Estimating Vertically Acquired HIV Infections and the Impact of the Prevention of Mother-to-Child Transmission Program in Zimbabwe: Insights From Decision Analysis Models

Health Care Provider Utilization and Cost of an mHealth Intervention in Vulnerable People Living With HIV in Vancouver, Canada: Prospective Study

BACKGROUND

Improving adherence to combined antiretroviral therapy (cART) can be challenging, especially among vulnerable populations living with HIV. Even where cART is available free of charge, social determinants of health act as barriers to optimal adherence rates. Patient-centered approaches exploiting mobile phone communications (mHealth) have been shown to improve adherence to cART and promote achievement of suppressed HIV plasma viral loads. However, data are scarce on the health care provider (HCP) time commitments and health care costs associated with such interventions. This knowledge is needed to inform policy and programmatic implementation.

OBJECTIVE

The purpose of this study was to approximate the resources required and to provide an estimate of the costs associated with running an mHealth intervention program to improve medication adherence in people living with HIV (PLWH).

METHODS

This prospective study of HCP utilization and costs was embedded within a repeated measures effectiveness study of the WelTel short-message service (SMS) mHealth program. The study included 85 vulnerable, nonadherent PLWH in Vancouver, Canada, and resulted in improved medication adherence and HIV plasma viral load among participants. Study participants were provided mobile phones with unlimited texting (where required) and received weekly bidirectional text messages to inquire on their status for one year. A clinic nurse triaged and managed participants' responses, immediately logging all patient interactions by topic, HCP involvement, and time dedicated to addressing issues raised by participants. Interaction costs were determined in Canadian dollars based on HCP type, median salary within our health authority, and their time utilized as part of the intervention.

RESULTS

Participant-identified problems within text responses included health-related, social, and logistical issues. Taken together, management of problems required a median of 43 minutes (interquartile range, IQR 17-99) of HCP time per participant per year, for a median yearly cost of Can $36.72 (IQR 15.50-81.60) per participant who responded with at least one problem. The clinic nurse who monitored the texts solved or managed 65% of these issues, and the remaining were referred to a variety of other HCPs. The total intervention costs, including mobile phones, plans, and staffing were a median Can $347.74/highly vulnerable participant per year for all participants or Can $383.18/highly vulnerable participant per year for those who responded with at least one problem.

CONCLUSIONS

Bidirectional mHealth programs improve HIV care and treatment outcomes for PLWH. Knowledge about the HCP cost associated, here less than Can $50/year, provides stakeholders and decision makers with information relevant to determining the feasibility and sustainability of mHealth programs in a real-world setting.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02603536; https://clinicaltrials.gov/ct2/show/NCT02603536 (Archived by WebCite at http://www.webcitation.org/70IYqKUjV).

Can mother-to-child transmission of HIV be eliminated without addressing the issue of stigma? Modeling the case for a setting in South Africa

BACKGROUND

Stigma and discrimination ontinue to undermine the effectiveness of the HIV response. Despite a growing body of evidence of the negative relationship between stigma and HIV outcomes, there is a paucity of data available on the prevalence of stigma and its impact. We present a probabilistic cascade model to estimate the magnitude of impact stigma has on mother-to-child-transmission (MTCT).

METHODS

The model was parameterized using 2010 data from Johannesburg, South Africa, from which loss-to-care at each stage of the antenatal cascade were available. Three scenarios were compared to assess the individual contributions of stigma, non-stigma related barriers, and drug ineffectiveness on the overall number of infant infections. Uncertainty analysis was used to estimate plausible ranges. The model follows the guidelines in place in 2010 when the data were extracted (WHO Option A), and compares this with model results had Option B+ been implemented at the time.

RESULTS

The model estimated under Option A, 35% of infant infections being attributed to stigma. This compares to 51% of total infections had Option B+ been implemented in 2010. Under Option B+, the model estimated fewer infections than Option A, due to the availability of more effective drugs. Only 8% (Option A) and 9% (Option B+) of infant infections were attributed to drug ineffectiveness, with the trade-off in the proportion of infections being between stigma and non-stigma-related barriers.

CONCLUSIONS

The model demonstrates that while the effect of stigma on retention of women at any given stage along the cascade can be relatively small, the cumulative effect can be large. Reducing stigma may be critical in reaching MTCT elimination targets, because as countries improve supply-side factors, the relative impact of stigma becomes greater. The cumulative nature of the PMTCT cascade results in stigma having a large effect, this feature may be harnessed for efficiency in investment by prioritizing interventions that can affect multiple stages of the cascade simultaneously.

Mobile Text Messaging to Improve Medication Adherence and Viral Load in a Vulnerable Canadian Population Living With Human Immunodeficiency Virus: A Repeated Measures Study

Background

Combination antiretroviral therapy (cART) as treatment for human immunodeficiency virus (HIV) infection is effective and available, but poor medication adherence limits benefits, particularly in vulnerable populations. In a Kenyan randomized controlled trial, a weekly text-messaging intervention (WelTel) improved cART adherence and HIV viral load (VL). Despite growing evidence for short message service (SMS) text-message interventions in HIV care, there is a paucity of data utilizing these interventions in marginalized or female cohorts.

Objective

This study was undertaken to assess whether the standardized WelTel SMS text-message intervention applied to a vulnerable, predominantly female, population improved cART adherence and VL.

Methods

We conducted a repeated measures study of the WelTel intervention in high-risk HIV-positive persons by measuring change in VL, CD4 count, and self-reported adherence 12 months before and 12 months after the WelTel intervention was introduced. Inclusion criteria included VL ≥200 copies/mL, indication for treatment, and meeting vulnerability criteria. Participants were given a mobile phone with unlimited texting (where required), and weekly check-in text messages were sent for one year from the WelTel computer platform. Clinical data were collected for control and intervention years. Participants were followed by a multidisciplinary team in a clinical setting. Outcomes were assessed using Wilcoxon signed ranks tests for change in CD4 and VL from control year to study end and mixed-effects logistic regressions for change in cART adherence and appointment attendance. A secondary analysis was conducted to assess the effect of response rate on the outcome by modeling final log₁₀ VL by number of responses while controlling for mean log₁₀ VL in the control year.

Results

Eighty-five participants enrolled in the study, but 5 withdrew (final N=80). Participants were predominantly female (90%, 72/80) with a variety of vulnerabilities. Mean VL decreased from 1098 copies/mL in the control year to 439 copies/mL at study end (P=.004). Adherence to cART significantly improved (OR 1.14, IQR 1.10-1.18; P<.001), whereas appointment attendance decreased slightly with the intervention (OR 0.81, IQR 0.67-0.99; P=.03). A response was received for 46.57% (1753/3764) of messages sent and 9.62% (362/3764) of text messages sent were replied to with a problem. An outcome analysis examining relationship between reply rate and VL did not meet statistical significance (P=.07), but may be worthy of investigating further in a larger study.

Conclusions

WelTel may be an effective tool for improving cART adherence and reducing VLs among high-risk, vulnerable HIV-positive persons.

Trial Registration

Clinicaltrials.gov NCT02603536; https://clinicaltrials.gov/ct2/show/NCT02603536 (Archived by WebCite at http://www.webcitation.org/6qK57zCwv)

The impact of school subsidies on HIV-related outcomes among adolescent female orphans

PURPOSE

We examine effects of school support as a structural HIV prevention intervention for adolescent female orphans in Zimbabwe after 5 years.

METHODS

Three hundred twenty-eight orphan adolescent girls were followed in a clustered randomized controlled trial from 2007 to 2010. The experimental group received school fees, uniforms, and school supplies and were assigned a school-based "helper." In 2011-2012, the control group received delayed partial treatment of school fees only. At the final data point in 2012, survey, HIV, and Herpes Simplex Virus Type 2 (HSV-2) biomarker data were collected from approximately 88% of the sample. Bivariate and multivariate analyses were conducted on end point outcomes, controlling for age, religious affiliation, and baseline socioeconomic status.

RESULTS

The two groups did not differ on HIV or HSV-2 biomarkers. The comprehensive 5-year intervention continued to reduce the likelihood of marriage, improve school retention, improve socioeconomic status (food security), and marginally maintain gains in quality of life, even after providing school fees to the control group.

CONCLUSIONS

Paying school fees and expenses resulted in significant improvements in life outcomes for orphan adolescent girls. Biological evidence of HIV infection prevention, however, was not observed. Our study adds to the growing body of research on school support as HIV prevention for girls in sub-Saharan Africa, but as yet, no clear picture of effectiveness has emerged.

An integrated city-driven perinatal HIV prevention program covering 1.8 million pregnant women in Shenzhen, China, 2000 to 2010

BACKGROUND

Despite the scale-up of prevention of mother-to-child transmission (PMTCT) programs worldwide, the translation from research studies into public health policy has been slow. This report details the experiences of a city-driven PMTCT program in China using existing health resources.

METHODS

The PMTCT program was devised to hospital based and city-wide. It achieves full use of available resources: the local Centers for Disease Control and Prevention, the Infectious Disease Hospital, Maternal and Child Health Hospitals, and all qualified comprehensive hospitals.

RESULTS

From 2000 to 2010, 1,843,122 pregnant women attended prenatal care or labor and delivery services. Overall, 97.4% received pretest HIV counseling, and 96.2% were tested for HIV. Among the 81.1% (1,495,122) of women who attended prenatal clinics, 97.2% (1,452,753) received pretest counseling and 95.7% (1,430,799) were tested for HIV. Among the 18.9% (348,000) of women with an undocumented HIV status at labor and delivery, 98.6% (343,038) received pretest counseling, and 98.1% (341,371) were tested for HIV. In total, 229 women were determined HIV positive for a prevalence of 1.3 per 10,000 pregnant women. Among the 107 HIV-infected women who carried to delivery, 87.9% received antiretroviral prophylaxis for themselves and their infants. Among the 58 women who were identified HIV positive at labor, 10.3% of mothers and 72.4% of infants received antiretroviral prophylaxis. The estimated mother-to-child transmission rate was 5.3% (95% confidence interval, 2.2%-10.7%).

CONCLUSIONS

With appropriate integration, existing health care resources are adequate for a comprehensive city-driven PMTCT program in an area with a low HIV prevalence.

Population-level benefits from providing effective HIV prevention means to pregnant women in high prevalence settings

BACKGROUND

HIV prevalence among pregnant women in Southern Africa is extremely high. Epidemiological studies suggest that pregnancy increases the risk of HIV sexual acquisition and that HIV infections acquired during pregnancy carry higher risk of mother-to-child transmission (MTCT). We analyze the potential benefits from extending the availability of effective microbicide to pregnant women (in addition to non-pregnant women) in a wide-scale intervention.

METHODS AND FINDINGS

A transmission dynamic model was designed to assess the impact of microbicide use in high HIV prevalence settings and to estimate proportions of new HIV infections, infections acquired during pregnancy, and MTCT prevented over 10 years. Our analysis suggests that consistent use of microbicide with 70% efficacy by 60% of non-pregnant women may prevent approximately 40% and 15% of new infections in women and men respectively over 10 years, assuming no additional increase in HIV risk to either partner during pregnancy (RR(HIV/preg) = 1). It may also prevent 8-15% MTCT depending on the increase in MTCT risk when HIV is acquired during pregnancy compared to before pregnancy (RRMTCT/preg). Extending the microbicides use during pregnancy may improve the effectiveness of the intervention by 10% (RR(HIV/preg) = 1) to 25% (RR(HIV/preg) = 2) and reduce the number of HIV infections acquired during pregnancy by 40% to 70% in different scenarios. It may add between 6% (RR(HIV/preg) = 1, RR(MTCT/preg) = 1) and 25% (RR(HIV/preg) = 2, RR(MTCT/preg) = 4) to the reduction in the residual MTCT.

CONCLUSION

Providing safe and effective microbicide to pregnant women in the context of wide-scale interventions would be desirable as it would increase the effectiveness of the intervention and significantly reduce the number of HIV infections acquired during pregnancy. The projected benefits from covering pregnant women by the HIV prevention programs is more substantial in communities in which the sexual risk during pregnancy is elevated.

Mother to Mother (M2M) peer support for women in Prevention of Mother to Child Transmission (PMTCT) programmes: a qualitative study

Introduction

Mother-to-Mother (M2M) or “Mentor Mother” programmes utilise HIV positive mothers to provide support and advice to HIV positive pregnant women and mothers of HIV exposed babies. Médecins Sans Frontières (MSF) supported a Mentor Mother programme in Bulawayo, Zimbabwe from 2009 to 2012; with programme beneficiaries observed to have far higher retention at 6–8 weeks (99% vs 50%, p<0.0005) and to have higher adherence to Prevention of Mother to Child Transmission (PMTCT) guidelines, compared to those not opting in. In this study we explore how the M2M progamme may have contributed to these findings.

Methods

In this qualitative study we used thematic analysis of in-depth interviews (n = 79). This study was conducted in 2 urban districts of Bulawayo, Zimbabwe’s second largest city.

Results

Interviews were completed by 14 mentor mothers, 10 mentor mother family members, 30 beneficiaries (women enrolled both in PMTCT and M2M), 10 beneficiary family members, 5 women enrolled in PMTCT but who had declined to take part in the M2M programme and 10 health care staff members. All beneficiaries and health care staff reported that the programme had improved retention and provided rich information on how this was achieved. Additionally respondents described how the programme had helped bring about beneficial behaviour change.

Conclusions

M2M programmes offer great potential to empower communities affected by HIV to catalyse positive behaviour change. Our results illustrate how M2M involvement may increase retention in PMTCT programmes. Non-disclosure to one’s partner, as well as some cultural practices prevalent in Zimbabwe appear to be major barriers to participation in M2M programmes.

High HIV incidence and sexual behavior change among pregnant women in Lilongwe, Malawi: implications for the risk of HIV acquisition

Background

HIV incidence is higher among pregnant women than their non-pregnant counterparts in some sub-Saharan African settings. Our aims were (1) to estimate HIV incidence during pregnancy and (2) to compare sexual activity between pregnant, postpartum, and non-pregnant women.

Methods

We examined a retrospective cohort of 1087 women to identify seroconverters using antenatal and labor ward HIV test results. We also conducted a cross-sectional survey, including a quantitative questionnaire (n = 200) and in-depth interviews (n = 20) among women in early pregnancy, late pregnancy, postpartum, and non-pregnancy. Outcomes included measures of sexual activity, reported spouse’s risky behavior, and beliefs about abstinence.

Results

11 of 1087 women seroconverted during pregnancy yielding a 1% seroconversion risk and an incidence rate of 4.0/100 person years (95% CI 2.2–7.2). The reported sexual activity of the early pregnancy and non-pregnancy groups was similar, but significantly higher than the late pregnancy and postpartum groups (p<0.001). During pregnancy, sex acts decreased as gestation increased (p = 0.001). There was no reported difference in the spouse’s risky behavior. Most women believed that sex should cease between the 6^th and 8^th month of pregnancy and should not resume until 6 months postpartum. Some talked about conflict between their cultural obligation to abstain and fear of HIV infection if their spouses find other partners.

Conclusions

HIV incidence is high among pregnant women in Malawi, and sexual activity decreases during pregnancy and postpartum. Pregnant women need to be informed of their increased risk for HIV and the importance of using condoms throughout pregnancy and the postpartum period.

The contribution of maternal HIV seroconversion during late pregnancy and breastfeeding to mother-to-child transmission of HIV

BACKGROUND

The prevention of mother-to-child transmission (PMTCT) of HIV has been focused mainly on women who are HIV positive at their first antenatal visit, but there is uncertainty regarding the contribution to overall transmission from mothers who seroconvert after their first antenatal visit and before weaning.

METHOD

A mathematical model was developed to simulate changes in mother-to-child transmission of HIV over time, in South Africa. The model allows for changes in infant feeding practices as infants age, temporal changes in the provision of antiretroviral prophylaxis and counseling on infant feeding, as well as temporal changes in maternal HIV prevalence and incidence.

RESULTS

The proportion of mother-to-child transmission (MTCT) from mothers who seroconverted after their first antenatal visit was 26% [95% confidence interval (CI): 22% to 30%] in 2008, or 15,000 of 57,000 infections. It is estimated that by 2014, total MTCT will reduce to 39,000 per annum, and transmission from mothers seroconverting after their first antenatal visit will reduce to 13,000 per annum, accounting for 34% (95% CI: 29% to 39%) of MTCT. If maternal HIV incidence during late pregnancy and breastfeeding were reduced by 50% after 2010, and HIV screening were repeated in late pregnancy and at 6-week immunization visits after 2010, the average annual number of MTCT cases over the 2010-2015 period would reduce by 28% (95% CI: 25% to 31%), from 39,000 to 28,000 per annum.

CONCLUSION

Maternal seroconversion during late pregnancy and breastfeeding contributes significantly to the pediatric HIV burden and needs greater attention in the planning of prevention of MTCT programs.

Measuring and correcting biased child mortality statistics in countries with generalized epidemics of HIV infection

OBJECTIVE

Under Millennium Development Goal 4, countries are required to reduce child mortality by two-thirds between 1990 and 2015. In countries with generalized epidemics of human immunodeficiency virus (HIV) infection, standard statistics based on fertility history may misrepresent progress towards this target owing to the correlation between deaths among mothers and early childhood deaths from acquired immunodeficiency syndrome.

METHODS

To empirically estimate this bias, child mortality data and fertility history, including births to deceased women, were collected through prospective household surveys in eastern Zimbabwe during 1998-2005. A mathematical model was then used to investigate the determinants and temporal dynamics of the bias, first in Zimbabwe and then in other countries with different background mortality rates and HIV-related epidemic profiles.

FINDINGS

According to the empirical data, standard cross-sectional survey statistics underestimated true infant and under-5 mortality by 6.7% and 9.8%, respectively. These estimates were in agreement with the output from the model, in which the bias varied according to the magnitude and stage of the epidemic of HIV infection and background mortality rates. The bias was greater the longer the period elapsed before the survey and in later stages of the epidemic. Bias could substantially distort the measured effect of interventions to reduce non-HIV-related mortality and of programmes to prevent mother-to-child transmission, especially when trends are based on data from a single survey.

CONCLUSION

The correlation between the HIV-related deaths of mothers and their children can bias survey estimates of early child mortality. A mathematical model with a user-friendly interface is available to correct for this bias when measuring progress towards Millennium Development Goal 4 in countries with generalized epidemics of HIV infection.

Life span extension by resveratrol, rapamycin, and metformin: The promise of dietary restriction mimetics for an healthy aging

Life expectancy at the turn of the 20th century was 46 years on average worldwide and it is around 65 years today. The correlative increase in age-associated diseases incidence has a profound public health impact and is an important matter of concern for our societies. Aging is a complex, heterogeneous, and multifactorial phenomenon, which is the consequence of multiple interactions between genes and environment. In this review, we survey animals models that have been of great help for both investigating mechanism of aging and identifying molecules, which slow down the onset of age-related diseases. Resveratrol (RSV) is one of those. We will report evidences supporting RSV as a molecule that acts by mimicking the beneficial effects of dietary restriction, and may share common downstream targets with rapamycin and metformin. Although those molecules do not reveal all the secrets of the fountain of youth, they may help us maintaining the quality of life in the old age.

Expanding HAART treatment to all currently eligible individuals under the 2008 IAS-USA Guidelines in British Columbia, Canada

Background

In 2008, the IAS-USA published the revised guidelines for the use of HAART in adults substantially increasing the number of individuals eligible for HAART. The epidemic in British Columbia (BC) is mainly among men who have sex with men and those with injection drug use. Here, we explored the potential impact of different HAART coverage scenarios, based on the new guidelines, on the HIV-related incidence, morbidity and mortality in BC, Canada.

Methodology

We built a mathematical transmission model to investigate different HAART coverage scenarios (50%, 60%, 75% and 100%) of those medically eligible to receive HAART under the 2008 IAS guidelines. All new scenarios were compared to the current coverage in BC under the 2006 IAS guidelines (i.e. baseline scenario). In BC, it is estimated that 25–30% of individuals are unaware of their status. Costs were drug-related and reported in Canadian dollars. HIV-related morbidity and mortality were estimated based on the disability-adjusted life years (DALY) methodology.

Principal Findings

Currently, there are 4379 individuals on HAART under the IAS 2006 guidelines and 6781 individuals who qualify for treatment based on the new guidelines. Within 5 years, increasing HAART coverage decreased yearly new infections by at least 44.8%. In the 50% scenario, in 5 years, DALY decreased by 53% corresponding to 4155 averted DALYs, and in 25 years it decreased by 66% corresponding to 5837 averted DALYs. The effect was even stronger if the 75% scenario was chosen instead. Compared to the 100% expansion scenario, we observed an excess in annual direct treatment expenditures at the end of 5 years of approximately 1 million dollars in the 75% scenario, and of approximately 2 million dollars in the 50% scenario.

Conclusions/Significance

The individual and public health benefits of these new guidelines are immense. The results show that by increasing the number of individuals on HAART save lives, it is cost averting, and it positively impacts society by decreasing the number of new HIV infections. Thus, public health community should consider incremental gains when considering guidelines and policy.

Need to optimise infant feeding counselling: a cross-sectional survey among HIV-positive mothers in Eastern Uganda

BACKGROUND

The choice of infant feeding method is important for HIV-positive mothers in order to optimise the chance of survival of their infants and to minimise the risk of HIV transmission. The aim of this study was to investigate feeding practices, including breastfeeding, in the context of PMTCT for infants and children under two years of age born to HIV-positive mothers in Uganda.

METHODS

In collaboration with The Aids Support Organisation Mbale, we conducted a cross-sectional survey involving 235 HIV-positive mothers in Uganda. Infant feeding practices, reasons for stopping breastfeeding, and breast health problems were studied. Breastfeeding duration was analysed using the Kaplan-Meier method based on retrospective recall.

RESULTS

Breastfeeding was initiated by most of the mothers, but 20 of them (8.5%) opted exclusively for replacement feeding. Pre-lacteal feeding was given to 150 (64%) infants and 65 (28%) practised exclusive breastfeeding during the first three days. One-fifth of the infants less than 6 months old were exclusively breastfed, the majority being complementary fed including breast milk. The median duration of breastfeeding was 12 months (95% confidence interval [CI] 11.5 to 12.5). Adjusted Cox regression analysis indicated that a mother's education, socio-economic status, participation in the PMTCT-program and her positive attitude to breastfeeding exclusively, were all associated with a reduction in breastfeeding duration. Median duration was 3 months (95% CI 0-10.2) among the most educated mothers, and 18 months (95% CI 15.0-21.0) among uneducated mothers. Participation in the PMTCT program and being socio-economically better-off were also associated with earlier cessation of breastfeeding (9 months [95% CI 7.2-10.8] vs. 14 months [95% CI 10.8-17.2] and 8 months [95% CI 5.9-10.1] vs. 17 months [95% CI 15.2-18.8], respectively). The main reasons for stopping breastfeeding were reported as: advice from health workers, maternal illness, and the HIV-positive status of the mother.

CONCLUSION

Exclusive breastfeeding was uncommon. Exclusive replacement feeding was practised by few HIV-positive mothers. Well-educated mothers, mothers who were socio-economically better-off and PMTCT-attendees had the shortest durations of breastfeeding. Further efforts are needed to optimise infant feeding counselling and to increase the feasibility of the recommendations.

Participation of traditional birth attendants in prevention of mother-to-child transmission of HIV services in two rural districts in Zimbabwe: a feasibility study

Background

Prevention of Mother-to-Child Transmission of HIV (PMTCT) is among the key HIV prevention strategies in Zimbabwe. A decrease in use of antenatal care (ANC) services with an increase in home deliveries is affecting the coverage of PMTCT interventions in a context of accelerated economic crisis. The main objective was to evaluate acceptability and feasibility of reinforcing the role of traditional birth attendants (TBAs) in family and child health services through their participation in PMTCT programmes in Zimbabwe.

Methods

A community based cross-sectional survey was undertaken using multistage cluster sampling in two rural districts through interviews and focus group discussions among women who delivered at home with a TBA, those who had an institutional delivery and TBAs.

Results

45% of TBAs interviewed knew the principles of PMTCT and 8% delivered a woman with known HIV-positive status in previous year. Of the complete package of PMTCT services, more than 75% of TBAs agreed to participate in most activities with the exception of performing a blood test (17%), accompanying new-borns to closest health centre to receive medication (15%) and assisting health centres in documentation of the link ANC-PMTCT services (18%). Women who delivered at home were less likely to have received more than one ANC service or have had contact with a health centre compared to women who delivered in a health centre (91.0% vs 72.6%; P < 0.001). Also, 63.6% of the women who delivered in a health centre had the opportunity to choose the place of delivery compared to 39.4% of women who delivered at home (P < 0.001). More than 85% of women agreed that TBAs could participate in all activities related to a PMTCT programme with the exception of performing a blood test for HIV. Concerns were highlighted regarding confidentiality of the HIV-serostatus of women.

Conclusion

Although the long-term goal of ANC service delivery in Zimbabwe remains the provision of skilled delivery attendance, PMTCT programmes will benefit from complementary approaches to prevent missed opportunities. TBAs are willing to expand their scope of work regarding activities related to PMTCT. There is a need to reinforce their knowledge on MTCT prevention measures and better integrate them into the health system.