The global scale-up of Prevention of mother-to-child transmission (PMTCT) services is credited for a 52% worldwide decline in new HIV infections among children between 2001 and 2012. However, the epidemic continues to challenge maternal and paediatric HIV control efforts in Sub Saharan Africa (SSA), with repercussions on other health services beyond those directly addressing HIV and AIDS. This systematised narrative review describes the effects of PMTCT programs on other health care services and the implications for improving health systems in SSA as reported in the existing articles and scientific literature. The following objectives framed our review:
The majority of selected articles offered arguments for increased health services utilisation, notably of ante-natal care, and some evidence of beneficial synergies between PMTCT programs and other health services especially maternal health care, STI prevention and early childhood immunisation. Positive and negative impact of PMTCT on other health care services and health systems are suggested in thirty-two studies while twenty-five papers recommend more integration and synergies. However, the empirical evidence of impact of PMTCT integration on broader health systems is scarce. Underlying health system challenges such as weak physical and human resource infrastructure and poor working conditions, as well as social and economic barriers to accessing health services, affect both PMTCT and the health services with which PMTCT interacts.
The global scale-up of Prevention of Mother-To-Child Transmission (PMTCT) services is credited for a 52% worldwide decline in new Human Immunodeficiency Virus (HIV) infections among children between 2001 and 2012 . With adequate efforts, more funding and closely monitored progress, the United Nations Programme on HIV and AIDS (UNAIDS) still reported 160,000 new paediatric HIV infections in 2016 . Despite significant progress, the epidemic continues to challenge maternal and paediatric services in Sub Saharan Africa (SSA), with repercussions on other health services beyond those directly addressing HIV and Acquired Immunodeficiency Syndrome (AIDS) .
This PMTCT cascade reduces the chances for HIV to pass from an HIV-positive mother to her baby during pregnancy, labour, or delivery, or through breastfeeding [5, 6, 11]. Four components of the comprehensive PMTCT programme are articulated by WHO and UNICEF, namely: (1) primary prevention of HIV infection among women of childbearing age; (2) preventing unintended pregnancies among women living with HIV; (3) preventing HIV transmission from a woman living with HIV to her infant; and (4) providing appropriate treatment, care and support to mothers living with HIV and their children and families [6, 10]. The PMTCT cascade is partly or fully implemented by many actors from public and private for-profit and not-for-profit health care sectors (Non-Governmental Organisations (NGOs)), religious and community groups) operating locally but managed and funded at local, national and international levels [12,13,14].
These multiple actors with their diverse agendas and policies initially delivered PMTCT services as a stand-alone and externally funded programme. The programmes progressively won the interest of governments and are now increasingly supported through public funding in many countries, while still requiring substantial donor support . With time, the strong links this cascade has with maternal and child health services required closer collaboration with and increasing integration into broader services towards sustainable outcomes [14, 16].
The potential impact of PMTCT on health services may go beyond maternal and child health specialities and may involve other health care services indirectly, with potential opportunities to enhance overall quality of care but also posing threats such as brain drain and redirection of resources from programs not related to HIV in contexts where there is already weak infrastructure. This raises questions regarding the appropriate approaches to address the challenges regarding the accessibility, equity, and quality of healthcare in the efforts to facilitate service delivery and strengthen health systems .
The global monitoring framework and strategy put in place towards elimination of new HIV infections in children , reflects this wider perspective of integration across programs and services and calls for comprehensiveness through seven priority areas. These priorities are: (i) Ensure leadership and country ownership; (ii) Improve coverage, access and utilisation of services; (iii) Strengthen quality of Maternal, New born and Child Health services to deliver effective PMTCT of HIV and syphilis interventions; (iv) Enhance provision of linked services; (v) Strengthen human resource capacity, supply chain management and information systems; (vi) Improve measurement of performance and impact and (vi) Develop and engage community systems . This framework does not take PMTCT as a self-sufficient entity but instead calls for seeing PMTCT as integrated within a health system. It thus echoes the WHO-recommended integration of PMTCT programs with other healthcare services to achieve the more accessibility and improvement of health interventions . But what does integration entail, analytically and in practice?
One example that demonstrates the need for cooperative efforts to avoid negative effects of a vertical program on health systems and communities relates to the universal child immunisation goals. A study in six countries in Africa and Asia documented how a top-down model in immunisation interventions ended up creating conflicts between local demand and targets of immunisation policy, leading the authors to argue for more intersectoral collaboration if a specific programme is delivered and managed in a vertical way . This example is one among many that supports calls for shifting from a vertical view of PMTCT programs of HIV prevention and treatment towards a horizontal focus on maternal health care and other health care services [14, 38]. Unfortunately, the lessons that might be learned from immunisation programs and applied to thinking about PMTCT and health systems have not yet been taken fully into account.
The abstracts of pertinent papers were then retrieved following these inclusion criteria before selecting the full articles: (i) Papers - Research articles published in peer-reviewed scientific journals, grey literature and commentaries dealing with PMTCT in pregnant women in SSA were accepted for inclusion. (ii) Participants - Women at risk of transmitting HIV infection to their children. This could include pregnant women or those at risk of pregnancy and their children, regardless of HIV status. (iii) Interventions - All interventions to prevent or reduce HIV MTCT, including but not limited to strategies for antiretroviral therapy and replacement feeding. PMTCT collaboration with other health care services especially maternal and child health (MCH) were included. The following types of articles were excluded: (i) Studies focusing on countries other than SSA countries, (ii) Studies focusing on general HIV/AIDS prevention or other health care services without reference to PMTCT and (iii) Editorials or commentaries generally describing the PMTCT programs on one or more pre-specified healthcare services without studying its effects or integration.
Health care providers and funders across SSA have shown interest and engagement to make PMTCT services more and easily accessible to women and children [16, 47, 84, 101] but their efforts have not eliminated many challenges underlying SSA health systems. Added to social problems, these health system issues create a situation in which it is difficult for women to actually utilise services during pregnancy and postpartum, even when these are offered free of charge [76, 102, 103]. Looking within the health systems themselves, PMTCT services have positively impacted MCH and adequately reduced the spread of HIV infection , but optimal outcomes occur where the health services are delivered in conducive working conditions, with adequately equipped facilities and committed management . Such conditions are rare in SSA where the vertical transmission of HIV is the highest in the world. PMTCT and other HIV services in SSA depend on foreign funds estimated at billions of dollars but unfortunately the overall system and population-level results of such efforts and investments are seen as mixed .
PMTCT integration has for example, positively influenced maternal and child care services regarding service availability, accessibility and utilisation . Evjen-Olsen et al.  suggested that maternal and neonatal health can be improved by integrating health care services, supporting integration of health systems rather than separately organising and managing different vertical and horizontal programs especially in developing countries . The articles reviewed here also identified potential synergies between the integration or combination of PMTCT with specific health care activities outside of direct obstetrical and child care or MCH services, including sexually transmitted infection (STI) control and immunisation [16, 71], sexual and reproductive health and family planning [56, 58, 61], nutrition , tuberculosis  and vitamin A supplementation . The synergies are variously achieved in different contexts through progressive efforts, such as staff training and motivation, planning and evaluation of services, restructured management and financing among others. In terms of integration itself as a theme, the following synergies were examined by retained studies, apart from MCH: HIV/PMTCT services integration with tuberculosis screening and treatment [26, 91,92,93,94], with SRH, STIs and FP services [16, 75, 78, 79, 82, 85, 89] and with immunisation and HIV screening among children . These linkages helped to increase and improve training of care providers, to review and enhance funding and implementation policies, to increase access and adherence to services, to reduce drug stock outs and improve basic infrastructures. 2b1af7f3a8