BACKGROUND : The prevention of mother-to-child transmission (PMTCT) program in South Africa is now successful in
ensuring HIV-free survival for most HIV-exposed children, but gaps in PMTCT coverage remain. The study objective
was to identify missed opportunities for prevention of mother-to-child transmission of HIV using the four PMTCT
stages outlined in National Guidelines.
METHODS : This descriptive study enrolled HIV-exposed children who were below the age of 7 years and therefore
born during the South African PMTCT era. The study site was in Gauteng, South Africa and enrolment was from
June 2009 to May 2010. The clinical history was obtained through a structured caregiver interview and review of
medical records and included socio-demographic data, medical history, HIV interventions, infant feeding information
and HIV results. The study group was divided into the “single dose nevirapine” (“sdNVP”) and “dual-therapy” (nevirapine
& zidovudine) groups due to PMTCT program change in February 2008, with subsequent comparison between the
groups regarding PMTCT steps during the preconception stage, antenatal care, labor and delivery and postpartum care.
RESULTS :: Two-hundred-and-one HIV-exposed children were enrolled: 137 (68%) children were HIV infected and 64
(32%) were HIV uninfected. All children were born between 2002 and 2009, with 78 (39%) in the “sdNVP” and 123 (61%)
in the “dual-therapy” groups. The results demonstrate significant improvements in antenatal HIV testing and PMTCT
enrolment, known maternal HIV diagnosis at delivery, mother-infant antiretroviral interventions, infant HIV-diagnosis
and cotrimoxazole prophylaxis. Missed opportunities without improvement include pre-conceptual HIV-services and
family planning, tuberculosis screening, HIV disclosure, psychosocial support and postnatal care. Not receiving
consistent infant feeding messaging was the only PMTCT component that worsened over time.
CONCLUSIONS : Multiple missed opportunities for optimal PMTCT were identified, which collectively increase children’s
risk of HIV acquisition. Although HIV-testing and antiretroviral interventions improved, all PMTCT components need to
be optimized to reach the goal of total pediatric HIV elimination.