Reconstructing the PMTCT cascade using cross-sectional household survey data: The PEARL Study.

Background: Given the ambitious targets to reduce pediatric AIDS worldwide ongoing assessment of programs to prevent mother-to-child HIV transmission (PMTCT) is critical. The concept of a “PMTCT cascade” has been used widely to identify bottlenecks in program implementation; however most efforts to reconstruct the cascade have relied on facility-based approaches that may limit external validity. Methods: We analyzed data from the PEARL household survey which measured PMTCT effectiveness in 26 communities across Zambia South Africa Cote d’Ivoire and Cameroon. We recruited women who reported a delivery in the past two years. Among mothers confirmed to be HIV-infected at the time of survey we reconstructed the PMTCT cascade with self-reported participant information. We also analyzed data about the child’s vital status; for those still alive HIV testing was performed via DNA PCR. Results: Of the 976 eligible women only 355 (36%) completed every step of the PMTCT cascade. Among the 621 mother-child pairs who did not 22 (4%) reported never seeking antenatal care 103 (17%) were not tested for HIV during pregnancy 395 (64%) reported testing but never received their HIV-positive result 48 (8%) did not receive maternal antiretroviral prophylaxis and 53 (9%) did not receive infant antiretroviral prophylaxis. The lowest prevalence of infant HIV infection or death was observed in those completing the cascade (10% 95%CI: 7%-12%). Conclusions: Future efforts to measure population PMTCT impact should incorporate dimensions explored in the PEARL Study -- including HIV testing of HIV-exposed children in household surveys --to better understand program effectiveness.