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Evaluation of PMTCT coverage in four African countries: the PEARL study
By: D. Coetzee1, E.M. Stringer2, B.H. Chi2, N. Chintu2, T.L. Creek3, D.K. Ekouevi4, K. Stinson1, P. Tih5, T. Welty5, F. Dabis6, N. Shaffer3, C.M. Wilfert7, J.S.A. Stringer2

Background: PMTCT coverage at the population level has not been widely assessed in Africa.
Methods: Cord blood samples were collected from 43 delivery centers in Cameroon, Cote d'Ivoire, South Africa, and Zambia. All sites used single-dose nevirapine (SD-NVP) for PMTCT - with or without zidovudine (ZDV) - and/or NVP-based HAART. Our primary outcome was PMTCT coverage: the proportion of mother-child pairs with antibody-positive cord blood with confirmed maternal (detectable NVP in cord blood) and infant (chart review) NVP ingestion. In Western Cape (South Africa), we also tested cord blood for 3TC and ZDV.
Results: Between Apr-2007 and Oct-2008, we collected 29,095 cord blood specimens. 3,396 (12%) were HIV+, of which 3244 had complete data available. Cumulatively, 1509 (49%) received both mother and infant NVP. Coverage varied significantly by country (17%-69%). Reasons for non-coverage included HIV testing not offered (273, 16%); testing declined (104, 6%); HIV+ result not given (219, 13%); NVP not dispensed (116, 7%); mother did not adhere (440, 27%); infant not dosed (249, 15%). Older mothers were more likely to be covered (AOR:0.97 [0.95 - 0.99] per year of age) as were women with more ANC visits (AOR:0.88 [0.8 - 0.9] per visit). Failed maternal adherence (i.e. absence of cord blood NVP in women with documented NVP dispensation) was more likely in women who were prescribed ZDV+SD-NVP, compared to SD-NVP (AOR: 1.6 [1.3 - 2.1]).Of the 448 seropositive deliveries in the Western Cape, 29 (6%) had only NVP detected, 212 (47%) had ZDV+NVP, 35 (8%) had only ZDV, 56 (13%) had 3TC (a surrogate for HAART), and 116 (26%) had no drugs detectable.
Conclusions: Even in sites where PMTCT is available, < 50% of HIV-exposed infants received SD-NVP prophylaxis. Failures occurred along each step of the PMTCT “cascade”. Interventions must systematically target better performance at each step to maximize their benefits.

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