Table 1

Summary of public health literature on PMTCT in India
Experiences of implementing a PMTCT program (N = 20)
Reference State Facility* Objective Main results
Numeric summary of uptake of services (N = 9) Table 2
Barriers to accessing PMTCT services (N = 3)
Hancart Petitet et al. (2008) [35] Tamil Nadu Public To explore sociocultural factors limiting women’s access to PMTCT services. Lack of caregiver’s access to information, inadequate attention to social and gender issues and lack of decentralization of PMTCT activities affect access to PMTCT.
Rahangdale et al. (2010) [18] Karnataka Public To study the role of stigma on access to PMTCT services. Women who experienced stigma with health care providers, community, & family felt that it was a barrier to access services and disclosure of HIV status to avail PMTCT services was not perceived as an option.
Panditrao et al. (2011) [20] Maharashtra Private (N = 734&770) To understand the socio-demographic factors associated with loss to follow-up (LTF). 10.9% women were LTF before delivery and 19.6% after delivery. Factors associated with LTF were low education, poor socioeconomic status, late registration in the program and having HIV uninfected partner.
Outreach (taking PMTCT services beyond ANC clinics) (N = 1)
Madhivanan et al. (2010) [24] Karnataka - (N = 417) To understand the knowledge and attitudes of traditional birth attendants (TBA) about HIV. Only 12% TBA had heard about AIDS. Among them, knowledge about modes of transmission and PMTCT was low (44%).
Cost effectiveness (N = 6)
Dandona et al. (2005) [28] Andhra Pradesh Public To estimate the total and unit cost of providing voluntary counseling and testing (VCT) services. The cost per client varied 6 fold among VCTCs (range US$ 2.92–17.14). The incremental cost of providing complete VCT services to each HIV-positive and HIV-negative client was US$ 2.54 and US$ 1.22, respectively.
Kumar et al. (2006) [25] - Public To estimate the additional costs of universal HIV screening program for pregnant women. Comparison of universal screening program vs. program restricted to high prevalence states showed that implementation of program only in high prevalence states would achieve 45% of the target in 20% cost.
Dandona et al. (2008a) [30] Andhra Pradesh Public To assess the cost and efficiency of the PMTCT centers in Andhra Pradesh. The cost per mother-neonate pair who received NVP showed a wide variation, ranging from US$ 98 to US$ 4,047. Cost was inversely related to the scale of the program.
Dandona et al. (2008b) [29] Andhra Pradesh Public To estimate the changes in the unit cost of VCT and sex-workers program between 2002–2003 and 2005–2006. Over 3 years, the unit cost of VCT dropped by half and it increased 2.4 times for services provided to sex workers due to increases in male condom distribution, staff salaries and training, and treatment for sexually transmitted infections.
Dandona et al. (2009a) [32] Andhra Pradesh Public To conduct composite economic analysis of HIV prevention interventions to inform efficient utilization of resources.

The highest number of HIV infections averted per 1000

persons receiving an intervention was for MSM and women sex worker programs, followed by STI clinics and blood banks, whereas the lowest was for IEC for the general public.

Dandona et al. (2010) [31] Andhra Pradesh Public To measure cost effectiveness of HIV prevention interventions by estimating disability adjusted life years (DALY) saved. The cost per DALY saved was<US $50 for blood banks, MSM, VCT, PPTCT, STI and women sex-workers programs and>US $100 and up to US $140 for street children, condom promotion, workplace and mass media programs.
Integration of family planning (FP)/sexual and reproductive health (SRH) services in PMTCT program (N = 1)
Rutenberg et al. (2005) [17] - - To review field experiences with provision of family planning services within PMTCT. High acceptance of sterilization among women suggests the program’s priority of reducing the number of children born to HIV-infected women rather than ensuring mother’s reproductive health and rights.
Studies on individual components of the cascade (N = 26)
Counseling and HIV testing (N = 14)
Acceptability and utilization of counseling and HIV testing by women (N = 8)
Brown et al. (2001) [38]

Tamil Nadu

& Karnataka

Public (N = 666) To assess attitudes of pregnant women towards prenatal HIV testing and ARV prophylaxis. 86% agreed to undergo prenatal HIV testing, 21% would make this decision independently while 46% said their husband would have to decide. 97% said that they would take ARV if needed.
Shankar et al. (2003) [48] Maharashtra Public (N = 94 in ANC & 50 in DR) To assess acceptability of HIV testing in ANC and delivery room (DR). Acceptance of HIV testing was 83% in ANC clinics and 68% in the DR. Partners demonstrated very strong support for their wives to make such decisions independently.
Rogers et al. (2006) [45] Karnataka Private (N = 202) To assess knowledge about VCT among pregnant women in rural area. 85% of women were willing to be tested. 94% had heard of HIV/AIDS and 60% had good knowledge about modes of transmission. However, 48% did not know about PMTCT.
Samuel et al. (2007) [46] Tamil Nadu Public (N = 3722) To assess acceptance of educational session and VCT by pregnant women and to study HIV seroprevalence. 3,691 (99.2%) agreed to participate in the group educational session and 3,715 (99.8%) had VCT. Baseline knowledge regarding HIV was limited and a highly significant improvement was observed (P<0.0001) in the post-educational session.
Sinha et al. (2008) [49] Maharashtra - (N = 400) To assess HIV testing utilization among rural women. Recently pregnant rural women report low HIV testing (3.3%).
Vajpeyee et al. (2009) [50] Not specified - (N = 1169 men, 581 women) To report VCT experience at a tertiary care center Of 1750 participants, 67 percent were men. The main reason for seeking VCT was a history of sexual risk behavior (54.7%) for men and HIV-positive status of their spouse (38.7%) for women. Perceived discrimination based on serostatus was very high.
Dandona et al. (2009b) [39] Andhra Pradesh - (N = 12994) To assess the uptake of HIV testing and study reasons for undergoing HIV testing. The uptake of HIV test was higher in women (27.2%) than in men (18.8%). Increasing education level, urban area residence and having a job were significantly associated with the uptake. Pregnancy (57.4%) was the most common reason for seeking HIV test for women.
Kandwal et al. (2010) [42] Andhra Pradesh Public To study effect of stigma on women’s access to HIV testing centers. Geo-spacial analysis suggested that women go to a different mandal (sub-district) to be tested for HIV because of stigma.
Feasibility and provision of counseling and HIV testing (N = 6)
Bharucha et al. (2005) [37] Maharashtra Public (N = 6702) To examine the eligibility and acceptability of VCT among pregnant women in labor 49% of the eligible women could be provided VCT in labor room (LR). VCT in the LR was feasible but it would be of greater value where there is little or no ANC care available.
Pai et al. (2008) [44] Maharashtra Private (N = 1252) To investigate the impact of round-the-clock, rapid HIV testing in rural India. 98% of the women accepted HIV testing. A program of round-the-clock rapid HIV testing, including pre-partum and extended postpartum counseling sessions was shown to be feasible.
Sastry et al. (2004) [47] Maharashtra Public (N = 224) To develop tools to enhance, standardize and improve the communication of messages during the group education and counseling sessions.

Visual aids during group counseling sessions increased women's

overall understanding of key issues regarding informed consent from 38% to 72%. If these same visuals were reinforced during individual counseling, improvements in women’s overall comprehension rose to 96%.

Gupta et al. (2007) [41] Tamil Nadu Public (N = 213) To assess effectiveness of group perinatal counseling on HIV knowledge. The knowledge scores after group pre-test counseling increased by 21%. The study showed that group counseling sessions achieved small gains in HIV knowledge.
Dhadwal et al. (2009) [40] Haryana & Himachal Pradesh

-

(N = 82)

To assess the impact of 12-day PPTCT counselor training program on improving counseling skills. There was significant improvement in the post-test scores after counselor training. The average gain index ranged from 33% to 37% for the three batches.
Orne-Gliemann et al. (2010) [43] Indian site: Maharashtra Private To understand the acceptability and feasibility of couple-oriented prenatal counseling (COC) among women in ANC clinics. COC was considered by the respondents to be a feasible and acceptable strategy to actively encourage men to participate in prenatal HIV counseling and testing and overall reproductive health services.
ARV assessment/provision/utilization (N = 6)
Samuel et al. (1996) [55] Full paper not available
Sinha et al. (2007) [56] Maharashtra

Public

(N = 467)

To determine prevalence of anemia, (Hb<10 gm/Dl) and assess Zidovudine (ZDV) use and toxicity in HIV-positive pregnant women. Prevalence of anemia was 38.7% and ZDV use was not associated with persistent or worsening anemia. At delivery, regardless of anemia status at enrollment, women receiving ≥ 2 weeks of ZDV were 70% less likely to be anemic compared with women who were not prescribed ZDV.
Read et al. (2007) [54] Tamil Nadu Public (N = 60) To assess safety of Zidovudine and Nevirapine (NVP) Long-term ZDV (with or without concomitant NVP prophylaxis) was well accepted and well tolerated.
Mawar et al. (2007) [51] Maharashtra - To understand concerns and experiences of women regarding PMTCT. HIV-infected pregnant women perceived PMTCT through AZT as a useful means of enabling them to fulfill their social responsibility of bearing a child, free from HIV infection.
Patel et al. (2009) [53] Gujarat Private (N = 88) To evaluate efficacy of 3-drug combination ART for PMTCT. MTCT was 5.55% on intention-to-treat analysis and 1.11% on as-treated analysis. Overall effectiveness was comparable to other published studies.
Murthy et al. (2011) [52] Maharashtra Public (N = 73) To assess safety of single-dose NVP to mother and baby. Mother and child, followed for 1 week postpartum, did not show serious and adverse reaction to NVP.
Delivery/repeat HIV testing (N = 1)
Mukherjee et al. (2010) [61] Tamil Nadu Public (N = 362) To determine the cost effectiveness of childbirth strategies for mothers receiving NVP. Vaginal delivery was cost-effective as compared to elective Caesarian section (CS) for women receiving NVP. The incremental cost of preventing an additional HIV transmission through CS was INR 76,000.
Infant feeding (n = 4)
Phadke et al. (2003) [57] Maharashtra Public (N = 148) To assess post-partum morbidity among infants receiving replacement feeding for PMTCT. Replacement feeding, primarily diluted animal milk was associated with higher rate of hospitalization (0.093 hospitalizations per 100 person-days). 14% infants required hospitalization within the 1st 6 months of life.
Suryavanshi et al. (2003) [60] Maharashtra Public (N = 101) To assess factors influencing infant feeding decisions of HIV-infected mothers. Equal number of women (44%) intended to either breast-feed or use top feeding. Lack of disclosure, lack of funds, poor hygienic conditions and risk of social repercussions were more commonly noted as reasons to breast-feed.
Shankar et al. (2005) [59] Maharashtra Public (N = 240) To examine how the infant feeding recommendations have been actualized within the local context. There was a significant increase (47%) in the number of women intending to breast-feed from 2000–2004. Availability of local information on morbidity and the influence of counselors in making infant feeding choice were important factors for the rise.
Read et al. (2010) [58] Tamil Nadu Public (N = 60)

To assess the infant feeding choices of HIV-1-infected

women

One-third of women did not breast-feed their infants. Of those who initiated breast-feeding, the median duration of breast-feeding was approximately 3 months.
Infant diagnosis and linkage to postnatal care (N = 1)
Agrawal et al. (2008) [62] Uttar Pradesh Public To report the false positive test results of DNA PCR test for HIV diagnosis in infants. Three HIV-exposed infants who received PMTCT prophylaxis and who did not receive breastfeeding were tested positive by DNA PCR at 6 weeks of age and were tested negative by two different ELISA tests after 18 months.

*Sample size for quantitative studies is presented in parenthesis.

Darak et al.

Darak et al. BMC Public Health 2012 12:320   doi:10.1186/1471-2458-12-320

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