High and low pMTCT performance: The role of facility-level factors in Côte d'Ivoire, Kenya, and Mozambique

Background: Services to prevent mother-to-child transmission (pMTCT) of HIV require well-functioning health facilities to realize the vision of an HIV-free generation. This study aimed to identify health facility characteristics associated with high pMTCT performance in three sub-Saharan African countries. 

Methods: Ninety antenatal care (ANC) facilities were sampled in Côte d’Ivoire, Kenya, and Mozambique and ranked based on pMTCT performance in 2012 (defined as the proportion of pregnant women tested for HIV at first ANC visit (ANC1), multiplied by the proportion of HIV-positive pregnant women on dual or triple anti-retroviral regimens). The top and bottom 10 facilities per country were defined as “high” and “low” performers, respectively. Facility characteristics were ascertained during on-site visits. Binomial regression quantified associations between facility factors and performance.

Results: Sixty ANC facilities were included. High performance was associated with high clinic volume (RR per 100 ANC1 visits=1.05, 95% CI: 1.03-1.07), high staffing levels (RR per midwife=1.05, 95% CI: 1.04-1.07; RR per physician=1.04, 95% CI: 1.03-1.06), and on-site CD4 testing services (RR=2.00, 95% CI: 1.28-3.11). Other characteristics – including year of pMTCT initiation, support groups, active tracing of patients lost to follow-up, and HIV test or zidovudine stock-outs over 3 months – were not associated with performance.

Conclusions: Staffing levels, on-site CD4 testing, and patient volume were associated with high pMTCT performance. Several services – such as support groups and active tracing – were common in both high- and low-performing clinics. A ranking system based on routinely available data can highlight modifiable characteristics to maximize pMTCT effectiveness.