Table 1.

Key characteristics of studies included in review of barriers and promoters to delivery of prevention of vertical transmission of HIV (PVT) services in sub-Saharan Africa (n=47)

No.	Author(s), Year	Year conducted	Country	Settinga	Study methodologiesb	Participantsc	Objective	Theoretical framework
Studies conducted prior to 2007 (n=20)
1	Buskens and Jaffe, 2008	2003	Namibia, South Africa, Swaziland	Urban and rural: 11 health centers and hospitals a	FGDs, IDIs, participant observation	5 PVT physicians or coordinators, 10 nurses, 7 counsellors, 167 mothers, 11 pregnant women, 32 relatives	To explore the perceptions and experiences of mothers and providers on infant feeding counseling in the context of PVT	None
2	Chopra and Rollins, 2008	2003	Botswana, Kenya, Malawi, Uganda	Urban and rural: 29 health centers	FGDs, participant observation, surveys	334 HWs, 640 patients in counselling observations, men and women (in 34 FGDs)	To assess provider knowledge and quality of infant feeding counseling of PVT programs	None
3	Creek et al., 2007	2003	Botswana	Urban and rural: 12 clinics, 1 maternity hospitala	Surveys	66 midwives, 16 counsellors, 504 pregnant/postpartum women	To characterize the factors influencing women to accept or refuse an HIV test; to describe what constitutes adequate PVT knowledge for HWs	None
4	de Paoli et al., 2002	2000–2001	Tanzania	Urban: 1 private hospital	IDIs	2 doctors, 16 nurses, 5 counsellors	To evaluate the quality and perceived influence of infant feeding counseling on HIV-infected pregnant women	None
5	Delva, 2006	2003	South Africa	Urban: 1 public hospital	SSIs	3 program coordinators, 3 doctors, 1 pharmacist, 7 midwives	To explore the challenges and potential solutions for use of single-dose Neverapine for PVT	None
6	Doherty et al., 2005	2002	South Africa	Urban and rural: 18 PVT sitesa	Records review, SSIs	HWs (unspecified)	To evaluate the uptake and performance of South Africa’s national pilot PVT program	None
7	Fadnes et al., 2010	2003–2005	Uganda	Rural: public hospitals, health centers, and NGO projectsa	FGDs, IDIs, surveys	18 clinical officers, nurses and midwives, HIV-exposed women (in 7 FGDs), community members (in 8 FGDs), 727 HIV-uninfected and 235 HIV-infected mothers	To assess delivery of infant feeding counselling; to evaluate the experiences of providers and mothers delivering and receiving this counseling	None
8	Horwood et al., 2010(B)	2006	South Africa	Urban and rural: public health centersa	FGDs	Nurses, mothers and family members	To characterize attitudes and experiences of nurses and mothers during HIV testing in the integrated management of childhood illness	None
9	Ledikwe et al., 2013	2002–2010	Botswana	Urban, peri-urban, and rural: public health centersa	Counselling observations, client exit interviews, FGDs, IDIs	17 policymakers, 23 district coordinators, 39 HWs (physicians, nurses, midwives, social workers), 400+ lay counsellors, 47 patients	To evaluate the effectiveness and contributions of lay HIV counsellors	None
10	Leshabari et al., 2007	2003–2004	Tanzania	Urban: 2 public hospitals and 2 public health centers	FGDs, IDIs	25 nurses	To explore experiences and concerns of nurses providing infant feeding counselling in the context of PVT	None
11	Levy, 2009	2004–2005	Malawi	Rural: 1 public clinic	FGDs, longitudinal IDIs, participant observation	21 health personnel (PVT policymakers, aid organizations, medical staff, nurses), 55 HIV-infected women	To characterize women’s expectations and experiences of HIV treatment and care	None
12	Malema et al., 2010	2006	South Africa	Urban: 15 public health centers	SSIs	15 lay counsellors	To characterize the experience of lay counselors who provide HIV counseling and testing	None
13	Mazia et al., 2009	2006–2007	Swaziland	Urban and rural: 3 public and private hospitals and 4 public MCH units	Postnatal care training intervention; HW interviews, patient exit interviews, patient observations, health center assessment	134 HWs (mostly nurses) trained. 700 patients (HIV-infected and -uninfected)	To evaluate the feasibility of integration of postnatal care with PVT care following intervention (training)	None
14	Medley et al, 2010	2005	Uganda	Urban and rural: 10 public and private clinicsa	SSIs	3 center managers, 27 counsellors	To characterize the challenges of provider-initiated testing and counselling	None
15	Nuwagaba-Biribonwoha et al., 2007	2003	Uganda	Rural: 5 public and private hospitals	IDIs	5 PVT coordinators, 5 doctors, 5 counsellors	To characterize the experiences of key HWs in early implemention of PVT services	None
16	Perez et al., 2008	2006	Zimbabwe	Rural: community-based	FGDs, surveys	72 TBAs (FGDs), 627 women (surveys)	To evaluate the acceptability and feasibility of TBAs’ inclusion in MCH through participation in PVT	None
17	Piwoz et al., 2006	2002	Malawi	Urban and rural: health centersa	SSIs	5 clinical officers and medical assistant, 14 nurses and midwives	To characterize health workers’ attitudes and infant feeding counselling messages in the context of PVT	None
18	Shah et al., 2005	2000	South Africa	Rural: 1 public hospital and 14 public health centers	SSIs, surveys	14 doctors, 41 nurses, 16 CHWs	To assess HW breastfeeding and PVT knowledge	None
19	Simba et al., 2008	2005	Tanzania	Urban and rural: 60 predominantly public health centersa	Participant observation, records review	435 service providers	To assess the impact of integrating and scaling up PVT into routine MCH services on staff workload	None
20	Wanyu et al., 2007	2002–2005	Cameroon	Rural: community-based	TBA PVT training intervention; SSIs	30 TBAs	To evaluate the effectiveness of TBAs in delivery of PVT care	None
Studies conducted in 2007 and later
21	Agadjanian and Hayford, 2009	2008	Mozambique	Urban and rural: 6 public health centers	Participant observation, SSIs	2 CHW coordinators, 16 nurses, 4 CHWs	To characterize how integration of PVT services in MCH units shapes provider-client interactions and reproductive choices of HIV-infected women	None
22	Asefa and Mitike, 2014	2010	Ethiopia	Urban: 1 public hospital, 3 public health centers, 2 private hospitals, 2 private health centers	Surveys	31 nurses, midwives, public health officers, and physicians, 423 women seeking ANC	To characterize maternal satisfaction with PVT services and implementation challenges faced by providers	None
23	Chinkonde et al., 2010	2009	Malawi	1 peri-urban and 1 rural public PVT clinic	SSIs, participant observation	5 policymakers, 2 doctors, 8 nurses, 1 lay counsellor	To assess policymakers’ and HWs’ experiences with adapting and implementing global breastfeeding guidelines to national recommendations	None
24	Doherty et al., 2009	2007	South Africa	Rural: 18 public health centers	Quality improvement intervention; observation, surveys, workshops	15 center managers, 35 lay counsellors	To evaluate a participatory intervention seeking to improve quality of care in integrated PVT programs	Expanded health systems approach
25	Falnes et al., 2010	2007–2008	Tanzania	Urban and rural: 5 public clinics	Counselling observations, FGDs, IDIs, surveys	5 nurse counsellors (IDIs), mothers (in 4 FGDs, 8 IDIs, 311 surveys)	To characterize experiences of mothers and nurse counsellors during PVT	None
26	Geelhoed et al., 2013	2009–2010	Mozambique	Rural: 6 public health centers	Integration of PVT services itervention; service delivery statistics, SSIs	70 MCH providers	To assess the viability of integrated PVT care and follow-up of HIV-exposed infants	None
27	Hamela et al., 2014	2008	Malawi	Urban: 4 public PVT sites	TBA training intervention, log review, FGDs	21 TBAs	To evaluate the benefits of incorporating TBAs into HC-based PVT services	None
28	Horwood et al., 2010(A)	2007–2008	South Africa	Peri-urban and rural: 1 public health center and 1 public hospital	Surveys	25 nurses, 27 lay counsellors, 882 mothers	To evaluate implementation and integration of PVT with MCH. To describe the responsibilities of nurses and counsellors	None
29	Israel-Ballard et al., 2014	2008	Kenya	12 public clinicsa	Counselling observations, exit interviews, SSIs	80 mothers, 11 nurses/nutritionists	To evaluate how infant feeding counselors manage challenges encountered in delivery of care	None
30	Kim et al., 2013	2010	Zambia	Urban and rural: 8 military clinics	Observations, surveys	4 medical assistant, 10 clinical officers, 1 pharmacist, 14 nurses, 11 midwives	To evaluate provider performance for PVT and ART care and perception of work environment	None
31	Kwapong et al., 2014	2011	Ghana	Urban: 5 clinicsa	FGDs, IDIs, surveys	12 nurses and midwives (IDIs), 40 pregnant women (5 FGDs), 300 pregnant women (surveys)	To characterize heath center factors’ influence on on HIV testing and counseling during ANC to inform implementation	None
32	Labhardt et al., 2009	2007–2008	Cameroon	Rural: 62 public and private clinics and 8 public hospitals	Supply and equipment intervention; inventory, surveys	102 nurses	To evaluate effectiveness of intervention on equipment availability and staff PVT knowledge	None
33	Lippmann et al., 2012	2007	Malawi	Urban: community based	FGDs	17 TBAs (registered)	To assess the willingness and feasibility of TBAs to provide NVP to infants and mothers	None
34	Mnyani and McIntyre, 2013	2009	South Africa	Peri-urban: 10 public clinics	Surveys	44 nurses, 30 lay counsellors, 6 other HWs, 201 HIV-infected women	To assess quality of PVT care via the knowledge and experiences of HIV-infected women and HWs	None
35	Peltzer et al., 2010	2008	South Africa	Urban and rural: 44 public health centers including 5 hospitals	IDIs, register and records review, SSIs	31 program coordinators, 11 health center managers, 8 HWs	To assess challenges and proposed solutions to implemention of PVT care; to assess of clinic registers and health records	None
36	Rispel et al., 2009	2007	South Africa	Urban and rural: 3 hospitals and 20 clinicsa	IDIs, surveys	20 PVT managers, 9 nurses, 18 lay counsellors, 4 maternity staff, 54 TBAs, 47 TMPs, 296 clinic users, 8 community organizations	To assess missed PVT opportunities to inform evaluation of program implementation	Developed framework (based on Alma Ata Declaration, formative work)
37	Rujumba et al., 2012	2010	Uganda	Rural and peri-urban: 10 public and private hospitals and health centers	IDIs, observation, SSIs	2 doctors, 3 clinical officers, 15 nurses, 4 counsellors	To characterize HW experineces in implementation in order to identify necessary steps to strengthen PVT service delivery	None
38	Sarker et al., 2009	2007	Burkina Faso	Rural: 4 public health centers	Counselling observations, IDIs	1 health officer, 1 PVT coordinator, 1 midwife, 6 counsellors, 16 pregnant women	To evaluate implementation of opt-in HIV testing services in the context of scaling-up PVT programming	None
39	Shayo et al., 2013	2011	Tanzania	Urban and rural: public and faith baseda	FGDs, IDIs	22 HWs delivering PVT services, 11 district and regional managers, 10 health center PVT in-charges	To assess the priority setting process in planning the PVT program at district level	None
40	Sprague et al., 2011	2008–2009	South Africa	1 urban public hospital, 3 peri-urban public health centers	Health records review, IDIs	38 HWs (public health specialists, doctors, nurses, lay counsellors), 83 HIV-infected women, 32 caregivers of HIV-infected children	To characterize the barriers for patients and providers in the continuum of PVT care	None
41	Stinson and Myer, 2012	2007–2008	South Africa	Urban: 4 public primary health centers, 2 public hospitals	SSIs	3 service managers, 9 doctors, 1 nurse, 1 counsellor, 28 HIV-infected pregnant and postpartum women	To characterize barriers to initiating life-long ART during pregnancy and challenges to postpartum retention in HIV care	None
42	Turan et al., 2012	2009–2011	Kenya	Rural: 4 hospitals, 8 health centersa	Prospective cluster randomized controlled trial for service integration (HW training)	1,172 HIV-infected pregnant women	To evaluate the effects of integrating HIV treatment into ANC clinics	None
43	Uwimana et al., 2012(A)	2008	South Africa	Rural: public and private, 4 hospitals, 7 clinics, 5 NGOs	FGDs, IDIs	29 managers, 36 counsellors	To characterize managers’ and CHWs’ perceptions of barriers related to collaboratively implementing TB/HIV/PVT services	None
44	Uwimana et al., 2012(B)	2008–2009	South Africa	Rural: public and private, 42 hospitals, 5 clinics, 33 NGOs	FGDs, household surveys, IDIs, NGO and health center audits	Health managers, 36 counsellors, 3,867 households	To characterize NGO and CHW engagement in and barriers to collaborative implementation of integrated TB/HIV/PVT services	None
45	Vernooij and Hardon, 2013	2008	Uganda	Rural: 1 public clinic	SSIs, observations	2 PVT managers, 2 clinical officers, 2 midwives, 2 counsellors, 2 lab techs, 2 CHWs	To elucidate different HW cadres’ perceptions and experiences in obtaining informed consent and conducting opt-out HIV testing in the context of PVT	Foucalt’s theory of governmentality
46	Watson-Jones et al., 2012	2008–2009	Tanzania	Urban: 3 public health centers, 2 public hospitals	Intervention for referrals; ANC observations, prospective cohort of HIV-infected women, surveys	30 HWs, 9 observations, 403 HIV-infected women	To evaluate the drop-out of care of HIV-infected women from the cascade of PVT services; to identify and characterize potential barriers to PVT service effectiveness	None
47	Yeap et al., 2010	2008	South Africa	Urban and rural: 6 private heath centers	IDIs	7 doctors, 5 nurses, 9 counsellors, 3 care center staff, 21 caregivers	To describe the barriers and facilitators to uptake of HIV care among children	None

Notes:

^aUnclear breakdown of urban/rural and/or public/private facility numbers

^bCross sectional unless otherwise noted

^cSome specialized health workers were grouped into general cadres to streamline categorization; e.g. “doctors” included specialists (e.g. pediatricians and obstetricians) and “nurses” included professional and auxiliary nurses

Technical abbreviations: ART - anti-retroviral therapy; CHW - community health worker; HW - health worker; MCH - maternal and child health; NGO - non-governmental organization; NVP - nevirapine; PVT prevention of vertical transmission; TB - tuberculosis; TBA - traditional birth attendant; TMP - traditional medical practitioner Method abbreviations: FGD - focus group discussion; IDI - in-depth interview; SSI - semi-structured interview