Cynthia Mouafo Piaplié
M.A Candidate, International Affairs
The Norman Paterson School of International Affairs,
Carleton University, Ottawa, Ontario, Canada
This paper provides a review of the available literature regarding prevention of mother-to-child HIV transmission (PMTCT) in sub-Saharan Africa. To narrow the focus of this broad subject, the review concentrates on antenatal care (ANC) and its effects on PMTCT. how do inadequate maternal services (antenatal clinics) affect the rate of mother-to-child HIV transmission in sub-Saharan Africa? The paper attempts to answer the question by focusing on peer-reviewed literature, as well as policy literature published from 2005 until now. The aim is to compare existing evidence on PMTCT with actual policy programs in order to evaluate any gaps between theory and practice. This was done through the examination of three recurrent themes identified while conducting research: 1) access and quality of ANC, 2) stigma and discrimination surrounding HIV/AIDS, and 3) knowledge and education available on HIV/AIDS.
Mother-to-child human immunodeficiency virus (HIV) transmission is defined as “the spread of HIV from an HIV-infected woman to her child during pregnancy, childbirth, or breastfeeding.”1 While mother-to-child transmission is the most common method by which children become infected with the virus, with the transmission rate ranging from 15% to 45% without intervention this rate can be reduced to below 5% with effective interventions during the periods of pregnancy, labor, delivery and breastfeeding,1 Globally, goals have been set by the international health community in attempts to prevent transmission to children, particularly in the most affected regions such as Sub-Saharan Africa. For instance, the joint United Nations Programme on HIV/AIDS (UNAIDS), in partnership with the United States’ health initiative, President’s Emergency Plan for AIDS Relief (PEPFAR) outlined objectives towards prevention of mother-to-child transmission (PMTCT) including reducing the number of new HIV infections among children to fewer than 40,000 by 2018 and to fewer than 20,000 by 2020.2 UNAIDS and PEPFAR have also jointly committed to ensure that 95% of pregnant women living with HIV are receiving lifelong HIV treatment by 2018. As a result of these objectives, MTCT has been nearly eliminated in high income countries with effective voluntary testing and counseling, access to antiretroviral therapy, safe delivery practices, and the widespread availability and safe use of breast-milk substitutes.3 However, despite the availability of such interventions and measures to ensure PMTCT, the pandemic still lingers in sub-Saharan Africa. In fact, approximately 50% of HIV-positive pregnant women in the region do not have access to the medications necessary to prevent mother-to-child transmission.4 This shortcoming is alarming because transmission can be avoided through a more comprehensive application of the aforementioned measures.
This paper provides a review of the available literature regarding PMTCT in sub-Saharan Africa. Specifically, the review concentrates on care during pregnancy (antenatal care or ANC) and its effects on PMTCT. The following question is addressed: how do inadequate maternal services (antenatal clinics) affect the rate of mother-to-child HIV transmission in sub-Saharan Africa? The paper attempts to answer the question by focusing on peer-reviewed literature, as well as policy literature published from 2005 to 2015. 2005 was chosen as a cutoff point due to the various initiatives undertaken throughout the year, some of them listed as followed: 5
|G8||Implementation of a package of HIV prevention, treatment and care|
|Governments, donors and implementing partners||Call to Action for the Elimination of HIV infection in Infants and Children|
|United Nations International Children’s Emergency Fund (UNICEF) and UNAIDS||Campaign to support universal access to treatment and address the impact of HIV and AIDS on children|
Searching from 2005 to 2015 allows long-term analysis, as well as for adequate analysis of potential changes following these implementations.
HIV prevalence varies greatly among regions within sub-Saharan Africa, going as low as 00.5% (Senegal) in West Africa to as high as 27.4% (Swaziland) in East Africa.6 Yet, many countries in the region face the same barriers to HIV prevention. Such barriers include (1) dependence upon external funds and resources in order to tackle the epidemics; (2) stigma and discrimination surrounding the issue; (3) and elevation in HIV-specific criminal legislation in parts of sub-Saharan Africa which does not acknowledge the role of antiretroviral therapy (ART). ART, defined as a “treatment of people infected with HIV using anti-HIV drugs,”7 can be crucial in reducing transmission risk and improving quality of life for those living with HIV.8 Given the similar obstacles faced by many sub-Saharan countries, it is assumed that the conclusions drawn in the present paper can be applicable to most of the countries in the region. Research was conducted to find any particular barriers that affect only certain regions/countries, in which none could be found hence a general regional pattern can thus be established.9
Literature on HIV/AIDS in sub-Saharan Africa with particular reference to maternal services remains limited. By consequence, a broad search strategy for the literature review was necessary. The policy literature was collected from four databases: Scopus, BioMed Central, ScienceDirect, and Google Scholar. The input terms chosen included “maternal services”, “HIV”, “mother-to-child transmission”, “sub-Saharan Africa”, “antenatal clinics”, and “PMTCT”. Additional search parameters included the exclusion of web page data and opinion pieces, as well as any articles written prior to 2005. The policy literature collected was found on the databases of the official websites of the international organizations known to be the most involved in HIV/AIDS issues. These organizations are: PEPFAR, The Global Fund to Fight AIDS, Tuberculosis and Malaria (The Global Fund), UNAIDS, International Drug Purchase Facility (UNITAID), and the World Health Organization (WHO).
While conducting research, seven articles from the peer-reviewed literature and six articles from policy literature were retained. The aim was to compare existing evidence on PMTCT with actual policy programs in order to evaluate any gaps between theory and practice. The results generated across the various databases were summarized into three different types of obstacles identified during the research: 1) normative (knowledge and education available on HIV/AIDS); 2) sociocultural and environmental (stigma and discrimination surrounding HIV/AIDS); and 3) economic and structural (access and quality of ANC). Additional evidence from various sources was also integrated to the paper to support its claims. After offering a brief overview of each theme from the perspectives of both peer-reviewed and policy literature, a discussion outlining all the elements is presented.
Knowledge and education of HIV/AIDS
One of the main issues raised in the peer-reviewed literature available on the subject was the overall knowledge and education displayed regarding HIV/AIDS-related issues. The peer-reviewed literature considers this to be the least impactful of the three, suggesting that access and quality of ANC, and the stigma surrounding HIV tend to have more implications. Nonetheless, knowledge and education are important for PMTCT because populations, particularly women, need to know about HIV, but also about methods of transmission, in order to understand and reject misconceptions regarding the disease, and to know how to protect themselves from infection.10 The literature suggests that mass information campaigns should be launched given the lack of universal belief that PMTCT is beneficial. The loveLife campaign initiated in South Africa is a good example of such outreach and support programmes as it specifically targets the most vulnerable populations.11 The information should also be accessible to all, and especially illiterate women, since studies show that illiterate women are more likely to believe that HIV cannot be prevented.12 A study conducted by Keating et al. in Nigeria shows that people were twice as likely to know that HIV risk is reduced by condoms and a half times as likely to discuss HIV with their partner if they have been highly exposed to mass-media campaigns via television and radio.13 Moreover, lack of information and the presence of misinformation perpetuate stigma and discrimination, and foster mistrust of, and reluctance to engage in PMTCT testing and medication. In a survey of 1200 women of reproductive age in Bida Emirate of Niger State, Nigeria, only 15% were able to describe HIV/AIDS as a deadly disease.12 As such, the literature notes the need for real health education, as well as HIV/AIDS sensitization on all levels and among both women and men.17
The literature further argues the need to provide more general information on HIV and PMTCT, both inside and outside of health structures. Also recognized by Torpey et al. is the importance of opinion leaders’ engagement in community sensitization and mobilization with regard to HIV/AIDS issues. In Luapula Province, Zambia, for instance, the involvement of traditional leaders within the community is encouraged. PMTCT providers from local hospitals first lead a series of informational campaigns targeting opinion leaders. Subsequent community meetings are then led by the leaders, where all men are encouraged to accompany their spouses to ANC appointments and to be actively involved in their care.18 The role of informal sources such as radio shows and peer-to-peer conversations in transmitting information is also raised in most of the literature, and warnings of possible medical and superstitious fallacies contained in such discourse given. For instance, in a survey of adolescents attending high schools in Addis Ababa, Ethiopia, one-third thought there was a vaccine for AIDS.19 Moreover, a study of secondary students in Nigeria shows that 72% believed AIDS could be cured.20 The myth that having sex with a virgin can cure AIDS is also widespread through the region.21 Overall, the peer-reviewed literature acknowledges the importance of governmental and local support in health literacy, especially with respect to HIV/AIDS, ANC and PMTCT.
The policy literature barely outlines the importance of education and mobilization in convincing pregnant women to seek ANC and adhere to PMTCT programs. Moreover, it attributes sole responsibility of implementation, reforms and campaigns to national leaders and the international community, stating that leadership and good governance are central in any sort of advocacy. The approach of the policy literature is mostly macroscopic and state-centered in comparison to the more microscopic and grassroot stance of the peer-reviewed literature.
Stigma and discrimination
The peer-reviewed literature unanimously highlights the role that stigma plays in preventing pregnant women from seeking ANC in sub-Saharan Africa. Several studies have found that HIV/AIDS-related stigma tends to be associated with contentious behavior such as sexual promiscuity, resulting in HIV/AIDS victims being seen as people with a ‘spoilt’ identity.22 A multi-site mixed methods study conducted in Burkina Faso, Kenya, Malawi, and Uganda found that only 37% of HIV-positive pregnant women disclose their HIV status to their husband.23 More often than not, pregnant women avoid going to antenatal clinics out of fear of exposure to their community. Studies conducted in sub-Saharan Africa on the subject found that “pregnant women [do] not disclose their HIV status to relatives for fear of stigma and discrimination,”24 with discrimination potentially taking the form of family exclusion. For example, according to the Demographic and Health Survey in 2003, only 40% of Nigerians were willing to care for an HIV-infected family member.25 In Nigeria, “when one member of the family becomes HIV-positive, the whole family will be called an “AIDS family” by other villagers, and will experience shame for being treated discriminatory by their entourage.26 Women are also reluctant to disclose their HIV diagnosis to their husbands out of fear of potential repercussions, especially intimate partner violence.27 A study conducted by Karamagi et al. established a strong correlation between intimate partner violence and HIV due to similar underlying factors such as poverty, gender inequality, alcoholism, and multiple partners, and outlined the need to address these underlying factors to prevent said violence.28 The stigma surrounding HIV/AIDS is so prominent that many pregnant women identified as HIV-positive prefer to change to another antenatal clinic where their status is not known. This makes proper follow-up and monitoring more difficult and greatly affects PMTCT. Stigma and discrimination from health personnel further discourages consultation. HIV also remains a major obstacle to individuals in the workplace who may be unable to find or continue working as a result of discrimination. For instance, the People Living with HIV (PLHIV) Stigma Index indicates that in 2012, 50% of the respondents in Kenya claimed discrimination was involved in the loss of their employment/source of income.29 In addition to the stigma and discrimination surrounding HIV/AIDS, the literature notes a lack of involvement from male partners of pregnant women in antenatal clinics. It is estimated that in West Africa, the involvement has rarely been over 10%, and has sometimes been even lower.30
Another reason for the lack of male involvement in antenatal clinics is that most men feel that their wives’ HIV-test results will mirror their own.31 This rationale is closely related to the lack of mass information and awareness campaigns. The literature also provides a semantic explanation that is illustrated by the terminology employed when referring to PMTCT and ANC. The use of terms such as ‘mother-to-child transmission’ is itself troublesome as it appears to place the burden associated with HIV/AIDS solely on the mother and reinforces male disengagement.32 Lastly, stigmatization and discrimination are closely related to a lack of female empowerment that seems to be prevalent in most sub-Saharan African communities. As such, the literature argues for interventions that empower women, and more specifically mothers, living with HIV/AIDS. Take for example Mothers2Mothers, a PMTCT intervention that began in South Africa in 2001 which seeks to “empower mothers living with HIV/AIDS by enabling them to fight stigma in their communities and to live positive and productive lives.33” The nonprofit organization currently works in over 400 sites in 7 countries in sub-Saharan Africa and employs over a 1000 women living with HIV.34 Hence, by citing examples like this one, the peer-reviewed literature appears to advocate for grassroots initiatives to challenge popular beliefs and fight stigmatization surrounding HIV.
Compared to the peer-reviewed literature, the policy literature overlooks the effect of stigma and discrimination on PMTCT. UNAIDS is the only organization to formally recognize the need to address stigma and discrimination, as well as the necessity of increased male involvement. This stance may very well be the result of UNAIDS’ collaboration with civil society when elaborating its policy report. UNICEF briefly mentions stigma and outlines the important role that women peer support groups can play in helping to fight it. In addition to the issue of stigma being considered a minor barrier to the effective responses to the HIV epidemic in policy literature, “there is little consensus among policy-makers and program implementers about how best to define, measure, and diminish the phenomenon.”35 For instance, a study conducted in Botswana by Weiser et al. indicates that some people may avoid going to the doctor out of fear of reprisals, suggesting that prevailing stigma in the general population leads to unintended but significant consequences.36 As such, policy recommendations should encourage community preparedness and social mobilization, as well as relevant legal and public service organizations to minimize these unintended consequences. In 2002 for instance, local leaders were being trained to address issues of discrimination and stigma and to be knowledgeable advocates on HIV/AIDS in their communities. The program was supported by the African Capacity-Building Foundation, which was funded by the African Development Bank, the United Nations Programme for Development (UNDP), African governments, and bilateral donors.37 While the involvement of the UNDP in this initiative shows that stigma and discrimination are being considered as potential obstacles to reduction of mother-to-child transmission, the fact that few other initiatives of the kind have been launched since indicates that this consideration remains minimal.
Access and quality of ANC
The third and last theme identified in the research is access to, and quality of, maternal services. According to all the peer-reviewed articles assessed, the lack of integration of PMTCT programs into maternal services is one of the major contributors of ineffective PMTCT. All peer review literature agree that integrated services may result in increased workload, increased training needs, and a lack of space and equipment. This ultimately leads to a lack of motivation to provide more and better quality services.38 Nonetheless, there is a consensus that “in sub-Saharan Africa […] integrating ANC and HIV services may result in a variety of benefits for HIV-positive women and their families; including better uptake of services, more women receiving counseling, reduction of the time to treatment initiation, improved quality of care, and reduction of stigma.”39 Service integration would remove the requirement of multiple visits, which can be particularly hard for pregnant women and can increase the risk of breaches in confidentiality. To avoid compromising confidentiality, the literature encourages the implementation of same-day test results coupled with onsite post-result counselling, better follow-up from health personnel and increased availability of ART in antenatal clinics.40
In addition to lacking HIV testing, antenatal clinics in sub-Saharan Africa are typically characterized by insufficiently trained health personnel, limited equipment, a shortage of tests, long wait times and a lack of appropriate places to conduct counseling.41 In sub-Saharan Africa, the number of women visiting antenatal clinics four or more times has remained static, at about 44%.42 As shown in the literature review conducted by Msellati, implementation, childcare research and treatment programs in West Africa shows an inability of health providers to establish friendly and trusting relationships with their patients due to not being equipped to deal with the great psychological distress experienced by HIV-infected pregnant women.43 The review states that “from a more general point of view, patients have not yet identified health workers as being as friendly as they should be”.44 The perceived lack of sensitivity in health care workers makes it hard for pregnant women to continue with consultation, because they often do not confide and open up in an environment in which they feel uncomfortable. As a result, many pregnant women tend to avoid antenatal clinics. This is highly problematic since antenatal clinics constitute the primary way for pregnant women to access PMTCT programs and testing. Furthermore, Msellati identifies other practical obstacles faced by pregnant women: lack of time in an already busy schedule, cost of transportation, the language barrier between them and the staff, and the distance between their residence and the antenatal clinics are among the top impediments that pregnant women face when trying to access ANC. Finally, pregnant women may also be restricted in their access to ANC by their economic dependence on their spouse, which can be particularly troublesome when considering the cost of treatment and the remoteness of the clinics. For instance, prior to 2003, people living in rural Kenya areas might have to travel hundreds of miles to test for HIV.45 In fact, antenatal clinics in sub-Saharan Africa are, for the most part, designed without consideration of men and most health workers are not trained and/or at ease to deal with men. As a result, ANC tends to be specifically and exclusively addressed to women when, in reality, it needs to be targeted at both parents-to-be to allow for positive impact in PMTCT. Hence, the peer-reviewed literature emphasizes the limitations in access to, and quality of, maternal services by looking at specific case studies in various sub-Saharan African countries.
Policy literature treats the question of access and quality of ANC from a more medical perspective. Having been strongly influenced by western ideas and approaches in dealing with HIV, the policy literature46 promotes the idea of HIV as a special disease demanding confidentiality47. As a result, policy literature argues that the solution to improving access and quality of ANC lies with a greater initiation of ART irrespective of gestational age in antenatal clinics. While ART drugs used for PMTCT of HIV can virtually eliminate the risk of childhood HIV infection, failure to couple such actions with regular HIV testing, as well as adequate counseling and proper health education may result in cumulative losses of pregnant mothers from PMTCT services, with increased risk of HIV transmission to their infants. These claims seem to be supported by a study conducted by Sweat and Denison which looked at strategies to reduce HIV incidence in developing countries.48 As concluded by the authors, HIV is not just a health problem, since the spread of the virus is highly correlated with social, cultural, political and economic factors. Such factors require the development of culturally-appropriated and community-sponsored prevention programs on multiple levels.49 In contrast, according to the overall policy literature analyzed for the purpose of this paper, the solution rather lies in national implementation of HIV/AIDS treatment and effective monitoring in order to prevent mother-to-child transmission. This approach to the issue was officially adopted by the World Health Organization in its 2010 version of Recommendations for a Public Health, and has subsequently been supported by many international health organizations, such as the Global Fund, UNICEF and UNITAID. Some of the literature does mention the importance of taking into consideration the specificity of health systems, although, surprisingly, none of them actually elaborate on the nature of this specificity. This is because the strategies put forth are essentially a means to rapidly deliver targeted interventions instead of being directed towards the root causes of health system shortcomings. In addition, PEPFAR is the only actor advocating a better integration of PMTCT into maternal services in order “to strengthen national ownership of programs, increase the coverage of quality PMTCT […], increase program sustainability, strengthen the health system, and improve maternal, newborn and child health outcomes overall.”50 None of the literature addresses the economic, socio-cultural, and legal barriers to HIV prevention in sub-Saharan Africa, and although integration is indeed touched upon, it is always implied that the initiative can only come from decision-makers. As such, the solutions proposed by the policy literature to improve the access and quality of ANC reflect the macroscopic and medical approach of the actors who propose them. These solutions include “more active and earlier identification of pregnant women who are HIV-infected, improved screening and rapid initiation or referral of women eligible for ART, effective linkages between PMTCT and ART services, [and] longer duration of antiretroviral (ARV) prophylaxis during pregnancy”.51 The policy literature thus tackles the issue by adopting a more technical and medical stance, in comparison to the more structural outlook showcased by the peer-reviewed literature.
Comparing the peer-reviewed literature and the policy literature reveals significant gaps in terms of how each analyzes the effects of maternal services on PMTCT. On one hand, the peer-reviewed literature appears to offer a more localized and sensitive perspective on the issue. It identifies structural challenges specific to the targeted populations and supports its arguments with rigorous data collected from relevant case studies from different sub-Saharan countries. The variety of sampled countries and the fact that conclusions are similar, confirm the reasonable generalizations that can be made when tackling the specific issue of ANC and PMTCT. These countries were considered to be among the worst in terms of mother-to-child transmission rate; for example, UNAIDS reports prevalence rates of 33.7 percent in Zimbabwe, 11.8 percent in Cameroon, and 21.5 percent in Zambia.52 All of the studies assessed showed significant improvement in PMTCT after peer-reviewed literature solutions were implemented, suggesting that the recommendations made by the peer-reviewed articles are more credible and convincing.
Given the peer-reviewed literature, one might reasonably assume that following the proposed recommendations – namely mass information campaigns, grassroot awareness initiatives, and large-scale training and implementation programs –, could allow for positive results similar to those obtained in the case studies. Yet, looking at the policy literature, the disparity between the evidence gathered in the field and the rationale of the policies actually implemented is remarkable. Essentially, the evidence gathered from international health organizations seems to focus solely on medical supply and equipment, and to prioritize national actions over any sort of grassroots initiative which can be a source of mainstream innovation for sustainable development. At times the role that communities can play during implementation of policies is mentioned, as well as the necessity of strengthening national systems by addressing structural difficulties and eliminating stigma surrounding HIV/AIDS and women. However, the policy literature reviewed never elaborates on the nature of those challenges, or on their implications for ANC and consequently, PMTCT. In neglecting this, the policy literature reveals a failure to comprehend the structural, sociocultural and normative dimensions associated with sub-Saharan Africa in terms of HIV/AIDS issues which may partly explain why the region is still so afflicted by the epidemic despite countless interventions In evaluating the effects of inadequate ANC on PMTCT, putting emphasis on national leadership and good governance alone does not reflect the complexity of the topic, as it does not encompass all of its components and variables.
Another alarming realization is that decontextualization is often hidden behind a shallow discourse that pretends to adopt a more microscopic approach. As stated by Catherine Campbell, professor at the London School of Economics and Political Science, “the discourses of HIV prevention are often the discourses of western science and policy, regardless of the extent to which these are appropriate for local conditions. [As a result,] projects are often designed by ‘overseas experts’, with only minimal and tokenistic consultation of local people, who may have little sense of ‘ownership’ of project proposals and lack the conceptual understandings, technical skills, or trained staff to implement them properly.”53 In other words, the solutions offer little to no innovation and the objectives, as well as the rationale, are often vague and are not tailored to the targeted populations. As a result, although the policy literature appears more substantial in terms of its elaboration and length, it becomes evident after review that the peer-reviewed literature offers a more comprehensive understanding of how inadequate ANC may affect PMTCT, doing so by adopting a multilevel approach and supporting its arguments with actual case studies. The overall assessment of the literature outlined throughout this paper further illustrates the relative redundancy and limitations of the policy literature. The focus was not the result of biased preference, but rather that of an elusive policy literature that did not incorporate any of the peer-reviewed literature into its analysis and subsequent recommendations. Doing so would have undoubtedly strengthened the arguments found in the policy literature and, more concretely, might have played a significant role in improving PMTCT in sub-Saharan Africa through extensive ANC reforms.
This contrast is further illustrated by the ongoing debate of the horizontal versus vertical approach to global health. The horizontal approach, as embodied by the peer-reviewed literature, focuses on all the activities whose primary purpose is to promote, restore and maintain health. In contrast, the vertical approach, reflected in the policy literature, focuses on tackling the issue of inadequate ANC through a one-dimensional action that would most likely come from decision-makers.
In light of the obstacles raised by the peer-reviewed literature, it can be concluded that in order for sub-Saharan Africa to eliminate the vertical transmission of HIV, interventions need to move beyond an individual-level or state-centered approach to address the structural and social barriers preventing women from receiving ANC which would subsequently increase PMTCT. The peer-reviewed literature already supports these claims, and a next logical step would be for the policy literature to adopt a similar approach. This would allow for significant improvement in prevention of mother-to-child HIV transmission, as outlined in most of the case studies presented. Lastly, there needs to be less focus on remedial measures and more attention given to prevention to address the root causes of transmission and allow for sustainable results. This will only be possible with significant structural reforms and capacity-building initiatives, mass awareness campaigns and education programs, and comprehensive and active attacks denouncing stigma and discrimination surrounding HIV/AIDS and gender. Nonetheless, this may only be possible if more literature is devoted to this approach and if this is appropriately reflected in policy implementation
The objective of the current literature review was to analyze and compare both theory (the peer-reviewed literature) and practice (policy literature) produced from 2005 to the present, in order to answer the following question: how do inadequate maternal services (antenatal clinics) affect the rate of mother-to-child HIV transmission in sub-Saharan Africa?54 Through the review of the different articles found, three recurrent themes were identified as potential outcomes and were examined in-depth: access to and quality of ANC, the stigma surrounding HIV/AIDS, and the knowledge and information available on the issues. The results revealed that while peer-reviewed literature seems to attribute the inadequacy of ANC in preventing mother-to-child HIV transmission to a combination of structural, environmental and normative factors, the policy literature supports a more state-centered and technical approach in understanding the relationship between ANC and PMTCT by advocating for the strengthening of national systems and for increased provisions of medication and testing. Of course, focusing on sub-Saharan Africa does not take away from the fact that the region is diverse and heterogeneous, characterized by different cultures, languages, mentalities and challenges. As such, although the conclusions made throughout this review tend to be generally applicable, it is important to keep in mind that some nuances and exceptions will most likely be present.
One of the main challenges when researching the topic of PMTCT and ANC, was the lack of literature currently available, as well as the lack of content in the articles that were found. This showcases the significant gap in understanding the correlation between inadequate maternal services and the prevention of mother-to-child HIV transmission that remains, despite some improvement in recent years. The initial research question has been partially answered, as discussed in this paper, but additional field research is required for real improvement. There is a current lack of analysis regarding the social structures hindering HIV PMTCT; as such, in order to eliminate mother-to-child transmission of HIV, the context in which HIV-positive mothers make decisions regarding their status needs to be better understood in the literature, and adequately addressed through efficient policies.
Appendix A: Sub-Saharan Africa
Sub-Saharan African consists of the following countries: Angola, Benin, Botswana, Burkina Faso, Burundi, Cameroon, Cape Verde, Central African Republic, Chad, Comoros, Congo, Côte d’Ivoire, Djibouti, Equatorial Guinea, Ethiopia, Gabon, The Gambia, Ghana, Guinea, Guinea-Bissau, Kenya, Lesotho, Liberia, Madagascar, Malawi, Mali, Mauritania, Mauritius, Mozambique, Namibia, Niger, Nigeria, Rwanda, Sao Tome and Principe, Senega, Seychelles, Sierra Leone, Somali, South Africa, Sudan, Swaziland, Tanzania, Togo, Uganda, Zaire, Zambia, and Zimbabwe. The evidence gathered for this paper is supported by actual case studies conducted in different sub-Saharan countries. These countries include Cameroon, Zambia, Uganda, South Africa, Benin, Kenya, Malawi and Rwanda.
Appendix B: Exclusion/Inclusion Criteria
Appendix C: Search Strategy for Peer-reviewed Literature
Appendix D: Search Strategy for Policy Literature
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- UNAIDS, President’s Emergency Plan for AIDS Relief (PEPFAR) and Partners (2016) ‘Start Free, Stay Free, AIDS Free: A super fast track framework for ending AIDS among children, adolescents and young women by 2020’.
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- Karen Hampada, Vertical Transmission of HIV in Sub-Saharan Africa: Applying Theoretical Frameworks to Understand Social Barriers to PMTCT, ISRN Infectious Diseases, Volume 2013, p. Page retrieved from https://www.hindawi.com/journals/isrn/2013/420361/.
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- AVERT (2013). HIV AND AIDS IN SUB-SAHARAN AFRICA REGIONAL OVERVIEW. Page retrieved from https://www.avert.org/professionals/hiv-around-world/sub-saharan-africa/overview
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- Global Commission on HIV and the Law (2012) ‘Risks, Rights and Health’.
- Gourlay, A., Birdthistle, I., Mburu, G., Iorpenda, K., & Wringe, A. (2013). Barriers and facilitating factors to the uptake of antiretroviral drugs for prevention of mother-to-child transmission of HIV in sub-Saharan Africa: a systematic review. Journal of the International AIDS Society, 16(1).
- Detailed documentation of the research process is available in appendices B. C and D.
- Burgoyne, A. D., & Drummond, P. D. (2008). Knowledge of HIV and AIDS in women in sub-Saharan Africa. African Journal of Reproductive Health, 12(2),
- AVERT (2015). HIV AND AIDS IN SOUTH AFRICA. Page retrieved from https://www.avert.org/professionals/hiv-around-world/sub-saharan-africa/south-africa.
- UNAIDS, United Nations Population Fund (UNFPA) and UNIFEM (2004). Women and HIV/AIDS: Confronting the Crisis, p. 39. Page retrieved from http://www.unfpa.org/sites/default/files/pub-pdf/women_aids.pdf.
- Keating, J., Meekers, D., & Adewuyi, A. (2006). Assessing effects of a media campaign on HIV/AIDS awareness and prevention in Nigeria: results from the VISION Project. BMC Public health, 6(1), 123.
- Burgoyne, A. D., & Drummond, P. D. Ibid, 17.
- Kwasi Torpey et al. Increasing the uptake of prevention of mother-to-child transmission of HIV services in a resource-limited setting, BMC Health Services Research, (2010) 10, p. 29.
- Ibid, p. 13.
- Cherie A, Mitkie G, Ismail S, Berhane Y. Perceived sufficiency and usefulness of IEC materials and methods related to HIV/AIDS among high school youth in Addis Ababa, Ethiopia. African Journal of Reproductive Health 2005; 9(1): 66-77.
- Oyo-Ita AE, Ikpeme BM, Etokidem AJ, Offor JB, Okokon EO, Etuk SJ. Knowledge of HIV/AIDS among secondary school adolescents in Calabar- Nigeria. Annals of African Medicine 2005; 4: 2-6.
- Simbayi LC, Kalichman SC, Jooste S, Cherry C, Mfecane S, Cain D. Risk factors for HIVAIDS among youth in Cape Town, South Africa. AIDS and Behavior 2005; 9: 53-61.
- Apanga, P. (2014). HIV/AIDS-Related Stigma and Discrimination in Sub-Saharan Africa: A Review. Journal of Natural Science Research, 4, 41.
- Karen Hampada, p. 3.
- Kautz, p. 9.
- Li, L., Wu, S., Wu, Z., Sun, S., Cui, H., & Jia, M. (2006). Understanding family support for people living with HIV/AIDS in Yunnan, China. AIDS and Behavior, 10(5), p. 510.
- Philippe Msellati, p. 809.
- Karamagi, C. A., Tumwine, J. K., Tylleskar, T., & Heggenhougen, K. (2006). Intimate partner violence against women in eastern Uganda: implications for HIV prevention. BMC public health, 6(1), 284, p. 10.
- Global Network of People Living with HIV. The People Living with HIV Stigma Index. Evidence Brief: Stigma and Discrimination at Work. 2012, p. 12. Retrieved from http://www.gnpplus.net/assets/wbb_file_updown/4621/Stigma%20and%20Discrimination%20at%20work.pdf.
- Ibid, p. 810.
- Karen Hampada, p. 3.
- Where We Work. Retrieved from https://www.m2m.org/where-we-work/.
- Mahajan, A. P., Sayles, J. N., Patel, V. A., Remien, R. H., Ortiz, D., Szekeres, G., & Coates, T. J. (2008). Stigma in the HIV/AIDS epidemic: a review of the literature and recommendations for the way forward. AIDS (London, England), 22(Suppl 2), S67.
- Weiser SD, Heisler M, Leiter K, et al. Routine HIV testing in Botswana: A population based study on attitudes, practices, and human rights concerns. PLoS Med. 2006;3:e261.
- Kelly, M. M. (2002). Fighting AIDS-related stigma in Africa.
- Karen Hampada. Vertical Transmission of HIV in Sub-Saharan Africa: Applying Theoretical Frameworks to Understand Social Barriers to PMTCT, ISRN Infectious Diseases, Volume 2013, p. Page retrieved from https://www.hindawi.com/journals/isrn/2013/420361/; Janet M. Turan et al. The Study of HIV and Antenatal Care Integration in Pregnancy in Kenya: Design, Methods, and Baseline Results of a Cluster-Randomized Controlled Trial. PLOS ONE, September 2012, 7(9), p. 2. Page retrieved from http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0044181; Philippe Msellati. Improving mothers’ access to PMTCT programs in West Africa: A public health perspective. Social Science & Medicine 69, 2009, p. 808. Retrieved from http://journals2.scholarsportal.info.proxy.library.carleton.ca/pdf/02779536/v69i0006/807_imatppwaaphp.xml/ Kwasi Torpey et al. Increasing the uptake of prevention of mother-to-child transmission of HIV services in a resource-limited setting, BMC Health Services Research, (2010) 10, p. 29. Retrieved from http://go.galegroup.com.proxy.library.carleton.ca/ps/i.do?p=AONE&u=ocul_carleton&id=GALE|A220675846&v=2.1&it=r&sid=summon&userGroup=ocul_carleton&authCount=1#/; Thiloshini Govender and Hoosen Coovadia. Eliminating mother to child transmission of HIV-1 and keeping mothers alive: Recent progress. Journal of Infection (2014) 68, p. 557-562. Retrieved from http://www.sciencedirect.com.proxy.library.carleton.ca/science/article/pii/S016344531300282X/; Putu Duff et al. Barriers to accessing highly active antiretroviral therapy by HIV-positive women attending an antenatal clinic in a regional hospital in western Uganda. Journal of the International AIDS Society, 2010, 13(27). Retrieved from http://jiasociety.biomedcentral.com/articles/10.1186/1758-2652-13-37/; Ange Anitha Irakoze. Uptake of PMTCT sites for increasing accessibility of services in prevention of mother to child HIV transmission program in Rwanda, January 2005 – June 2010, Retrovirology, 2012, 9(1). Retrieved from http://retrovirology.biomedcentral.com/articles/10.1186/1742-4690-9-S1-P100.
- Janet M. Turan et al. The Study of HIV and Antenatal Care Integration in Pregnancy in Kenya: Design, Methods, and Baseline Results of a Cluster-Randomized Controlled Trial. PLOS ONE, September 2012, 7(9), p. 2. Page retrieved from http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0044181.
- Philippe Msellati. Improving mothers’ access to PMTCT programs in West Africa: A public health perspective. Social Science & Medicine 69, 2009, p. 808. Retrieved from http://journals2.scholarsportal.info.proxy.library.carleton.ca/pdf/02779536/v69i0006/807_imatppwaaphp.xml.
- Ibid, p. 808.
- Finlayson, Kenneth, and Soo Downe. “Why do women not use antenatal services in low-and middle-income countries? A meta-synthesis of qualitative studies.” PLoS Med10, no. 1 (2013): e1001373.
- Msellati, p. 809.
- Ibid, p. 811.
- Kautz, T. (2008). Stigma, Fear and Hope: A Model of HIV Testing in Sub-Saharan Africa, p. 24.
- The policy literature collected comes from from the WHO, PEPFAR, UNAIDS, the Global Fund to Fight AIDS, Tuberculosis, and Malaria (Global Fund), UNICEF and the International Drug Purchasing Facility (UNITAID).
- Dickinson, C., & Buse, K. (2008). Understanding the politics of national HIV policies: the roles of institutions, interests and ideas. HLSP institute.
- Sweat, M. D., & Denison, J. A. (1995). Reducing HIV incidence in developing countries with structural and environmental interventions. Aids, 9, S251-7.
- Guidance on Integrating Prevention of Mother to Child Transmission of HIV, Maternal, Neonatal, and Child Health and Pediatric HIV Services. January 2011, p. 1. Retrieved from http://www.pepfar.gov/documents/organization/158963.pdf.
- World Health Organization. Antiretroviral Drugs for Treating Pregnant Women and Preventing HIV Infection in Infants: Recommendations for a Public Health Approach. 2010, p. 66. Retrieved from http://apps.who.int/iris/bitstream/10665/75236/1/9789241599818_eng.pdf.
- UNAIDS, Report on the Global HIV/AIDS Epidemic: July 2002.
- Campbell, Catherine (2003) Why HIV prevention programmes fail. Student BMJ, 11, p. 479.