduction of sdNVP at first contact in selected sites. Data from 79 PMTCT sites was reviewed from April 2006 to March 2007 (when sdNVP was offered only after 32 weeks) and compared to the period of April 2007-March 2008. In the pre-intervention period (April 2006-March 2007), the monthly average of pregnant women who received sdNVP per site was 5.02. Post-intervention (April 2007-March 2008), the monthly average increased by 59% to 7.97 (p-value0.05). In pre-intervention period when sdNVP was dispensed at 32 weeks, the average proportion of pregnant women who received antiretroviral prophylaxis was 59%. This increased to 82% after the intervention. Current systems for dispensing sdNVP may be used as a foundation for implementation of more efficacious PMTCT regimens. The sdNVP administered at first contact should be a safety net for women who are unable to receive more efficacious regimen.