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Item does not contain fulltext Although 23 antiretroviral drugs are approved for use in adults, only six are approved by regulatory authorities for use in term neonates born to women with HIV, with even fewer options for preterm neonates. A major hurdle for approvals is the delay in the generation of pharmacokinetic and safety data for antiretrovirals in neonates. The median time between the year of approval from the US Food and Drug Administration of an antiretroviral agent for adults and the first publication date for pharmacokinetic data in neonates less than 4 weeks old is 8 years (range 2-23 years). In this Viewpoint, we address pharmacokinetic research gaps and priorities for current and novel antiretroviral use in neonates. We also consider the challenges and provide guidance on neonatal clinical pharmacology research on antiretroviral agents with the goal of stimulating research and expediting the availability of safe medications for the prevention and treatment of HIV in this vulnerable population.

BackgroundThe survival of HIV-infected infants depends on early identification and initiation on effective treatment. HIV-exposed infants are tested at 6 weeks of age; however, testing for HIV sooner (e.g., shortly after birth) can identify in utero infection, which is associated with rapid progression. Infant early diagnostic virologic tests often have long turnaround times, reducing the utility of early testing. Point-of-care (POC) testing allows neonates born in health facilities to get results prior to discharge. This study aimed to understand the views of mothers and health workers regarding the use and acceptability of POC birth testing.MethodsBeginning in 2018, Zimbabwe offered standard HIV testing at birth to high-risk HIV-exposed infants; as part of a pilot program, at 10 selected hospitals, POC birth testing (BT) was offered to every HIV-exposed infant. In order to understand experiences at the selected sites, 48 interviews were held: 23 with mothers and 25 with health workers, including 6 nurses-in-charge. Participants were purposively sampled across the participating sites. Interviews were held in English, Shona, or Ndebele, and transcribed in English. Line-by-line coding was carried out, and the constant comparison method of analysis was used to identify key themes for each respondent type.ResultsFindings were organized under four themes: challenges with BT, acceptability of BT, benefits of BT, and recommendations for BT programs. Overall, BT was well accepted by mothers and health workers because it encouraged mothers to better care for their uninfected newborns or initiate treatment more rapidly for infected infants. While the benefits were well understood, mothers felt there were some challenges, namely that they should be informed in advance about testing procedures and tested in a more private setting. Mothers and HCWs also recommended improving awareness of BT, both among health care workers and in the community in general, as well as ensuring that facilities are well-stocked with supplies and can deliver results in a timely way before scaling up programs.ConclusionsMothers and health workers strongly support implementation and expansion of birth testing programs due to the benefits for newborns. The challenges noted should be taken as planning guidance, rather than reasons to delay or discontinue birth testing programs.

Triple elimination is an initiative supporting the elimination of mother-to-child transmission of three diseases - human immunodeficiency virus (HIV) infection, syphilis and hepatitis B. Significant progress towards triple elimination has been made in some regions, but progress has been slow in sub-Saharan Africa, the region with the highest burden of these diseases. The shared features of the three diseases, including their epidemiology, disease interactions and core interventions for tackling them, enable an integrated health-systems approach for elimination of mother-to-child transmission. Current barriers to triple elimination in sub-Saharan Africa include a lack of policies, strategies and resources to support the uptake of well established preventive and treatment interventions. While much can be achieved with existing tools, the development of new products and models of care, as well as a prioritized research agenda, are needed to accelerate progress on triple elimination in sub-Saharan Africa. In this paper we aim to show that health systems working together with communities in sub-Saharan Africa could deliver rapid and sustainable results towards the elimination of mother-to-child transmission of all three diseases. However, stronger political support, expansion of evidence-based interventions and better use of funding streams are needed to improve efficiency and build on the successes in prevention of mother-to-child transmission of HIV. Triple elimination is a strategic opportunity to reduce the morbidity and mortality from HIV infection, syphilis and hepatitis B for mothers and their infants within the context of universal health coverage.La triple élimination est une initiative visant à soutenir l'éradication de la transmission mère-enfant de trois maladies – l'infection au virus de l'immunodéficience humaine (VIH), la syphilis et l'hépatite B. Bien que des avancées considérables aient été observées en ce sens dans certaines régions, les progrès demeurent lents en Afrique subsaharienne, pourtant durement touchée par ces maladies. Les caractéristiques communes aux trois affections, notamment leur épidémiologie, les interactions entre elles et les principales interventions nécessaires à leur prise en charge permettent aux systèmes de santé d'adopter une approche intégrée pour éviter la transmission mère-enfant. Plusieurs obstacles entravent actuellement la triple élimination en Afrique subsaharienne, parmi lesquels l'absence de politiques, de stratégies et de ressources pour garantir la disponibilité de traitements préventifs et curatifs bien établis. Les outils existants offrent déjà de nombreuses solutions; mais pour accélérer la progression de cette triple élimination en Afrique subsaharienne, il est indispensable de développer de nouveaux produits et modèles de soins, ainsi qu'un programme de recherche prioritaire. Dans le présent document, nous voulons montrer que si les systèmes de santé collaborent avec les communautés en Afrique subsaharienne, ils pourront obtenir des résultats rapides et durables en vue d'éradiquer la transmission mère-enfant des trois maladies susmentionnées. Néanmoins, une telle démarche implique un soutien politique massif, l'expansion des interventions fondées sur des données scientifiques, et une meilleure utilisation des sources de financement afin d'améliorer l'efficacité et de s'appuyer sur les réussites en matière de prévention de la transmission du VIH de la mère à l'enfant. La triple élimination représente une occasion stratégique de réduire la morbidité et la mortalité liées à l'infection au VIH, à la syphilis et à l'hépatite B, tant chez les mères que chez les nourrissons, dans un contexte de couverture maladie universelle.La triple eliminación es una iniciativa que apoya la eliminación de la transmisión maternoinfantil de tres enfermedades: la infección por el virus de la inmunodeficiencia humana (VIH), la sífilis y la hepatitis B. En algunas regiones se han logrado avances significativos hacia la triple eliminación, pero los progresos se han desarrollado con mayor lentitud en el África subsahariana, la región con la mayor carga de estas enfermedades. Las características comunes de las tres enfermedades, como su epidemiología, las interacciones entre ellas y las intervenciones básicas para combatirlas, permiten un enfoque integrado de los sistemas de salud para la eliminación de la transmisión maternoinfantil. Los obstáculos actuales para la triple eliminación en el África subsahariana incluyen la falta de políticas, estrategias y recursos para apoyar la adopción de intervenciones preventivas y de tratamiento bien establecidas. Aunque se puede lograr mucho con las herramientas existentes, se necesita el desarrollo de nuevos productos y modelos de atención, así como una agenda de investigación prioritaria, para acelerar el progreso de la triple eliminación en el África subsahariana. En este documento pretendemos demostrar que los sistemas de salud que trabajan conjuntamente con las comunidades del África subsahariana podrían obtener resultados rápidos y sostenibles hacia la eliminación de la transmisión maternoinfantil de las tres enfermedades. Sin embargo, se necesita un mayor apoyo político, la ampliación de las intervenciones basadas en la evidencia y un mejor uso de los flujos de financiación para mejorar la eficiencia y aprovechar los éxitos en la prevención de la transmisión maternoinfantil del VIH. La triple eliminación es una oportunidad estratégica para reducir la morbilidad y la mortalidad de la infección por el VIH, la sífilis y la hepatitis B para las madres y sus hijos en el contexto de la cobertura sanitaria universal.إن القضاء على هذه الأمراض الثلاثة هو مبادرة لدعم القضاء على انتقال ثلاثة أمراض من الأم إلى الطفل، وهي عدوى فيروس نقص المناعة البشرية (HIV)، والزهري، والالتهاب الكبدي ب. تم إحراز تقدم كبير نحو القضاء على هذه الأمراض الثلاثة في ​​بعض المناطق، إلا أن التقدم المحرز كان بطيئًا في جنوب الصحراء الكبرى بأفريقيا، وهي المنطقة التي تزخر بأكبر عبء لهذه الأمراض. إن السمات المشتركة لهذه الأمراض الثلاثة، بما يشمل سماتها في علم الأوبئة، وتفاعلاتها المرضية والتدخلات الأساسية للتعامل معها، تتيح اتباع نهج النظم الصحية المتكاملة للقضاء على انتقال العدوى من الأم إلى الطفل. إن العوائق الحالية أمام القضاء على الأمراض الثلاثة في جنوب الصحراء الكبرى بأفريقيا، تشمل الافتقار إلى السياسات والاستراتيجيات والموارد لدعم استيعاب التدخلات الوقائية والعلاجية الراسخة. بينما يمكن إنجاز الكثير باستخدام الأدوات الحالية، إلا أن هناك حاجة إلى تطوير منتجات ونماذج جديدة للرعاية، وكذلك وضع جدول أعمال بحثي على رأس الأولويات، لتسريع التقدم في القضاء على الأمراض الثلاثة في جنوب الصحراء الكبرى بأفريقيا. نهدف في هذه الورقة البحثية إلى توضيح أن الأنظمة الصحية التي تعمل جنبًا إلى جنب مع المجتمعات في جنوب الصحراء الكبرى بأفريقيا، يمكنها أن تحقق نتائج سريعة ومستدامة في سبيل القضاء على انتقال الأمراض الثلاثة من الأم إلى الطفل. وبالرغم من ذلك، فإن هناك حاجة إلى دعم سياسي أقوى، وتوسيع نطاق التدخلات المعتمدة على الدلائل، واستخدام أفضل لتدفقات التمويل، وذلك لتحسين الكفاءة، واستغلال النجاحات في الحيلولة دون انتقال فيروس نقص المناعة البشرية من الأم إلى الطفل. إن القضاء على الأمراض الثلاثة هو فرصة استراتيجية للحد من الحالات المرضية والوفيات من جراء عدوى فيروس نقص المناعة البشرية والزهري والالتهاب الكبدي ب، لكل من الأمهات ومواليدهن في سياق التغطية الصحية الشاملة.三重消除是一项支持消除三种疾病【人类免疫缺陷病毒 (HIV) 感染、梅毒和乙型肝炎】母婴传播的计划。在有些地区，三重消除取得了重大进展，但在撒哈拉以南非洲地区，该计划的进展缓慢，因此，该地区在对抗这些疾病方面的任务最为繁重。这三种疾病在其流行病学、疾病相互作用和相关核心干预措施方面具有共同特点，因此，卫生系统能够综合采取方法来消除母婴传播。目前阻碍撒哈拉以南非洲地区三重消除计划实施的障碍包括缺乏支持采用既定预防和治疗措施的政策、战略和资源。虽然利用现有工具可取得很大的成就，但还是需要开发新的护理产品和模式，并制定优先研究议程，以加快撒哈拉以南非洲地区三重消除计划的进展。在本文中，我们的目的在于表明撒哈拉以南非洲地区的卫生系统与社区开展合作，能够为消除这三种疾病的母婴传播带来迅速且可持续的效果。但是，需要加强政治支持、扩大循证干预措施和更好地利用资金流，以提高效率，并在预防 HIV 母婴传播方面奠定成功的基础。三重消除是一种战略机遇，可以在全民保健范围内降低母亲及其婴儿因感染 HIV、梅毒和乙型肝炎而导致的发病率和死亡率。.Тройная элиминация, это инициатива, поддерживающая элиминацию передачи от матери ребенку трех заболеваний: инфекции, вызванной вирусом иммунодефицита человека (ВИЧ), сифилиса и гепатита В. В некоторых регионах был достигнут значительный прогресс в направлении тройной элиминации, однако на территориях к югу от Сахары (в регионе Африки с самым высоким бременем этих болезней) такой прогресс был медленным. Общие характеристики трех болезней, включая их эпидемиологию, взаимодействие болезней и основные меры по борьбе с ними, позволяют использовать комплексный подход в рамках систем здравоохранения к элиминации передачи от матери ребенку. Текущие препятствия на пути тройной элиминации в странах Африки к югу от Сахары включают отсутствие политик, стратегий и ресурсов для поддержки внедрения хорошо зарекомендовавших себя профилактических и лечебных мер. Несмотря на то что с помощью существующих инструментов можно добиться многого, для ускорения прогресса в области тройной элиминации в странах Африки к югу от Сахары необходима разработка новых продуктов и моделей оказания медицинской помощи, а также повестка дня в области приоритетных научных исследований. В этом документе авторы стремятся показать, что системы здравоохранения, работающие вместе с общественностью в странах Африки к югу от Сахары, могут обеспечить быстрые и устойчивые результаты в направлении элиминации передачи всех трех заболеваний от матери ребенку. Однако для повышения эффективности и достижения успехов в профилактике передачи ВИЧ от матери ребенку необходимы: более сильная политическая поддержка, расширение научно обоснованных мер и лучшее использование потоков финансирования. Тройная элиминация, это стратегическая возможность снизить заболеваемость и смертность от ВИЧ-инфекции, сифилиса и гепатита B для матерей и их младенцев в контексте всеобщего охвата услугами здравоохранения.

Supplemental Digital Content is Available in the Text., Background: Although the World Health Organization recommends HIV-exposed infants receive a 6-week diagnostic test, few receive results by 12 weeks. Point-of-care (POC) early infant diagnosis (EID) may improve timely diagnosis and treatment. This study assesses the impact of routine POC versus laboratory-based EID on return of results by 12 weeks of age. Methods: This was a cluster-randomized stepped-wedge trial in Kenya and Zimbabwe. In each country, 18 health facilities were randomly selected for inclusion and randomized to timing of POC implementation. Findings: Nine thousand five hundred thirty-nine infants received tests: 5115 laboratory-based and 4424 POC. In Kenya and Zimbabwe, respectively, caregivers were 1.29 times [95% confidence interval (CI): 1.27 to 1.30, P < 0.001] and 4.56 times (95% CI: 4.50 to 4.60, P < 0.001) more likely to receive EID results by 12 weeks of age with POC versus laboratory-based EID. POC significantly reduced the time between sample collection and return of results to caregiver by an average of 23.03 days (95% CI: 4.85 to 21.21, P < 0.001) in Kenya and 62.37 days (95% CI: 58.94 to 65.80, P < 0.001) in Zimbabwe. For HIV-infected infants, POC significantly increased the percentage initiated on treatment, from 43.2% to 79.6% in Zimbabwe, and resulted in a nonsignificant increase in Kenya from 91.7% to 100%. The introduction of POC EID also significantly reduced the time to antiretroviral therapy initiation by an average of 17.01 days (95% CI: 9.38 to 24.64, P < 0.001) in Kenya and 56.00 days (95% CI: 25.13 to 153.76, P < 0.001) in Zimbabwe. Conclusions: POC confers significant advantage on the proportion of caregivers receiving timely EID results, and improves time to results receipt and treatment initiation for infected infants. Where laboratory-based EID systems are unable to deliver results to caregivers rapidly, POC should be implemented as part of an integrated testing system.

Background In 2017, Zimbabwe adopted a modified version of the World Health Organization 2016 recommendation on HIV birth testing by offering HIV testing at birth only to infants at "high risk" of HIV transmission. There is limited evidence on the effectiveness of this approach. Our study assessed the sensitivity and specificity of birth testing "high risk" infants only. Methods We conducted a cross-sectional study at 10 health facilities from November 2018 to July 2019. A nucleic acid test for HIV was performed on all HIV-exposed infants identified within 48 hours of life, irrespective of risk status. Univariate and bivariate analyses were used to estimate the performance of the risk screening tool. Results HIV nucleic acid test was successfully performed on 1970 infants (95%), of whom 266 (13.5%) were classified as high-risk infants. HIV prevalence for all infants tested was 1.5% (95% CI: 1% to 2%), whereas prevalence among high-risk infants and low-risk infants was 6.8% (95% CI: 3.7% to 9.8%) and 0.6% (95% CI: 0.3% to 1%) respectively. Sensitivity and specificity of the maternal risk screening tool was at 62.1% (95% CI: 44.4% to 79.7%) and 87.2% (95% CI: 85.7% to 88.7%), respectively; positive and negative predictive values were 6.8% (95% CI: 3.7% to 9.8%) and 99.4% (95% CI: 99.0% to 99.7%) respectively. Conclusions Despite high negative predictive value, sensitivity was relatively low, with potential of missing 2 in every 5 HIV infected infants. Given the potential benefits of early ART initiation for all exposed infants, where feasible, universal testing for HIV-exposed infants at birth may be preferred to reduce missing infected infants.

Although mother-to-child transmission (MTCT) of human immunodeficiency virus (HIV) is preventable through antiretroviral treatment (ART) during pregnancy and postpartum, the Joint United Nations Programme on HIV/AIDS (UNAIDS) estimates that 160,000 new HIV infections occurred among children in 2018 (1). Child survival and HIV-free survival rates* are standard measures of progress toward eliminating MTCT† (2). Nationally representative Population-based HIV Impact Assessment (PHIA)§ survey data, pooled from eight sub-Saharan African countries¶ were used to calculate survival probability among children aged ≤3 years by maternal HIV status during pregnancy and HIV-free survival probability among children aged ≤3 years born to women with HIV infection, stratified by maternal ART** status during pregnancy. Survival probability was significantly lower among children born to women with HIV infection (94.7%) than among those born to women without HIV infection (97.6%). HIV-free survival probability of children born to women with HIV infection differed significantly by the timing of initiation of maternal ART: 93.0% among children whose mothers received ART before pregnancy, 87.8% among those whose mothers initiated ART during pregnancy, and 53.4% among children whose mothers did not receive ART during pregnancy. Focusing on prevention of HIV acquisition and, among women of reproductive age with HIV infection, on early diagnosis of HIV infection and ART initiation when applicable, especially before pregnancy, can improve child survival and HIV-free survival.

Diarrhoeal illness is a leading cause of childhood morbidity and mortality and has long-term negative impacts on child development. Although flooring, water and sanitation have been identified as important routes of transmission of diarrhoeal pathogens, research examining variability in the association between flooring and diarrhoeal illness by water and sanitation is limited.We utilised cross-sectional data collected for the evaluation of Zimbabwe's Prevention of Mother-to-Child HIV transmission programme in 2014 and 2017-18. Mothers of infants 9-18 months of age self-reported the household's source of drinking water and type of sanitation facility, as well as infant diarrhoeal illness in the four weeks prior to the survey. Household flooring was assessed using interviewer observation, and households in which the main material of flooring was dirt/earthen were classified as having unimproved flooring, and those with solid flooring (e.g. cement) were classified as having improved flooring.Mothers of infants living in households with improved flooring were less likely to report diarrhoeal illness in the last four weeks (PDOur findings support the hypothesis that household flooring is an important pathway for the transmission of diarrhoeal pathogens, even in settings where other aspects of sanitation are sub-optimal. Improvements to household flooring do not require behaviour change and may be an effective and expeditious strategy for reducing childhood diarrhoeal illness irrespective of household access to improved water and sanitation.Les maladies diarrhéiques sont l'une des principales causes de morbidité et de mortalité infantiles et ont des effets négatifs à long terme sur le développement de l'enfant. Bien que le revêtement de sol, l'eau et l'assainissement aient été identifiés comme des voies de transmission importantes des agents pathogènes diarrhéiques, la recherche examinant la variabilité de l'association entre le revêtement de sol et les maladies diarrhéiques par l'eau et les sanitaires est rare. MÉTHODES: Nous avons utilisé des données transversales collectées pour l'évaluation du programme de prévention de la transmission du VIH de la mère à l'enfant au Zimbabwe en 2014 et 2017-18. Les mères de nourrissons âgés de 9 à 18 mois ont déclaré la source d'eau potable du ménage et le type d'installation sanitaire, ainsi que les maladies diarrhéiques de l’enfant au cours des quatre semaines précédant l'enquête. Le revêtement de sol des ménages a été évalué en utilisant l'observation de l'intervieweur. Les ménages dont le principal matériau de revêtement de sol était de la terre étaient classés comme ayant un revêtement de sol non amélioré et les ménages dont le revêtement de sol était en ciment étaient classés comme ayant un revêtement de sol amélioré. RÉSULTATS: Les mères de nourrissons vivant dans des ménages avec un revêtement de sol amélioré étaient moins susceptibles de déclarer une maladie diarrhéique au cours des quatre semaines précédentes (PDNos résultats corroborent l'hypothèse selon laquelle le revêtement de sol domestique est une voie importante pour la transmission d'agents pathogènes diarrhéiques, même dans des contextes où d'autres aspects des sanitaires ne sont pas optimaux. L'amélioration du revêtement de sol domestique ne nécessite pas de changement de comportement et peut être une stratégie efficace et rapide pour réduire les maladies diarrhéiques infantiles, indépendamment de l'accès des ménages à une eau et à des sanitaires améliorés.

BACKGROUND: Improving efforts toward elimination of mother-to-child transmission of HIV requires timely early infant diagnosis (EID) among all HIV-exposed infants, but the occurrence of timely EID and infant survival may be underascertained in routine, facility-bound program data. METHODS: From March 2015 to May 2015, we traced a random sample of HIV-positive mother and HIV-exposed infant pairs lost to follow-up for EID in facility registers in Zimbabwe. We incorporated updated information into weighted survival analyses to estimate incidence of EID and death. Reasons for no EID were surveyed from caregivers. RESULTS: Among 2651 HIV-positive women attending antenatal care, 1823 (68.8%) infants had no documented EID by 3 months of age. Among a random sample of 643 (35.3%) HIV-exposed infants lost to follow-up for EID, vital status was ascertained among 371 (57.7%) and updated care status obtained from 256 (39.8%) mothers traced. Among all HIV-infected mother-HIV-exposed infant pairs, weighted estimates found cumulative incidence of infant death by 90 days of 3.9% (95% confidence interval: 3.4% to 4.4%). Cumulative incidence of timely EID with death as a competing risk was 60%. The most frequently cited reasons for failure to uptake EID were "my child died" and "I didn't know I should have my child tested." CONCLUSIONS: Our findings indicate uptake of timely EID among HIV-exposed infants is underestimated in routine health information systems. High, early mortality among HIV-exposed infants underscores the need to more effectively identify HIV-positive mother-HIV exposed infant pairs at high risk of adverse outcomes and loss to follow-up for enhanced interventions.

Background\ud \ud Maternal mental morbidity and low perinatal health service utilisation in resource-constrained settings contribute substantially to the global burden of poor maternal, newborn, and child health. The community-based Mbereko+Men program in rural Zimbabwe engaged women and men in complementary activities to improve men’s support for women and babies, coparents’ equitable, informed health decision-making, and ultimately, maternal mental health and care-seeking for maternal and newborn health services. The study aimed to test the effectiveness of the Mbereko+Men program on maternal mental health at 0-6 months after childbirth.\ud \ud Methods\ud \ud We conducted a cluster-randomised controlled pragmatic trial using a two-arm parallel design with four clusters per arm. Data was data collected through cross-sectional surveys before and after the implementation of the intervention or standard care. Rural health facility catchments in Mutasa District, Zimbabwe, were randomised using a true random number sequence. Survey participants were women who had given birth within 0-6 months and their male coparents. The primary outcome was women’s mean Edinburgh Postnatal Depression Scale (EPDS) score. Secondary outcomes captured care-seeking, men’s supportive behaviours, and gender dynamics in coparent relationships. Masking was not used. All clusters were included in the analysis. The trial was registered with the Australian New Zealand Clinical Trials Registry (ACTRN12620001014943) in October 2020.\ud \ud Results\ud \ud Between April 13 and May 20, 2016, 457 women and 242 men participated in the pre-intervention survey; between October 19 and November 30, 2017, 433 women and 273 men participated in the post-intervention survey. Women’s mean EPDS scores declined in both arms. The decline was 34% greater in the intervention arm (adjusted risk ratio = 0.66; 95% confidence interval = 0.48, 0.90, P = 0.008). Improvements in care-seeking, men’s support, and coparents’ relationships were detected.\ud \ud Conclusions\ud \ud A low-intensity gender-synchronised intervention engaged women and men to improve maternal mental health and care-seeking in a setting characterised by gender inequality and demand-side barriers to care.

Despite considerable progress in paediatric HIV treatment and timely revision of global policies recommending the use of more effective and tolerable antiretroviral regimens, optimal antiretroviral formulations for infants, children, and adolescents remain limited. The Paediatric Antiretroviral Drug Optimization group reviews medium-term and long-term priorities for antiretroviral drug development to guide industry and other stakeholders on formulations most needed for low-income and middle-income countries. The group convened in December, 2018, to assess progress since the previous meeting and update the list of priority formulations. Issues relating to drug optimisation for neonatal prophylaxis and paediatric treatment, and those relating to the investigation of novel antiretrovirals in adolescents and pregnant and lactating women were also discussed. Continued focus on identifying, prioritising, and providing access to optimal antiretroviral formulations suitable for infants, children, and adolescents is key to ensuring that global HIV treatment targets can be met.

Background In 2013, the World Health Organisation (WHO) recommended Option B+ as a strategy to prevent mother-to-child transmission (PMTCT) of HIV. In option B+ , lifelong antiretroviral therapy (ART) is offered to all HIV positive pregnant and breastfeeding women to reduce MTCT rate to less than or equal to 5%. Its success depends on retaining women on ART during pregnancy, delivery and breast-feeding period. There is limited data on early retention on ART among pregnant women in Zimbabwe. We therefore assessed early retention among women on Option B + from antenatal care (ANC) until 6 months post ANC booking and at delivery in Bulawayo city and Mazowe rural district of Zimbabwe. Methods We collected data for pregnant women booking for ANC between January and March 2018, comparing early retention among ART naïve women and those already on ART. The two cohorts were followed up for 6 months post ANC booking, and this was done in two districts. Data were collected from routine tools used at facility level which include ANC, delivery and ART registers. The Kaplan-Meier survival analysis was used to estimate retention probabilities at 1, 3 and 6 months post-delivery and for retention at delivery proportions were used. Poisson regression was used to investigate factors associated with non-retention at 6 months post ANC booking. Results A total of 388 women were included in the study with median age of 29 years (IQR: 25–34). Two-thirds booked in their second trimester. Retention at 3 and 6 months post ANC booking was 84% (95% CI 80–88) and 73% (95% CI 69–78) respectively. At delivery 81% (95% CI 76–84) were retained in care, 18% lost-to-follow-up and 1% transferred out. In this study we did not find marital status, gestation age, facility location, ART status at ANC booking, to be associated with loss to follow-up. Conclusion In this study, we found low retention at 3, 6 months and delivery, a threat to elimination of Mother-to-child Transmission of HIV in Zimbabwe. Our findings emphasize the need for enhanced interventions to improve early retention such as post-test counselling, patient tracing and visit reminders.

Background Achievement of the elimination target for mother-to-child transmission (MTCT) of HIV in selected countries has increased hope to end the HIV epidemic in children across the world. However, MTCT rates remain well above the 5% elimination target in most sub-Saharan Africa countries. These countries require innovative strategies to scale-up their interventions to end paediatric HIV. We describe how the Elizabeth Glaser Paediatric AIDS Foundation (EGPAF) consortium and the Children’s Investment Fund Foundation (CIFF) used the critical path method to facilitate rapid expansion and optimization of 2010 and 2013 WHO PMTCT guidelines to reduce Zimbabwe’s MTCT rate from 22% in 2010 to 6.4% in 2015. Methods We analysed activities implemented and PMTCT programme data for the period before and during the EGPAF-CIFF project. The critical path method involved a cycle of collecting and analysing quarterly PMTCT indicator data and planning and implementing targeted activities to improve the PMTCT indicators. We performed a graphical trend analysis of data that measured availability of PMTCT services. Using Pearson’s Chi2 test, we compared results of PMTCT uptake indicators at the start and end of the EGPAF-CIFF project and used regression discontinuity analysis to assess effectiveness of activities implemented to improve the PMTCT service uptake indicators. Results Zimbabwe rolled out WHO 2010 and 2013 PMTCT guidelines in less than 1 year during the EGPAF-CIFF project, yet it took more than 4 years to roll-out previous guidelines. All PMTCT indicators increased significantly (p Conclusion Zimbabwe rapidly rolled-out and optimised new WHO PMTCT guidelines and drastically reduced its MTCT rate using the critical path method. We recommend wider use of the critical path method in public health programmes.

Introduction\ud Despite improvements in prevention of mother‐to‐child transmission (PMTCT) of HIV outcomes, there remain unacceptably high numbers of mother‐to‐child transmissions (MTCT) of HIV. Programmes and research collect multiple sources of PMTCT data, yet this data is rarely integrated in a systematic way. We conducted a data integration exercise to evaluate the Zimbabwe national PMTCT programme and derive lessons for strengthening implementation and documentation.\ud \ud Methods\ud We used data from four sources: research, Ministry of Health and Child Care (MOHCC) programme, Implementer – Organization for Public Health Interventions and Development, and modelling. Research data came from serial population representative cross‐sectional surveys that evaluated the national PMTCT programme in 2012, 2014 and 2017/2018. MOHCC and Organization for Public Health Interventions and Development collected data with similar indicators for the period 2018 to 2019. Modelling data from 2017/18 UNAIDS Spectrum was used. We systematically integrated data from the different sources to explore PMTCT programme performance at each step of the cascade. We also conducted spatial analysis to identify hotspots of MTCT.\ud \ud Results\ud We developed cascades for HIV‐positive and negative‐mothers, and HIV exposed and infected infants to 24 months post‐partum. Most data were available on HIV positive mothers. Few data were available 6‐8 weeks post‐delivery for HIV exposed/infected infants and none were available post‐delivery for HIV‐negative mothers. The different data sources largely concurred. Antenatal care (ANC) registration was high, although women often presented late. There was variable implementation of PMTCT services, MTCT hotspots were identified. Factors positively associated with MTCT included delayed ANC registration and mobility (use of more than one health facility) during pregnancy/breastfeeding. There was reduced MTCT among women whose partners accompanied them to ANC, and infants receiving antiretroviral prophylaxis. Notably, the largest contribution to MTCT was from postnatal women who had previously tested negative (12/25 in survey data, 17.6% estimated by Spectrum modelling). Data integration enabled formulation of interventions to improve programmes.\ud \ud Conclusions\ud Data integration was feasible and identified gaps in programme implementation/documentation leading to corrective interventions. Incident infections among mothers are the largest contributors to MTCT: there is need to strengthen the prevention cascade among HIV‐negative women.

Objective To examine morbidity and mortality risk among HIV-exposed uninfected (HEU) infants. Design Secondary data analysis of HEU infants in a prospective cohort study of mother-infant pairs. Methods Infants were recruited from immunization clinics (n = 151) in Zimbabwe from February to August 2013, enrolled at 4-12 weeks age, and followed every 3 months until incident HIV-infection, death, or 18-month follow-up. We estimated cumulative mortality probability and hazard ratios with 95% confidence intervals (CIs) using Kaplan-Meier curves and Cox regression, respectively. We also described reported reasons for infant hospitalization and symptoms preceding death. Median weight-for-age z-scores (WAZ) and median age were calculated and analyzed across study visits. Results Of 1188 HIV-exposed infants, 73 (6.1%) contracted HIV; we analyzed the remaining 1115 HEU infants. In total, 54 (4.8%) infants died, with median time to death of 5.5 months since birth (interquartile range: 3.6-9.8 months). Diarrhea, difficulty breathing, not eating, fever, and cough were commonly reported (range: 7.4-22.2%) as symptoms preceding infant death. Low birth weight was associated with higher mortality (adjusted hazard ratio 2.66, CI: 1.35-5.25), whereas maternal antiretroviral therapy predelivery (adjusted hazard ratio 0.34, CI: 0.18-0.64) and exclusive breastfeeding (adjusted hazard ratio 0.50, CI: 0.28-0.91) were associated with lower mortality. Overall, 9.6% of infants were hospitalized. Infant median WAZ declined after 3 months of age, reaching a minimum at 14.5 months of age, at which 50% of infants were underweight (WAZ below -2.0). Conclusion Clinical interventions including maternal antiretroviral therapy; breastfeeding and infant feeding counseling and support; and early prevention, identification, and management of childhood illness; are needed to reduce HEU infant morbidity and mortality.

Introduction Uptake of early infant HIV diagnosis (EID) varies widely across sub-Saharan African settings. We evaluated the potential clinical impact and cost-effectiveness of universal maternal HIV screening at infant immunization visits, with referral to EID and maternal antiretroviral therapy (ART) initiation. Methods Using the CEPAC-Pediatric model, we compared two strategies for infants born in 2017 in Cote d'Ivoire (CI), South Africa (SA), and Zimbabwe: (1) existing EID programmes offering six-week nucleic acid testing (NAT) for infants with known HIV exposure (EID), and (2) EID plus universal maternal HIV screening at six-week infant immunization visits, leading to referral for infant NAT and maternal ART initiation (screen-and-test). Model inputs included published Ivoirian/South African/Zimbabwean data: maternal HIV prevalence (4.8/30.8/16.1%), current uptake of EID (40/95/65%) and six-week immunization attendance (99/74/94%). Referral rates for infant NAT and maternal ART initiation after screen-and-test were 80%. Costs included NAT ($24/infant), maternal screening ($10/mother-infant pair), ART ($5 to 31/month) and HIV care ($15 to 190/month). Model outcomes included mother-to-child transmission of HIV (MTCT) among HIV-exposed infants, and life expectancy (LE) and mean lifetime per-person costs for children with HIV (CWH) and all children born in 2017. We calculated incremental cost-effectiveness ratios (ICERs) using discounted (3%/year) lifetime costs and LE for all children. We considered two cost-effectiveness thresholds in each country: (1) the per-capita GDP ($1720/6380/2150) per year-of-life saved (YLS), and (2) the CEPAC-generated ICER of offering 2 versus 1 lifetime ART regimens (e.g. offering second-line ART; $520/500/580/YLS). Results With EID, projected six-week MTCT was 9.3% (CI), 4.2% (SA) and 5.2% (Zimbabwe). Screen-and-test decreased total MTCT by 0.2% to 0.5%, improved LE by 2.0 to 3.5 years for CWH and 0.03 to 0.07 years for all children, and increased discounted costs by $17 to 22/child (all children). The ICER of screen-and-test compared to EID was $1340/YLS (CI), $650/YLS (SA) and $670/YLS (Zimbabwe), below the per-capita GDP but above the ICER of 2 versus 1 lifetime ART regimens in all countries. Conclusions Universal maternal HIV screening at immunization visits with referral to EID and maternal ART initiation may reduce MTCT, improve paediatric LE, and be of comparable value to current HIV-related interventions in high maternal HIV prevalence settings like SA and Zimbabwe.

In their recent article in The BMJ (“Is elimination of vertical transmission of HIV in high prevalence settings achievable?”)1 Goga and colleagues make several important points, including that more realistic targets are needed to maintain momentum to reduce vertical transmission of HIV in countries with high prevalence. They also make a constructive proposal to encourage countries to use “dashboards” to track key coverage and process indicators, particularly during the “pre-elimination period,” and to encourage continuous programme assessment and use of data for improvement. We are concerned, however, that they misrepresent the World Health Organization (WHO) and global partners’ elimination of mother-to-child transmission of HIV and syphilis (EMTCT) initiative.2 The authors include a box showing the criteria for elimination of vertical transmission of HIV from the …

Zimbabwe has made large strides in addressing HIV. To ensure a continued robust response, a clear understanding of costs associated with its HIV program is critical. We conducted a cross-sectional evaluation in 2017 to estimate the annual average patient cost for accessing Prevention of Mother-To-Child Transmission (PMTCT) services (through antenatal care) and Antiretroviral Treatment (ART) services in Zimbabwe. Twenty sites representing different types of public health facilities in Zimbabwe were included. Data on patient costs were collected through in-person interviews with 414 ART and 424 PMTCT adult patients and through telephone interviews with 38 ART and 47 PMTCT adult patients who had missed their last appointment. The mean and median annual patient costs were examined overall and by service type for all participants and for those who paid any cost. Potential patient costs related to time lost were calculated by multiplying the total time to access services (travel time, waiting time, and clinic visit duration) by potential earnings (US$75 per month assuming 8 hours per day and 5 days per week). Mean annual patient costs for accessing services for the participants was US$20.00 [standard deviation (SD) = US$80.42, median = US$6.00, range = US$0.00–US$12,18.00] for PMTCT and US$18.73 (SD = US$58.54, median = US$8.00, range = US$0.00–US$ 908.00) for ART patients. The mean annual direct medical costs for PMTCT and ART were US$9.78 (SD = US$78.58, median = US$0.00, range = US$0.00–US$ 90) and US$7.49 (SD = US$60.00, median = US$0.00) while mean annual direct non-medical cost for US$10.23 (SD = US$17.35, median = US$4.00) and US$11.23 (SD = US$25.22, median = US$6.00, range = US$0.00–US$ 360.00). The PMTCT and ART costs per visit based on time lost were US$3.53 (US$1.13 to US$8.69) and US$3.43 (US$1.14 to US$8.53), respectively. The mean annual patient costs per person for PMTCT and ART in this evaluation will impact household income since PMTCT and ART services in Zimbabwe are supposed to be free.

Age-disaggregated analyses of prevention of mother-to-child transmission (PMTCT) program data to assess the uptake of HIV services by pregnant adolescent women are limited but are critical to understanding the unique needs of this vulnerable, high risk population. We conducted a retrospective analysis of patient-level PMTCT data collected from 2011 to 2013 in 36 health facilities in 5 districts of Zimbabwe using an electronic database. We compared uptake proportions for PMTCT services between adolescent ( 19 years) women. Multivariable binomial regression analysis was used to estimate the association of the women’s age group with each PMTCT service indicator. The study analysed data from 22,215 women aged 12 to 50 years (22.5% adolescents). Adolescents were more likely to present to ANC before 14 weeks gestational age compared to older women (adjusted relative risk (aRR)=1.34; 95% confidence interval (CI): 1.22–1.47) with equally low rates of completion of four ANC visits. Adolescents were less likely to present with known HIV status (aRR=0.34; 95% CI: 0.29–0.41) but equally likely to be HIV tested in ANC. HIV prevalence was 5.5% in adolescents versus 20.1% in adults. While > 84% of both HIV-positive groups received ARVs for PMTCT, 44% of eligible adolescents were initiated on ART versus 51.3% of eligible adults, though not statistically significant. Pregnant adolescents must be a priority for primary HIV prevention services and expanded HIV treatment services among pregnant women to achieve an AIDS-free generation in Zimbabwe and similar high HIV burden countries. This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.

INTRODUCTION Scale-up of Option B+ in Zimbabwe has increased antiretroviral therapy (ART) coverage but patient loss-to-follow-up remains high; thus, effective strategies to improve retention in care are needed. Evidence for Elimination, a cluster randomized controlled trial, evaluated the impact of point-of-care (POC) CD4 testing with CD4 count-specific adherence counseling on rates of retention among 1150 HIV-positive pregnant women initiating ART in Zimbabwe. METHODS Thirty-two primary care health facilities were randomized to offer either standard-of-care (SOC) or POC CD4 testing plus CD4-specific counseling to clients (POC Plus). The primary outcome was the proportion of HIV-positive pregnant women retained on ART after 12 months, calculated by cluster-adjusted proportions, unadjusted and adjusted relative risks (RR and aRR, respectively). RESULTS Retention in care 12 months after initiation was 50.7% and 54.5% in the POC Plus and SOC arms, respectively (RR 0.93, 95% confidence interval [CI]: 0.78 to 1.11; aRR 0.91, 95% CI: 0.77 to 1.07). Although considered not retained, 9.7% transferred to another facility and 0.2% died. Most women, 95.3% in POC Plus and 92.9% in SOC, initiated ART within 1 month of antenatal booking (RR 1.03, 95% CI: 0.97 to 1.08). DISCUSSION Although patient retention was similar in both arms, women in the POC Plus arm were more likely to have received a CD4 test at booking and a repeat CD4 test later in care. CD4 is no longer required for treatment initiation but is still recommended in national guidelines and is of value in clinical management. Further work is needed to identify effective strategies to increase patient retention in ART care.

BackgroundGlobally, ten percent of new HIV infections are among children and most of these children acquire infection through mother-to-child transmission. To prevent this, lifelong ART among pregnant and breast feeding (PBF) women living with HIV, irrespective of the WHO clinical stage, was adopted (option B+). There is limited cohort-wise assessment of VL testing among women on 'option B+'.ObjectiveAmong a pregnancy cohort on antiretroviral therapy in public hospitals and clinics of Mazowe district, Zimbabwe (2017), to determine the i) proportion undergoing VL testing anytime up to six months post child birth and associated factors; ii) turnaround time (TAT) from sending the specimen to results receipt and VL suppression among those undergoing VL testing.MethodsThis was a cohort study involving secondary programme data. Modified Poisson regression using robust variance estimates was used to determine the independent predictors of VL testing.ResultsOf 1112 women, 354 (31.8%, 95% CI: 29.2-34.6) underwent VL testing: 113 (31.9%) during pregnancy, 124 (35%) within six months of child birth and for 117 (33.1%), testing period was unknown. Of 354, VL suppression was seen in 334 (94.4%) and 13 out of 20 with VL non-suppression underwent repeat VL testing. Among those with available dates (125/354), the median TAT was 93 days (IQR 19.3-255). Of 1112, VL results were available between 32 weeks and child birth in 31 (2.8%) women. When compared to hospitals, women registered for antenatal care in clinics were 36% less likely to undergo VL testing [aRR: 0.64 (95% CI: 0.53, 0.76)].ConclusionAmong women on option B+, the uptake of HIV VL testing was low with unacceptably long TAT. VL suppression among those tested was satisfactory. There is an urgent need to prioritize VL testing among PBF women and to consider use of point of care machines. There is a critical need to strengthen the recording and local utilisation of routine clinic data in order to successfully monitor progress of healthcare services provided.

Purpose We assessed 18-month cumulative mother-to-child HIV transmission (MTCT) risk and risk factors for no antiretroviral medication use during pregnancy among adolescent, young women, and adult mothers in Zimbabwe. Methods We analyzed data from a prospective survey of 1,171 mother–infant pairs with HIV-exposed infants aged 4–12 weeks who were recruited from 151 immunization clinics from February to August 2013. HIV-exposed infants were followed until diagnosed with HIV, death, or age 18 months. Findings were weighted and adjusted for complex survey design and nonresponse. Results The 18-month cumulative MTCT risk was highest among adolescent aged ≤19 years (12%) followed by young women aged 20–24 years (7.5%) and adult women aged ≥25 years (6.9%). Across these groups, more than 94% had ≥1 antenatal care visit by 21 weeks of gestation, more than 95% had ≥1 HIV test, and more than 98% knew their HIV status. Of known HIV-positive mothers, maternal antiretroviral medication coverage during pregnancy was 76.8% (95% confidence interval: 65.1–85.5), 83.8% (78.6–87.9), and 87.8% (84.6–90.4) among adolescent, young women, and adult mothers, respectively. Among HIV-positive mothers diagnosed prenatally, the adjusted odds ratio of no ARV use during pregnancy was increased among those who had no antenatal care attendance (adjusted odds ratio: 7.7 [3.7–16.0]), no HIV testing (7.3 [2.3–23.5]), no prepartum CD4 count testing (2.1 [1.3–3.4]), and maternal HIV identification during pregnancy (2.9 [1.8–4.8]). Age was not a risk factor. Conclusions With similar coverage of prevention of MTCT services, the 18-month cumulative MTCT risk was higher among adolescents and young women, compared with adults. Additional research should examine the causes to develop targeted interventions.

Background WHO recommends that HIV infected women receive antiretroviral therapy (ART) minimally during pregnancy and breastfeeding (“Option B”), or ideally throughout their lives regardless of clinical stage (“Option B+”) (Coovadia et al., Lancet 379:221–228, 2012). Although these recommendations were based on clinical trials demonstrating the efficacy of ART during pregnancy and breastfeeding, the population-level effectiveness of Option B+ is unknown, as are retention on ART beyond the immediate post-partum period, and the relative impact and cost-effectiveness of Option B+ compared to Option A (Centers for Disease Control and Prevention, Morb Mortal Wkly Rep 62:148–151, 2013; Ahmed et al., Curr Opin HIV AIDS 8:473–488, 2013). To address these issues, we conducted an impact evaluation of Zimbabwe’s prevention of mother to child transmission programme conducted between 2011 and 2018 using serial, community-based cross-sectional serosurveys, which spanned changes in WHO recommendations. Here we describe the rationale for the design and analysis. Methods/design Our method is to survey mother-infant pairs residing in the catchment areas of 157 health facilities randomly selected from 5 of 10 provinces in Zimbabwe. We collect questionnaires, blood samples from mothers and babies for HIV antibody and viral load testing, and verbal autopsies for deceased mothers/babies. Using this approach, we collected data from two previous time points: 2012 (pre-Option A standard of care), 2014 (post-Option A / pre-Option B+) and will collect a third round of data in 2017–18 (post Option B+ implementation) to monitor population-level trends in mother-to-child transmission of HIV (MTCT) and HIV-free infant survival. In addition, we will collect detailed information on facility level factors that may influence service delivery and costs. Discussion Although the efficacy of antiretroviral therapy (ART) during pregnancy and breastfeeding for prevention of mother-to-child transmission of HIV (PMTCT) has been well-documented in randomized trials, little evidence exists on the population-level impact and cost-effectiveness of Option B+ or the influence of the facility on implementation (Siegfried et al., Cochrane Libr 7:CD003510, 2017). This study will provide essential data on these gaps and will provide estimates on retention in care among Option B+ clients after the breastfeeding period. Trial registration NCT03388398 Retrospectively registered January 3, 2018.

BackgroundDespite high antiretroviral (ARV) treatment coverage among pregnant women for prevention of mother-to-child transmission (PMTCT) of Human Immunodeficiency Virus (HIV) in Zimbabwe, the MTCT rate is still high. Therefore in 2016, the country adopted World Health Organization recommendations of stratifying pregnant women into "High" or"Low" MTCT risk for subsequent provision of HIV exposed infant (HEI) with appropriate follow-up care according to risk status.ObjectiveThe study sought to ascertain, among pregnant women who delivered in clinics of Harare in August 2017: the extent to which high risk MTCT pregnancies were identified at time of delivery; and whether their newborns were initiated on appropriate ARV prophylaxis, cotrimoxazole prophylaxis, subjected to early HIV diagnostic testing and initiated on ARV treatment.MethodsCross-sectional study using review of records of routinely collected program data.ResultsOf the 1,786 pregnant women who delivered in the selected clinics, HIV status at the time of delivery was known for 1,756 (98%) of whom 197 (11%) were HIV seropositive. Only 19 (10%) could be classified as "high risk" for MTCT and the remaining 90% lacked adequate information to classify them into high or low risk for MTCT due to missing data. Of the 197 live births, only two (1%) infants had a nucleic-acid test (NAT) at birth and 32 (16%) infants had NAT at 6 weeks. Of all 197 infants, 183 (93%) were initiated on single ARV prophylaxis (Nevirapine), 15 (7%) infants' ARV prophylaxis status was not documented and one infant got dual ARV prophylaxis (Nevirapine+Zidovudine).ConclusionThere was paucity of data requisite for MTCT risk stratification due to poor recording of data; "high risk" women were missed in the few circumstances where sufficient data were available. Thus "high risk" HEI are deprived of dual ARV prophylaxis and priority HIV NAT at birth and onwards which they require for PMTCT. Health workers need urgent training, mentorship and supportive supervision to master data management and perform MTCT risk stratification satisfactorily.

Background We assessed Zimbabwe's progress toward elimination of mother-to-child HIV transmission (MTCT) under Option A. Methods We analyzed 2012 and 2014 cross-sectional serosurvey data from mother-infant pairs residing in the same 157 health facility catchment areas randomly sampled from five provinces. Eligible women were at least 16 years and mothers/caregivers of infants born 9-18 months prior. We aggregated individual-level questionnaire and HIV serostatus within catchment areas or district to estimate MTCT and the number of HIV-infected infants; these data were mapped using facility global positioning system coordinates. Results A weighted population of 8800 and 10 404 mother-infant pairs was included from 2012 and 2014, respectively. In 2014, MTCT among HIV-exposed infants was 6.7% (95% confidence interval: 5.2, 8.6), not significantly different from 2012 (8.8%, 95% confidence interval: 6.9, 11.1, P = 0.13). From 2012 to 2014, self-reported antiretroviral therapy or prophylaxis among HIV-infected women increased from 59 to 65% (P = 0.05), as did self-reported infant antiretroviral prophylaxis (63 vs. 67%, P = 0.08). In 2014, 65 (41%), 55 (35%), and 37 (24%) catchment areas had the same, lower, and higher MTCT rate as in 2012, respectively. MTCT in 2014 varied by catchment areas (median = 0%, mean = 4.9%, interquartile range = 0-10%) as did the estimated number of HIV-infected infants (median = 0, mean = 1.1, interquartile range = 0-1.0). Also in 2014, 106 (68%) catchment areas had MTCT = 0%. Geovisualization revealed clustering of catchment areas where both MTCT and the estimated number of HIV-infected infants were relatively high. Conclusion Although MTCT is declining in Zimbabwe, geospatial analysis indicates facility-level variability. Catchment areas with high MTCT rates and a high burden of HIV-infected infants should be the highest priority for service intensification.

Background The postpartum period is an opportune time for contraception adoption, as women have extended interaction with the reproductive healthcare system and therefore more opportunity to learn about and adopt contraceptive methods. This may be especially true for women who experience unintended pregnancy, a key target population for contraceptive programs and programs to eliminate mother-to-child HIV transmission. Among women in Zimbabwe surveyed in 2014, we examined the relationship between pregnancy intention associated with a woman’s most recent pregnancy, and her subsequent postpartum contraceptive use. Methods In our analysis we utilized a dataset from a random selection of catchment areas in Zimbabwe to examine the association between pregnancy intention of most recent pregnancy and subsequent postpartum contraceptive use using multinomial logistic regression models. We also explored whether this association differed by women’s HIV status. Finally, we examined the association between pregnancy intention and changes in contraception from the pre- to postpartum periods. Results Findings suggest that women who reported that their pregnancy was unintended adopted less modern (all non-traditional) contraceptive methods overall, but adopted long-acting reversible contraception (LARC) more frequently than women reporting an intended pregnancy (OR 1.41; CI 1.18, 1.68). Among HIV-positive women, this relationship was particularly strong (OR 3.12; CI 1.96, 4.97). However, when examining changes in contraceptive use from the pre-pregnancy to the postpartum period, women who had an unintended pregnancy had lower odds of changing to a more effective method postpartum overall (OR 0.71; CI 0.64, 0.79). Conclusions We did not find evidence of higher modern method adoption in the postpartum period among women with an unintended pregnancy. However, women who were already on a method in the pre-pregnancy period were catalyzed to move to more effective methods (such as LARC) postpartum. This study provides evidence of low modern (non-traditional) method adoption in general in the postpartum period among a vulnerable sub-population in Zimbabwe (women who experience unintended pregnancy). Simultaneously, however, it shows a relatively greater portion specifically of LARC use among women with an unintended pregnancy. Further research is needed to more closely examine the motivations behind these contraceptive decisions in order to better inform distribution and counseling programs. Electronic supplementary material The online version of this article (10.1186/s12905-018-0668-z) contains supplementary material, which is available to authorized users.

The global HIV response is leaving children and adolescents behind. Because of a paucity of studies on treatment and care models for these age groups, there are gaps in our understanding of how best to implement services to improve their health outcomes. Without this evidence, policymakers are left to extrapolate from adult studies, which may not be appropriate, and can lead to inefficiencies in service delivery, hampered uptake, and ineffective mechanisms to support optimal outcomes. Implementation science research seeks to investigate how interventions known to be efficacious in study settings are, or are not, routinely implemented within real-world programmes. Effective implementation science research must be a collaborative effort between government, funding agencies, investigators, and implementers, each playing a key role. Successful implementation science research in children and adolescents requires clearer policies about age of consent for services and research that conform to ethical standards but allow for rational modifications. Implementation research in these age groups also necessitates age-appropriate consultation and engagement of children, adolescents, and their caregivers. Finally, resource, systems, technology, and training must be prioritized to improve the availability and quality of age-/sex-disaggregated data. Implementation science has a clear role to play in facilitating understanding of how the multiple complex barriers to HIV services for children and adolescents prevent effective interventions from reaching more children and adolescents living with HIV, and is well positioned to redress gaps in the HIV response for these age groups. This is truer now more than ever, with urgent and ambitious 2020 global targets on the horizon and insufficient progress in these age groups to date.

Introduction Heat‐stable lopinavir/ritonavir (LPV/r) oral pellets were developed to overcome challenges with administration and storage experienced with previously available tablet and syrup forms of LPV/r prescribed to paediatric HIV patients. We report on the adoption of LPV/r pellets for infants living with HIV in the public sector antiretroviral therapy (ART) programme in Zimbabwe. Methods Infants aged three months to three years who had been prescribed a LPV/r‐based regimen (including ART‐naïve patients) in fourteen facilities across the country were eligible to receive the pellets. Caregivers were counselled on the new formulation and provided with administration guides. A caregiver questionnaire was administered three to four months after the child initiated on pellets. Data were also extracted from patient ART records. Results and discussion One hundred and fifty‐seven children were enrolled (median age: 21 months; interquartile range 11.8 to 29.4). Survey data from 74 caregivers were included for analysis. Eighty‐one per cent of the caregivers preferred pellets while 19% preferred the syrup formulation. Eighty‐nine per cent assessed their child's response to taking the pellets as good or very good. Overall, 46% did not report any challenges while 54% reported one or more challenges with using the pellets. Difficulties with administration included: poor taste (36%; 26 participants); swallowing pellets (16%; 12 participants); finishing the dose (14%; 10 participants); and opening the capsule (10%; seven participants). Caregivers who were not confident to instruct others on pellet administration were 5.64 (95% confidence interval 1.45 to 21.95, p = 0.013) times as likely to experience a challenge. Conclusions A large proportion of caregivers preferred pellets to other formulations of LPV/r and reported a good response to pellets; however, they also reported challenges with administration. Counselling should focus on ensuring that caregivers can confidently administer pellets and are able to instruct others, to ensure high uptake and good adherence to treatment. LPV/r pellets may be an acceptable substitute for other available forms of LPV/r for eligible children under three years if they are currently on or in need of LPV/r‐containing regimens; however, challenges with administration still highlight the need for improved drug formulations for paediatric ART patients.

BACKGROUND. Preventing mother-to-child transmission of human immunodeficiency virus transmission (MTCT) depends on early initiation of antiretroviral therapy (ART). We report the 18-month MTCT risk during the transition from Option A to Option B+ in Zimbabwe, and assess whether ART preconception could eliminate MTCT in breastfeeding populations. METHODS. In 2013, we consecutively recruited a nationally representative sample of 6051 infants aged 4–12 weeks and their mothers from 151 immunization clinics using a multistage stratified cluster sampling method. We identified 1172 human immunodeficiency virus (HIV)–exposed infants and evaluated them at baseline and every 3 months until the child became HIV-infected, died, or reached age 18 months. RESULTS. The cumulative MTCT risk through 18 months postdelivery was 7.0%. Of the HIV-infected mothers, 35.3% started ART preconception, 28.9% during pregnancy, and 9.7% after delivery, and 16.0% received zidovudine during pregnancy. Compared to mothers without antiretroviral drug use, MTCT among those starting ART preconception and during pregnancy was lower by 88% (adjusted hazard ratio [aHR], 0.12; 95% confidence interval [CI], .06–.24) and 75% (aHR, 0.25; 95% CI, .14–.45), respectively. HIV-exposed infants with birth weight

BACKGROUND Practical ways are needed to scale-up pediatric HIV testing in sub-Saharan Africa, where testing is usually limited to HIV-exposed children in maternal and child health clinics. METHODS We implemented an enhanced pediatric HIV testing program in 33 health facilities in Zimbabwe by integrating HIV testing into all pediatric health services. We collected individual data on children tested by having health care workers complete a program-specific child health booklet. We compared numbers of children tested before and during the program using routinely collected aggregate program data reported by health facilities. RESULTS A total of 12,556 children aged 0-5 years were recorded in child health booklets; 9431 (75.1%) had information on HIV testing, of whom 7326 (77.7%) were tested; 7167 had test results of whom 122 (1.7%) were HIV-infected. Among children seen in outpatient clinics, 82.1% were tested compared with 66.5% tested among children seen in maternal/child health clinics. Of the 122 HIV-infected children identified, 77 (63.1%) could be missed under existing pediatric testing guidelines. The number of HIV-infected children identified during the 6-month program increased by 55% compared with the prior 6-month period (RR = 1.55, 95% CI: 1.22 to 1.96). Factors independently associated with HIV infection included being malnourished (adjusted odds ratio [AOR] = 7.7, 95% CI: 2.1 to 28.6), being exposed to TB (AOR = 8.1, 95% CI: 2.0 to 32.2), and having an HIV-infected mother (AOR = 41.6, 95% CI: 15.9 to 108.8). CONCLUSIONS Integrating HIV testing into all pediatric health services is feasible and can assist in identifying HIV-infected children who could be missed in current testing guidelines.

ObjectiveTo examine the uptake of services and behaviors in the prevention of mother-to-child HIV transmission (PMTCT) cascade in Zimbabwe and to determine factors associated with MTCT and maternal antiretroviral therapy (ART) or antiretroviral (ARV) prophylaxis.DesignAnalysis of cross-sectional data from mother-infant pairs.MethodsWe analyzed baseline data collected in 2012 as part of the impact evaluation of Zimbabwe's Accelerated National PMTCT Program. Using multistage cluster sampling, eligible mother-infant pairs were randomly sampled from the catchment areas of 157 facilities in 5 provinces, tested for HIV infection, and interviewed about PMTCT service utilization.ResultsOf 8800 women, 94% attended ≥ 1 antenatal care visit, 92% knew their HIV serostatus during pregnancy, 77% delivered in a health facility, and 92% attended the 6-8 week postnatal visit. Among 1075 (12%) HIV-infected women, 59% reported ART/ARV prophylaxis and 63% of their HIV-exposed infants received ARV prophylaxis. Among HIV-exposed infants, maternal receipt of ART/ARV prophylaxis was protective against MTCT [adjusted prevalence ratio (PR(a)): 0.41, 95% confidence interval (CI): 0.23 to 0.74]. Factors associated with receipt of maternal ART/ARV prophylaxis included ≥ 4 antenatal care visits (PR(a): 1.18, 95% CI: 1.01 to 1.38), institutional delivery (PR(a): 1.31, 95% CI: 1.13 to 1.52), and disclosure of serostatus (PRa: 1.30, 95% CI: 1.12 to 1.49).ConclusionsThese data from women in the community indicate gaps in the PMTCT cascade before the accelerated program, which may have been missed by examination of health facility data alone. These gaps were especially noteworthy for services targeted specifically to HIV-infected women and their infants, such as maternal and infant ART/ARV prophylaxis.

Background The INSPIRE-Integrating and Scaling Up PMTCT through Implementation REsearch-initiative was established as a model partnership of national prevention of mother-to-child transmission of HIV (PMTCT) implementation research in 3 high HIV burden countries-Malawi, Nigeria, and Zimbabwe. INSPIRE aimed to link local research groups with Ministries of Health (MOH), build local research capacity, and demonstrate that implementation research may contribute to improving health care delivery and respond to program challenges. Methodology We used a mixed methods approach to review capacity building activities, as experienced by health care workers, researchers, and trainers conducted in the 6 INSPIRE projects before and during study implementation. Results Between 2011 and 2016, over 3400 health care workers, research team members, and community members participated in INSPIRE activities. This included research prioritization exercises, proposal development, good clinical practice and research ethics training, data management and analysis workshops, and manuscript development. Health care workers in clinics and district health offices acknowledged the value of hosting implementation research projects and how the quality of services improved. Research teams acknowledged the opportunities that projects provided for personal development and the value of participating in a multicountry research network. Discussion INSPIRE provided an opportunity for African-led research in which researchers worked closely with national MOH to identify priority research questions and implement studies. Close partnerships between research teams and local implementers facilitated project responsiveness to local program issues. Consequently, processes and training needed for study implementation also improved local program management and service delivery. Additional benefits included improved data management, publications, and career development.

The urgency to scale-up sustainable programs for the prevention of mother-to-child transmission of HIV (PMTCT) prompted priority countries of the Global Plan Toward the Elimination of New HIV Infections Among Children by 2015 and Keeping Their Mothers Alive (Global Plan) to expand the delivery of PMTCT services through greater integration with sexual and reproductive health and child health services. Countries approached integration-what, where, and how services are provided-in diverse ways, with predominantly favorable results. Approaches to integrated services have increased access to a broader range of PMTCT interventions, and they also have proved to be largely acceptable to clients and providers. The integration of PMTCT interventions with maternal, newborn, and child health settings was supported by strategies to reconfigure service delivery to provide additional services, including shifting tasks to nurses (such as initiating antiretroviral therapy and providing long-term follow-up). This was complemented by supporting community outreach and integrating HIV and sexual and reproductive health services bidirectionally, including by providing family planning through antiretroviral therapy clinics and HIV testing in family planning clinics. A systematic and rigorous study of country experiences integrating HIV and maternal, newborn, and child health services, including maternal and pediatric TB services, cost analysis, could provide valuable lessons and demonstrate how such integration can improve systems for health care delivery.

Evidence for Elimination (E4E) is a collaborative project established in 2012 as part of the INSPIRE (INtegrating and Scaling up PMTCT through Implementation REsearch) initiative. E4E is a cluster-randomized trial with 2 arms; Standard of care and "POC Plus" [in which point-of-care (POC) CD4 devices and related counseling support are provided]; aimed at improving retention-in-care of HIV-infected pregnant women and mothers. In November 2013, Zimbabwe adopted Option B+ for HIV-positive pregnant women under which antiretroviral treatment eligibility is no longer based on CD4 count. However, Ministry of Health and Child Care guidelines still require baseline and 6-monthly CD4 testing for treatment monitoring, until viral load testing becomes widely available. Considering the current limited capacity for viral-load testing, the significant investments in CD4 testing already made and the historical reliance on CD4 by health care workers for determining eligibility for antiretroviral treatment, E4E seeks to compare the impact of the provision of POC CD4 technology and early knowledge of CD4 levels on retention-in-care at 12 months, with the current standard of routine, laboratory-based CD4 testing. The study also compares rates of initiation and time-to-initiation between the 2 arms and according to level of maternal CD4 count, the cost of retaining HIV-positive pregnant women in care and the acceptability and feasibility of POC CD4 in the context of Option B+. Outcome measures are derived from routine health systems data. E4E will provide data on POC CD4 testing and retention-in-care associated with Option B+ and serve as an early learning platform to inform implementation of Option B+ in Zimbabwe.

Early infant diagnosis (EID) of HIV provides an opportunity for early HIV detection and access to appropriate Antiretroviral treatment (ART). Dried Blood Spot (DBS) samples are used for EID of exposed infants, born to HIV-positive mothers. However, DBS rejection rates in Zimbabwe have been exceeding the target of less than 2% per month set by the National Microbiology Reference Laboratory (NMRL), in Harare. The aim of this study was to determine the DBS sample rejection rate, the reasons for rejection and the possible associations between rejection and level of health facility where the samples were collected. This is an analytical cross-sectional study using routine DBS sample data from the NMRL in Harare, Zimbabwe, between January and December 2017.A total of 34 950 DBS samples were received at the NMRL. Of these, 1291(4%) were rejected. Reasons for rejection were insufficient specimen volume (72%), missing request form (11%), missing sample (6%), cross-contamination (6%), mismatch of information (4%) and clotted sample (1%). Samples collected from clinics/rural health facilities were five times more likely to be rejected compared to those from a central hospital. Rejection rates were above the set target of

OBJECTIVE We evaluated the impact of Option A on HIV-free infant survival and mother-to-child transmission (MTCT) in Zimbabwe. DESIGN Serial cross-sectional community-based serosurveys. METHODS We analyzed serosurvey data collected in 2012 and 2014 among mother-infant pairs from catchment areas of 132 health facilities from five of 10 provinces in Zimbabwe. Eligible infants (alive or deceased) were born 9-18 months before each survey to mothers at least 16 years old. We randomly selected mother-infant pairs and conducted questionnaires, verbal autopsies, and collected blood samples. We estimated the HIV-free infant survival and MTCT rate within each catchment area and compared the 2012 and 2014 estimates using a paired t test and number of HIV infections averted because of the intervention. RESULTS We analyzed 7249 mother-infant pairs with viable maternal specimens collected in 2012 and 8551 in 2014. The mean difference in the catchment area level MTCT between 2014 and 2012 was -5.2 percentage points (95% confidence interval = -8.1, -2.3, P

We projected outcomes for mothers and infants following World Health Organization–recommended regimens to prevent mother-to-child human immunodeficiency virus (HIV) transmission. Compared with Option A, Option B improves life expectancy and saves money; compared with Option B, lifelong maternal therapy is of comparable value to common HIV-related interventions., Background. In 2010, the World Health Organization (WHO) released revised guidelines for prevention of mother-to-child human immunodeficiency virus (HIV) transmission (PMTCT). We projected clinical impacts, costs, and cost-effectiveness of WHO-recommended PMTCT strategies in Zimbabwe. Methods. We used Zimbabwean data in a validated computer model to simulate a cohort of pregnant, HIV-infected women (mean age, 24 years; mean CD4 count, 451 cells/µL; subsequent 18 months of breastfeeding). We simulated guideline-concordant care for 4 PMTCT regimens: single-dose nevirapine (sdNVP); WHO-recommended Option A, WHO-recommended Option B, and Option B+ (lifelong maternal 3-drug antiretroviral therapy regardless of CD4). Outcomes included maternal and infant life expectancy (LE) and lifetime healthcare costs (2008 US dollars [USD]). Incremental cost-effectiveness ratios (ICERs, in USD per year of life saved [YLS]) were calculated from combined (maternal + infant) discounted costs and LE. Results. Replacing sdNVP with Option A increased combined maternal and infant LE from 36.97 to 37.89 years and would reduce lifetime costs from $5760 to $5710 per mother–infant pair. Compared with Option A, Option B further improved LE (38.32 years), and saved money within 4 years after delivery ($5630 per mother–infant pair). Option B+ (LE, 39.04 years; lifetime cost, $6620 per mother–infant pair) improved maternal and infant health, with an ICER of $1370 per YLS compared with Option B. Conclusions. Replacing sdNVP with Option A or Option B will improve maternal and infant outcomes and save money; Option B increases health benefits and decreases costs compared with Option A. Option B+ further improves maternal outcomes, with an ICER (compared with Option B) similar to many current HIV-related healthcare interventions.

Objectives Zimbabwe has started to scale up Option B+ for the prevention of mother-to-child transmission of HIV, but there is little published information about uptake or retention in care. This study determined the number and proportion of pregnant and lactating women in rural districts diagnosed with HIV infection and started on Option B+ along with six-month antiretroviral treatment (ART) outcomes. Methods This was a retrospective record review of women presenting to antenatal care or maternal and child health services at 34 health facilities in Chikomba and Gutu rural districts, Zimbabwe, between January and March 2014. Results A total of 2728 women presented to care of whom 2598 were eligible for HIV testing: 76% presented to antenatal care, 20% during labour and delivery and 4% while breastfeeding. Of 2097 (81%) HIV-tested women, 7% were HIV positive. Lower HIV testing uptake was found with increasing parity, late presentation to antenatal care, health centre attendance and in women tested during labour. Ninety-one per cent of the HIV-positive women were started on Option B+. Six-month ART retention in care, including transfers, was 83%. Loss to follow-up was the main cause of attrition. Increasing age and gravida status ≥2 were associated with higher six-month attrition. Conclusion The uptake of HIV testing and Option B+ is high in women attending antenatal and post-natal clinics in rural Zimbabwe, suggesting that the strategy is feasible for national scale-up in the country.

Background Prevention of mother-to-child transmission of HIV (PMTCT) programs collect socio-demographic and HIV testing information similar to that collected by unlinked anonymous testing sero-surveillance (UAT) in antenatal settings. Zimbabwe evaluated the utility of PMTCT data in replacing UAT. Methods A UAT dataset was created by capturing socio-demographic, testing practices from the woman’s booking-card and testing remnant blood at a laboratory from 1 June to 30 September 2012. PMTCT data were collected retrospectively from ANC registers. UAT and PMTCT data were linked by bar-code labels that were temporarily affixed to the ANC register. A questionnaire was used to obtain facility-level data at 53 sites. Results Pooled HIV prevalence was 15.8 % (95 % CI 15.3–16.4) among 17,349 women sampled by UAT, and 16.3 % (95 % CI 15.8 %–16.9 %) among 17,150 women in PMTCT datasets for 53 sites. Pooled national percent-positive agreement (PPA) was 91.2 %, and percent-negative agreement (PNA) was 98.7 % for 16,782 women with matched UAT and PMTCT data. Based on UAT methods, overall median prevalence was 12.9 % (Range 4.0 %–19.4 %) among acceptors and refusers of HIV test in PMTCT compared to 12.5 % ((Range 3.4 %–19.5 %) among acceptors in ANC registers. There were variations in prevalence by site. Conclusion Although, there is no statistical difference between pooled HIV prevalence in UAT compared to PMTCT program, the overall PPA of 91.2 % and PNA of 98.7 % fall below World Health Organisation (WHO) benchmarks of 97.6 % and 99.6 % respectively. Zimbabwe will need to strengthen quality assurance (QA) of rapid HIV testing and data collection practices. Sites with good performance should be prioritised for transitioning. Electronic supplementary material The online version of this article (doi:10.1186/s12879-016-1425-2) contains supplementary material, which is available to authorized users.

Objective We estimated HIV-free infant survival and mother-to-child HIV transmission (MTCT) rates in Zimbabwe, some of the first community-based estimates from a UNAIDS priority country. Methods In 2012 we surveyed mother-infant pairs residing in the catchment areas of 157 health facilities randomly selected from 5 of 10 provinces in Zimbabwe. Enrolled infants were born 9–18 months before the survey. We collected questionnaires, blood samples for HIV testing, and verbal autopsies for deceased mothers/infants. Estimates were assessed among i) all HIV-exposed infants, as part of an impact evaluation of Option A of the 2010 WHO guidelines (rolled out in Zimbabwe in 2011), and ii) the subgroup of infants unexposed to Option A. We compared province-level MTCT rates measured among women in the community with MTCT rates measured using program monitoring data from facilities serving those communities. Findings Among 8568 women with known HIV serostatus, 1107 (12.9%) were HIV-infected. Among all HIV-exposed infants, HIV-free infant survival was 90.9% (95% confidence interval (CI): 88.7–92.7) and MTCT was 8.8% (95% CI: 6.9–11.1). Sixty-six percent of HIV-exposed infants were still breastfeeding. Among the 762 infants born before Option A was implemented, 90.5% (95% CI: 88.1–92.5) were alive and HIV-uninfected at 9–18 months of age, and 9.1% (95%CI: 7.1–11.7) were HIV-infected. In four provinces, the community-based MTCT rate was higher than the facility-based MTCT rate. In Harare, the community and facility-based rates were 6.0% and 9.1%, respectively. Conclusion By 2012 Zimbabwe had made substantial progress towards the elimination of MTCT. Our HIV-free infant survival and MTCT estimates capture HIV transmissions during pregnancy, delivery and breastfeeding regardless of whether or not mothers accessed health services. These estimates also provide a baseline against which to measure the impact of Option A guidelines (and subsequently Option B+).

Background: Food insecurity (FI) is the lack of physical, social, and economic access to sufficient food for dietary needs and food preferences. We examined the association between FI and women’s uptake of services to prevent mother-to-child HIV transmission (MTCT) in Zimbabwe. Methods: We analyzed cross-sectional data collected in 2012 from women living in five of ten provinces. Eligible women were ≥16 years old, biological mothers of infants born 9–18 months before the interview, and were randomly selected using multi-stage cluster sampling. Women and infants were tested for HIV and interviewed about health service utilization during pregnancy, delivery, and post-partum. We assessed FI in the past four weeks using a subset of questions from the Household Food Insecurity Access Scale and classified women as living in food secure, moderately food insecure, or severely food insecure households. Results: The weighted population included 8,790 women. Completion of all key steps in the PMTCT cascade was reported by 49%, 45%, and 38% of women in food secure, moderately food insecure, and severely food insecure households, respectively (adjusted prevalence ratio (PRa) = 0.95, 95% confidence interval (CI): 0.90, 1.00 (moderate FI vs. food secure), PRa = 0.86, 95% CI: 0.79, 0.94 (severe FI vs. food secure)). Food insecurity was not associated with maternal or infant receipt of ART/ARV prophylaxis. However, in the unadjusted analysis, among HIV-exposed infants, 13.3% of those born to women who reported severe household food insecurity were HIV-infected compared to 8.2% of infants whose mothers reported food secure households (PR = 1.62, 95% CI: 1.04, 2.52). After adjustment for covariates, this association was attenuated (PRa = 1.42, 95% CI: 0.89, 2.26). There was no association between moderate food insecurity and MTCT in unadjusted or adjusted analyses (PRa = 0.68, 95% CI: 0.43, 1.08). Conclusions: Among women with a recent birth, food insecurity is inversely associated with service utilization in the PMTCT cascade and severe household food insecurity may be positively associated with MTCT. These preliminary findings support the assessment of FI in antenatal care and integrated food and nutrition programs for pregnant women to improve maternal and child health.

Prevention of mother-to-child transmission (PMTCT) elimination goals are hampered by low rates of retention and antiretroviral treatment adherence. The Eliminating Pediatric AIDS in Zimbabwe (EPAZ) project is assessing whether mother support groups (MSGs) increase rates of retention-in-care of HIV-positive mothers and their exposed infants, increase male participation, and improve other maternal and infant health outcomes. EPAZ is a cluster randomized study involving 30 rural facilities in 2 health districts in Mutare province in eastern Zimbabwe. Facilities were randomly assigned to either the standard-of-care or intervention arms. We established MSGs for HIV-positive mothers at the 15 health facilities in the intervention arm. MSGs met every 2 weeks and were led by an HIV-positive mother who was appointed as MSG coordinator (MSG-C). MSG-Cs contacted nonattending patient-members of support groups by cell phone. If members still do not attend, MSG-Cs inform a health worker who initiates further outreach actions that are standard within the health system. At least 10 HIV-positive mothers are enrolled per facility. Enrollment started in July 2014. The primary outcome measure is retention-in-care of HIV-exposed infants at 12 months of age. Secondary outcome measures are: retention-in-care of HIV-positive mothers at 12 months postpartum, male participation, and other maternal and child health indicators. The study relies on routine health system data supplemented by additional data using tools created for the study. If shown to improve PMTCT retention outcomes, facility-based MSGs have the potential to be scaled up throughout the Zimbabwe National PMTCT program and could be considered in other country programs.

Countries with high HIV prevalence face the challenge of achieving high coverage of antiretroviral drug regimens interventions including for the prevention of mother-to-child transmission of HIV (PMTCT). In 2011, the World Health Organization and the Department of Foreign Affairs, Trade and Development, Canada, launched a joint implementation research (IR) initiative to increase access to effective PMTCT interventions. Here, we describe the process used for prioritizing PMTCT IR questions in Malawi, Nigeria, and Zimbabwe. Policy makers, district health workers, academics, implementing partners, and persons living with HIV were invited to 2-day workshops in each country. Between 42 and 70 representatives attended each workshop. Using the Child Health Nutrition Research Initiative process, stakeholder groups systematically identified programmatic barriers and formulated IR questions that addressed these challenges. IR questions were scored by individual participants according to 6 criteria: (1) answerable by research, (2) likely to reduce pediatric HIV infections, (3) addresses main barriers to scaling-up, (4) innovation and originality, (5) improves equity among underserved populations, and (6) likely value to policy makers. Highest scoring IR questions included health system approaches for integrating and decentralization services, ways of improving retention-in-care, bridging gaps between health facilities and communities, and increasing male partner involvement. The prioritized questions reflect the diversity of health care settings, competing health challenges and local and national context. The differing perspectives of policy makers, researchers, and implementers illustrate the value of inclusive research partnerships. The participatory Child Health Nutrition Research Initiative approach effectively set national PMTCT IR priorities, promoted country ownership, and strategically allocated research resources.

Background Prevention of unintended pregnancies among women living with HIV infection is a strategy recommended by the World Health Organization for prevention of mother-to-child transmission of HIV (PMTCT). We assessed pregnancy intentions and contraceptive use among HIV-positive and HIV-negative women with a recent pregnancy in Zimbabwe. Methods We analyzed baseline data from the evaluation of Zimbabwe’s Accelerated National PMTCT Program. Eligible women were randomly sampled from the catchment areas of 157 health facilities offering PMTCT services in five provinces. Eligible women were ≥16 years old and mothers of infants (alive or deceased) born 9 to 18 months prior to the interview. Participants were interviewed about their HIV status, intendedness of the birth, and contraceptive use. Results Of 8,797 women, the mean age was 26.7 years, 92.8% were married or had a regular sexual partner, and they had an average of 2.7 lifetime births. Overall, 3,090 (35.1%) reported that their births were unintended; of these women, 1,477 (47.8%) and 1,613 (52.2%) were and were not using a contraceptive method prior to learning that they were pregnant, respectively. Twelve percent of women reported that they were HIV-positive at the time of the survey; women who reported that they were HIV-infected were significantly more likely to report that their pregnancy was unintended compared to women who reported that they were HIV-uninfected (44.9% vs. 33.8%, p

In the 30 years of the AIDS pandemic, the devastating effects of HIV on infants and young children have often been overlooked and neglected. However, the ability to prevent mother-to-child transmission of HIV (PMTCT), or vertical transmission, has been one of the most significant prevention success stories in the global AIDS response. New HIV infections in children have been virtually eliminated in high-income countries and programmatic efforts have shifted to low-income and middle-income countries, particularly in sub-Saharan Africa, home to the vast majority of pediatric AIDS cases.Over the past decade, the dramatic scale-up of PMTCT programs has saved millions of lives and has provided a foundation for HIV prevention and care and treatment programs that are integrated within maternal and child health services. Although some countries in sub-Saharan Africa are now approaching universal PMTCT coverage, global access to PMTCT for HIV-positive pregnant women remains at nearly 50%. Recently, a new global plan has focused efforts and resources to keep HIV-positive mothers healthy and to virtually eliminate new pediatric infections by 2015.What programmatic and technical innovations will be necessary to overcome current service gaps and implementation barriers? How can countries continue the current momentum with sustainable locally-led programs that address the epidemic in women and children? And how can the vital perspectives of communities and people living with HIV help drive these efforts? Successfully addressing these and other issues will be key to ending HIV infections in children and creating an AIDS-free generation within the next decade.

Background The Zimbabwean national prevention of mother-to-child HIV transmission (PMTCT) program provided primarily single-dose nevirapine (sdNVP) from 2002–2009 and is currently replacing sdNVP with more effective antiretroviral (ARV) regimens. Methods Published HIV and PMTCT models, with local trial and programmatic data, were used to simulate a cohort of HIV-infected, pregnant/breastfeeding women in Zimbabwe (mean age 24.0 years, mean CD4 451 cells/µL). We compared five PMTCT regimens at a fixed level of PMTCT medication uptake: 1) no antenatal ARVs (comparator); 2) sdNVP; 3) WHO 2010 guidelines using “Option A” (zidovudine during pregnancy/infant NVP during breastfeeding for women without advanced HIV disease; lifelong 3-drug antiretroviral therapy (ART) for women with advanced disease); 4) WHO “Option B” (ART during pregnancy/breastfeeding without advanced disease; lifelong ART with advanced disease); and 5) “Option B+:” lifelong ART for all pregnant/breastfeeding, HIV-infected women. Pediatric (4–6 week and 18-month infection risk, 2-year survival) and maternal (2- and 5-year survival, life expectancy from delivery) outcomes were projected. Results Eighteen-month pediatric infection risks ranged from 25.8% (no antenatal ARVs) to 10.9% (Options B/B+). Although maternal short-term outcomes (2- and 5-year survival) varied only slightly by regimen, maternal life expectancy was reduced after receipt of sdNVP (13.8 years) or Option B (13.9 years) compared to no antenatal ARVs (14.0 years), Option A (14.0 years), or Option B+ (14.5 years). Conclusions Replacement of sdNVP with currently recommended regimens for PMTCT (WHO Options A, B, or B+) is necessary to reduce infant HIV infection risk in Zimbabwe. The planned transition to Option A may also improve both pediatric and maternal outcomes.

Background We assessed the integration of PMTCT services during the postpartum period including early infant diagnosis of HIV (EID) and adult and pediatric antiretroviral therapy (ART) in maternal and child health (MCH) facilities in Zimbabwe Methods and Findings From August to December 2012 we conducted a cross-sectional survey of a nationally representative sample of 151 MCH facilities. A questionnaire was used to survey each site about staff training, dried blood spot sample (DBS) collection, turnaround time (TAT) for test results, PMTCT services, and HIV care and treatment linkages for HIV-infected mothers and children and HIV-exposed infants. Descriptive analyses were used. Of the facilities surveyed, all facilities were trained on DBS collection and 92% responded. Approximately, 99% of responding facilities reported providing DBS collection and a basic HIV-exposed infant service package including EID, extended nevirapine prophylaxis, and use of cotrimoxazole. DBS collection was integrated with immunisations at 83% of facilities, CD4 testing with point-of-care machines was available at 37% of facilities, and ART for both mothers and children was provided at 27% of facilities. More than 80% of facilities reported that DBS test results take >4 weeks to return; TAT did not have a direct association with any specific type of transport, distance to the lab, or intermediate stops for data to travel. Conclusions Zimbabwe has successfully scaled up and integrated the national EID and PMTCT programs into the existing MCH setting. The long TAT of infant DBS test results and the lack of integrated ART programs in the MCH setting could reduce effectiveness of the national PMTCT and ART programs. Addressing these important gaps will support successful implementation of the 2014 Zimbabwe's PMTCT guidelines under which all HIV-infected pregnant and breastfeeding women will be offered life-long ART and decentralized ART care.