Background:  Increased availability of prenatal HIV testing services in Sub-Saharan Africa has resulted in the identification of many HIV-infected women who stand to benefit from interventions to decrease vertical transmission. However, uptake of prevention of mother-to-child transmission (PMTCT) interventions following HIV diagnosis has remained less than optimal. Determining barriers that limit access and utilization of PMTCT services is critical to developing strategies to improve utilization of these services.

Methods:  Mothers accompanying infants for routine 6-week immunizations at 6 maternal-child-health clinics in Nairobi and Nyanza were enrolled. A questionnaire was administered to assess sociodemographic characteristics, access to and utilization of health facilities for delivery and participation in perinatal HIV prevention programs during the last pregnancy. Mothers who utilized interventions to prevent vertical HIV transmission were compared to those who did not. 

Results:  Among 336 women identified as HIV infected antenatally, 104 (31%) did not deliver at health facilities. HIV infected mothers were more likely to have a non-facility delivery compared to uninfected mothers (31% vs 24%, P = 0.009). Non-facility delivery was associated with lower maternal education (91.4% vs 75.9%, P = 0.001), socioeconomic status, and non-use of maternal (43.8% vs 25.6%, P = 0.004) or infant (60.7% vs 22.5%, P <0.001) antiretrovirals (ARV). Most reasons given for non-facility delivery suggested lack of birth preparedness. Due to failure of facilities to dispense drugs and drug non-adherence by mothers, 20% of HIV-infected mothers and 17% of exposed infants did not use ARV. Marital status, disclosure of results to partner, and parity did not differ between HIV-infected women who delivered at health facilities or used ARV and those who did not. Prevalence of mixed feeding was 7.6%. Mothers who had not disclosed their status to their partners were more likely to mixed feed their infants (82.3% vs 57.9%, P = 0.01).

Conclusions:  Although maternal and infant ARV uptake was high (~80%), there were missed opportunities in offering ARV and utilization of facility delivery. Failure to utilize key interventions among women already identified as HIV infected greatly sets back efforts to reduce pediatric infections. Strengthening health system and promoting birth preparedness during antenatal care visits are important strategies boost PMTCT uptake and improve maternal and infant outcomes.