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PLoS One. 2014 Oct 10;9(10):e108150. doi: 10.1371/journal.pone.0108150. eCollection 2014.

A systematic review of health system barriers and enablers for antiretroviral therapy (ART) for HIV-infected pregnant and postpartum women.

Author information

Centre for Infectious Disease Epidemiology and Research (CIDER), Division of Social and Behavioural Sciences, School of Public Health and Family Medicine, University of Cape Town, Medical School Campus, Cape Town, South Africa.
Center for Health Services, Management Sciences for Health, Arlington, Virginia, United States of America.
Center for Pharmaceutical Management, Management Sciences for Health, Arlington, Virginia, United States of America.
United States Agency for International Development (USAID)/Africa Bureau, Washington, District of Columbia, United States of America.
USAID/Bureau for Global Health (BGH)/Office of HIV/AIDS, Washington, District of Columbia, United States of America.
USAID/BGH/Office of Health, Infectious Diseases and Nutrition, Washington, District of Columbia, United States of America.



Despite global progress in the fight to reduce maternal mortality, HIV-related maternal deaths remain persistently high, particularly in much of Africa. Lifelong antiretroviral therapy (ART) appears to be the most effective way to prevent these deaths, but the rates of three key outcomes--ART initiation, retention in care, and long-term ART adherence--remain low. This systematic review synthesized evidence on health systems factors affecting these outcomes in pregnant and postpartum women living with HIV.


Searches were conducted for studies addressing the population of interest (HIV-infected pregnant and postpartum women), the intervention of interest (ART), and the outcomes of interest (initiation, adherence, and retention). Quantitative and qualitative studies published in English since January 2008 were included. A four-stage narrative synthesis design was used to analyze findings. Review findings from 42 included studies were categorized according to five themes: 1) models of care, 2) service delivery, 3) resource constraints and governance challenges, 4) patient-health system engagement, and 5) maternal ART interventions.


Low prioritization of maternal ART and persistent dropout along the maternal ART cascade were key findings. Service delivery barriers included poor communication and coordination among health system actors, poor clinical practices, and gaps in provider training. The few studies that assessed maternal ART interventions demonstrated the importance of multi-pronged, multi-leveled interventions.


There has been a lack of emphasis on the experiences, needs and vulnerabilities particular to HIV-infected pregnant and postpartum women. Supporting these women to successfully traverse the maternal ART cascade requires carefully designed and targeted interventions throughout the steps. Careful design of integrated service delivery models is of critical importance in this effort. Key knowledge gaps and research priorities were also identified, including definitions and indicators of adherence rates, and the importance of cumulative measures of dropout along the maternal ART cascade.

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