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The overview summarizes the evaluation of community responses (15 studies, including 11 evaluations carried out in 8 countries). It presents the evaluation questions, the methodology, the key results achieved by community responses along the continuum of prevention, treatment, care and support, and the resulting policy and programmatic implications. Before the scale-up of the international response to the AIDS pandemic, community responses in developing countries played a crucial role in providing services and care for those affected. This study is the first comprehensive, mixed-method evaluation of the impact of that response. The evaluation finds that community response can be effective at increasing knowledge of HIV, promoting social empowerment, increasing access to and use of HIV services, and even decreasing HIV incidence, all through the effective mobilization of limited resources. By effectively engaging with this powerful community structure, future HIV and AIDS programs can ensure that communities continue to contribute to the global response to HIV and AIDS.

Introduction The implementation of lifelong antiretroviral treatment (ART) for all pregnant women (Option B+) in Malawi has resulted in a significant increase in the number of HIV‐positive pregnant women initiating treatment. However, research has highlighted the challenge of retaining newly initiated women in care. This study explores barriers and facilitators that affect a woman's decision to initiate and to adhere to Option B+. Methods A total of 39 in‐depth interviews and 16 focus group discussions were conducted. Eligible women were ≥18 years old, living with HIV and either pregnant and receiving antenatal care from a study site or had delivered a child within the last 18 months, breastfed their child and received services at one of the study sites. Eligible women were identified by healthcare workers (HCWs) in the antenatal clinic and ART unit. Focus groups were also conducted with HCWs employed in these departments. Qualitative data were analyzed using Maxqda version 10 (VERBI Software, Berlin, Germany). Results The general perception towards the drug regimen used in Option B+ was positive; women reported fewer side effects and acknowledged the positive benefits of ART. Women felt hopeful about prolonging their life and having an HIV‐uninfected baby, yet grappled with the fact that ART is a lifelong commitment. Women and HCWs discussed challenges with the counselling services for prevention of mother‐to‐child HIV transmission under the new Option B+ guidelines, and many women struggled with initiating ART on the same day as learning their HIV status. Women wanted to discuss their circumstances with their husbands first, receive a CD4 count and obtain an HIV test at another facility to confirm their HIV status. HCWs expressed concern that women might just agree to take the drugs to please them. HCWs also discussed concerns around loss to follow‐up and drug resistance. Conclusions Although Option B+ has significantly increased the number of women initiating ART, there are still challenges that need to be addressed to strengthen initiation, adherence and retention in care. Strategies to strengthen the counselling services upon diagnosis need to be developed to improve same‐day initiation of ART and long‐term adherence.

Introduction Community‐based mentor mothers (cMMs) are women living with HIV who provide peer support to pregnant/postpartum women living with HIV (PWLWH) to enhance antiretroviral therapy (ART) adherence, retention in care and prevent perinatal transmission of HIV. The goal of this study was to explore the experiences, perceptions, mechanisms and health impact of cMMs on PWLWH in Kenya from the perspective of cMMs. Methods We conducted a prospective mixed‐methods study in southwestern Kenya in 2015–2018. In the qualitative phase, we completed in‐depth interviews with cMMs to explore their perceptions and experiences in supporting PWLWH. Transcripts were broad‐coded according to identified themes, then fine‐coded using an inductive approach. In the quantitative phase, we analysed medical record data from PWLWH who were randomized in the cMM intervention to examine the impact of cMM visits on optimal prevention of mother‐to‐child transmission (PMTCT). We used cluster‐adjusted generalized estimating equation models to examine relationships with a composite outcome (facility delivery, infant HIV testing, ART adherence and undetectable viral load at 6 weeks postpartum). Finally, qualitative and quantitative results were integrated. Results Convergence of findings from cMM interviews (n = 24) and PWLWH medical data (n = 589) revealed: (1) The cMM intervention was utilized and perceived as acceptable. PWLWH received, on average, 6.2 of 8 intended home visits through 6 weeks postpartum. (2) The cMMs reported serving as role models and confidantes, supporting PWLWH's acceptance of their HIV status, providing assurances about PMTCT and assisting with male partner disclosure and communication. cMMs also described benefits for themselves, including empowerment and increased income. (3) The cMM visits supported PWLWH's completion of PMTCT steps. Having ≥4 cMM home visits up to 6 weeks postpartum, as compared to <4 visits, was associated with higher likelihood of an optimal PMTCT composite outcome (adjusted relative risk 1.42, p = 0.044). Conclusions We found that peer support from cMMs during pregnancy through 6 weeks postpartum was associated with improved uptake of critical PMTCT services and health behaviours and was perceived as beneficial for cMMs themselves. CMM support of PWLWH may be valuable for other low‐resource settings to improve engagement with lifelong ART and HIV services among PWLWH.

Aim To understand HIV stigma and self‐efficacy of labour and delivery (L&D) providers in caring for women living with HIV (WLHIV). Design Cross‐sectional descriptive mixed methods. Methods Data were collected in six primary healthcare facilities in the Kilimanjaro region, Tanzania between February and November 2022. We conducted eight focus groups with L&D providers (n = 36) and nurse‐midwifery students (n = 12). We conducted surveys with 60 L&D providers assessing HIV stigma (fear of acquisition, extra precautions and attitudes) and self‐efficacy in caring for WLHIV. Qualitative findings were complemented by survey data to provide a comprehensive understanding of providers' attitudes and experiences. Results Providers expressed fear of HIV acquisition when caring for WLHIV. Almost all providers noted that they used extra precautions with WLHIV; 97% used double gloves and 39% avoided touching WLHIV with bare hands, even when there were no bodily fluids. Most providers had positive attitudes towards WLHIV. Almost all rejected the idea that HIV was a punishment for bad behaviour, but 44% thought their patients might not be careful about infecting others. Qualitative data suggested providers worried that patients' reluctance to disclose their HIV status could raise the risk of occupational exposure. Provider self‐efficacy in normal birth was lower when caring for a woman with HIV compared with care for women who are HIV‐negative but did not differ significantly in other situations. Conclusion This study showed that providers had generally low‐stigmatising attitudes towards people living with HIV but feared occupational exposure, leading to avoidance of necessary patient contact. Training on clinical and interpersonal skills, coupled with evidence‐based care for women with HIV during childbirth, could benefit both providers and patients. Reporting Method The study is reported following the Good Reporting of a Mixed‐Methods Study (GRAMMS) checklist. Patient or Public Contribution Patients and the public were not involved in this research.

Introduction With the rapid scale‐up of antiretroviral treatment (ART) in the “Treat All” era, there has been increasing emphasis on using differentiated models of HIV service delivery. The gaps within the clinical cascade for mothers and their infants suggest that current service delivery models are not meeting families' needs and prompt re‐consideration of how services are provided. This article will explore considerations for differentiated care and encourage the ongoing increase of ART coverage through innovative strategies while also addressing the unique needs of mothers and infants. Discussion Service delivery models should recognize that the timing of the mother's HIV diagnosis is a critical aspect of determining eligibility. Women newly diagnosed with HIV require a more intensive approach so that adequate counselling and monitoring of ART initiation and response can be provided. Women already on ART with evidence of virologic failure are also at high risk of transmitting HIV to their infants and require close follow‐up. However, women stable on ART with a suppressed viral load before conception have a very low likelihood of HIV transmission and thus are strong candidates for multi‐month ART dispensing, community‐based distribution of ART, adherence clubs, community adherence support groups and longer intervals between clinical visits. A number of other factors should be considered when defining eligibility of mothers and infants for differentiated care, including location of services, viral load monitoring and duration on ART. To provide differentiated care that is client‐centred and driven while encompassing a family‐based approach, it will be critical to engage mothers, families and communities in models that will optimize client satisfaction, retention in care and quality of services. Conclusions Differentiated care for mothers and infants represents an opportunity to provide client‐centred care that reduces the burden on clients and health systems while improving the quality and uptake of services for families. However, with decreasing funding, stable HIV incidence, and aspirations for sustainability, it is critical to consider efficient, customized and cost‐effective models of care for these populations as we aspire to eliminate mother‐to‐child transmission of HIV.

Introduction Through The Global Plan Towards the Elimination of New HIV Infections Among Children by 2015 and Keeping their Mothers Alive, leaders have called for broader action to strengthen the involvement of communities. The Global Plan aspires to reduce new HIV infections among children by 90 percent, and to reduce AIDS‐related maternal mortality by half. This article summarizes the results of a review commissioned by UNAIDS to help inform stakeholders on promising practices in community engagement to accelerate progress towards these ambitious goals. Methods This research involved extensive literature review and key informant interviews. Community engagement was defined to include participation, mobilization and empowerment while excluding activities that involve communities solely as service recipients. A promising practice was defined as one for which there is documented evidence of its effectiveness in achieving intended results and some indication of replicability, scale up and/or sustainability. Results Promising practices that increased the supply of preventing mother‐to‐child transmission (PMTCT) services included extending community cadres, strengthening linkages with community‐ and faith‐based organizations and civic participation in programme monitoring. Practices to improve demand for PMTCT included community‐led social and behaviour change communication, peer support and participative approaches to generate local solutions. Practices to create an enabling environment included community activism and government leadership for greater involvement of communities. Committed leadership at all levels, facility, community, district and national, is crucial to success. Genuine community engagement requires a rights‐based, capacity‐building approach and sustained financial and technical investment. Participative formative research is a first step in building community capacity and helps to ensure programme relevance. Building on existing structures, rather than working in parallel to them, improves programme efficiency, effectiveness and sustainability. Monitoring, innovation and information sharing are critical to scale up. Conclusions Ten recommendations on community engagement are offered for ending vertical transmission and enhancing the health of mothers and families: (1) expand the frontline health workforce, (2) increase engagement with community‐ and faith‐based organizations, (3) engage communities in programme monitoring and accountability, (4) promote community‐driven social and behaviour change communication including grassroots campaigns and dialogues, (5) expand peer support, (6) empower communities to address programme barriers, (7) support community activism for political commitment, (8) share tools for community engagement, (9) develop better indicators for community involvement and (10) conduct cost analyses of various community engagement strategies. As programmes expand, care should be taken to support and not to undermine work that communities are already doing, but rather to actively identify and build on such efforts.

Introduction Loss‐to‐follow‐up (LTFU) in the prevention of mother‐to‐child HIV transmission (PMTCT) programmes can occur at multiple stages of antenatal and follow‐up care. This paper presents findings from a national assessment aimed at identifying major bottlenecks in Côte d'Ivoire's PMTCT cascade, and to distinguish characteristics of high‐ and low‐performing health facilities. Methods This cross‐sectional study, based on a nationally representative sample of 30 health facilities in Côte d'Ivoire used multiple data sources (registries, patient charts, patient booklets, interviews) to determine the magnitude of LTFU in PMTCT services. A composite measure of retention – based on child prophylaxis, maternal treatment and infant testing – was used to identify high‐ and low‐performing sites and determine significant differences using Student's t‐tests. Results Among 1,741 pregnant women newly recorded as HIV‐positive between June 2011 and May 2012, 43% had a CD4 count taken, 77% received appropriate prophylaxis and 70% received prophylaxis intended for their infant. During that time, 1,054 first infant HIV tests were recorded. A conservative rate of adherence to antiretroviral therapy was estimated at 50% (n=219 patient charts). Significant differences between high‐ and low‐performing sites included: duration of time elapsed between HIV testing and CD4 results (29.5 versus 56.3 days, p=0.001); and density (number per 100 first antenatal care visits) of full‐time physicians (6.7 versus 1.7, p=0.04), laboratory technicians (2.3 versus 0.7, p=0.046), staff trained in PMTCT (10.7 versus 4.7, p=0.01), and staff performing patient follow‐up activities (7.9 versus 2.5, p=0.02). Key informants highlighted staff presence and training, the availability of medical supplies and equipment (i.e., on‐site CD4 machine), and the adequacy of infrastructure (i.e., space and ventilation) as perceived key factors positively and negatively impacting retention in care. Conclusions Patient LTFU occurred throughout the PMTCT cascade from maternal to infant testing, with retention scores ranging from 0.10 to 0.83. Sites that scored higher had more dedicated and trained frontline health workers, and emphasised patient follow‐up through outreach and the reduction of delays in care. Strategies to improve patient retention and decrease transmission should emphasise patient tracking systems that utilise critical human resources to both improve data quality and increase direct patient follow‐up.

Introduction High maternal HIV incidence contributes substantially to mother‐to‐child HIV transmission (MTCT) in some settings. Since 2006, HIV retesting during the third trimester and breastfeeding has been recommended by the World Health Organization in higher prevalence (≥5%) settings to reduce MTCT. However, many countries lack clarity on when and how often to retest pregnant and postpartum women to optimize resources and service delivery. We reviewed and characterized national guidelines on maternal retesting based on timing and frequency. Methods We identified 52 countries to represent variations in HIV prevalence, geography, and MTCT priority and searched available national MTCT, HIV testing and HIV treatment policies published between 2007 and 2017 for recommendations on retesting during pregnancy, labour/delivery and postpartum. Recommended retesting frequency and timing was extracted. Country HIV prevalence was classified as: very low (<1%), low (1% to 5%), intermediate (>5 to <15%) and high (≥15%). Women with unknown HIV status at delivery/postpartum were included in retesting guidelines. Results and discussion Overall, policies from 49 countries were identified; 51% from 2015 or later and most (n = 25) were from Africa. Four countries were high HIV prevalence, seven intermediate, sixteen low and twenty‐two very low. Most (n = 31) had guidance on universal voluntary opt‐out HIV testing at the first antenatal care (ANC) visit. Beyond the first ANC visit, the majority (78%, n = 38) had guidance on retesting; 22 recommended retesting all women with unknown/negative status, five only if unknown HIV status, three in pregnancy based on risk and eight combining these approaches. Retesting was universally recommended during pregnancy, labour/delivery, and postpartum for all high prevalence settings and four of seven intermediate prevalence settings. Five UNAIDS priority countries for EMTCT with low/very low HIV prevalence, but high/intermediate MTCT, had no guidance on retesting. Conclusions Retesting guidelines for pregnant and postpartum women were ubiquitous in high prevalence countries and defined in some intermediate prevalence countries, but absent in some low HIV prevalence countries with high MTCT. Countries may require additional guidance on how to optimize maternal HIV testing and whether to prioritize retesting efforts or discontinue universal retesting based on HIV incidence. Research is needed to assess country‐level guideline implementation and impact.

Introduction Uptake of early infant HIV diagnosis (EID) varies widely across sub‐Saharan African settings. We evaluated the potential clinical impact and cost‐effectiveness of universal maternal HIV screening at infant immunization visits, with referral to EID and maternal antiretroviral therapy (ART) initiation. Methods Using the CEPAC‐Pediatric model, we compared two strategies for infants born in 2017 in Côte d’Ivoire (CI), South Africa (SA), and Zimbabwe: (1) existing EID programmes offering six‐week nucleic acid testing (NAT) for infants with known HIV exposure (EID), and (2) EID plus universal maternal HIV screening at six‐week infant immunization visits, leading to referral for infant NAT and maternal ART initiation (screen‐and‐test). Model inputs included published Ivoirian/South African/Zimbabwean data: maternal HIV prevalence (4.8/30.8/16.1%), current uptake of EID (40/95/65%) and six‐week immunization attendance (99/74/94%). Referral rates for infant NAT and maternal ART initiation after screen‐and‐test were 80%. Costs included NAT ( $24/infant), maternal screening ($ 10/mother–infant pair), ART ( $5 to 31/month) and HIV care ($ 15 to 190/month). Model outcomes included mother‐to‐child transmission of HIV (MTCT) among HIV‐exposed infants, and life expectancy (LE) and mean lifetime per‐person costs for children with HIV (CWH) and all children born in 2017. We calculated incremental cost‐effectiveness ratios (ICERs) using discounted (3%/year) lifetime costs and LE for all children. We considered two cost‐effectiveness thresholds in each country: (1) the per‐capita GDP ( $1720/6380/2150) per year‐of‐life saved (YLS), and (2) the CEPAC‐generated ICER of offering 2 versus 1 lifetime ART regimens (e.g. offering second‐line ART; $ 520/500/580/YLS). Results With EID, projected six‐week MTCT was 9.3% (CI), 4.2% (SA) and 5.2% (Zimbabwe). Screen‐and‐test decreased total MTCT by 0.2% to 0.5%, improved LE by 2.0 to 3.5 years for CWH and 0.03 to 0.07 years for all children, and increased discounted costs by$17 to 22/child (all children). The ICER of screen‐and‐test compared to EID was $ 1340/YLS (CI),$650/YLS (SA) and $ 670/YLS (Zimbabwe), below the per‐capita GDP but above the ICER of 2 versus 1 lifetime ART regimens in all countries. Conclusions Universal maternal HIV screening at immunization visits with referral to EID and maternal ART initiation may reduce MTCT, improve paediatric LE, and be of comparable value to current HIV‐related interventions in high maternal HIV prevalence settings like SA and Zimbabwe.

Background Integrating Prevention of Mother-to-Child Transmission (PMTCT) programmes into routine health services under complex socio-political and health system conditions is a priority and a challenge. The successful rollout of PMTCT in sub-Saharan Africa has decreased Human Immunodeficiency Virus (HIV), reduced child mortality and improved maternal health. In South Africa, PMTCT is now integrated into existing primary health care (PHC) services and this experience could serve as a relevant example for integrating other programmes into comprehensive primary care. This study explored the perspectives of both experts or key informants and frontline health workers (FHCWs) in South Africa on PMTCT integration into PHC in the context of post-AIDS denialism using a Complex Adaptive Systems framework. Methods A total of 20 in-depth semi-structured interviews were conducted; 10 with experts including national and international health systems and HIV/PMTCT policy makers and researchers, and 10 FHCWs including clinic managers, nurses and midwives. All interviews were conducted in person, audio-recorded and transcribed. Three investigators collaborated in coding transcripts and used an iterative approach for thematic analysis. Results Experts and FHCWs agreed on the importance of integrated PMTCT services. Experts reported a slow and partial integration of PMTCT programmes into PHC following its initial rollout as a stand-alone programme in the aftermath of the AIDS denialism period. Experts and FHCWs diverged on the challenges associated with integration of PMTCT. Experts highlighted bureaucracy, HIV stigma and discrimination and a shortage of training for staff as major barriers to PMTCT integration. In comparison, FHCWs emphasized high workloads, staff turnover and infrastructural issues (e.g., lack of rooms, small spaces) as their main challenges to integration. Both experts and FHCWs suggested that working with community health workers, particularly in the post-partum period, helped to address cases of loss to follow-up of women and their babies and to improve linkages to polymerase-chain reaction (PCR) testing and immunisation. Conclusions Despite organised efforts in South Africa, experts and FHCWs reported multiple barriers for the full integration of PMTCT in PHC, especially postpartum. The results suggest opportunities to address operational challenges towards more integrated PMTCT and other health services in order to improve maternal and child health.