Mother To Child Transmission (MTCT) of HIV is a major challenge in Sub-Saharan Africa due to a variety of socio-economic and political factors. In South Africa, for example, there was element of denialism by government on the fact that treatment could assist in reducing the likelihood of transmitting the virus to the baby. It was only in 2001 after the Treatment Action Campaign took the South African government to court that they were ordered to develop a programme to prevent the transmission of HIV from mother to child. The South African government established a PMTCT programme that aligned itself with the United Nations’ Millennium Goal of ensuring that all HIV positive pregnant women receive treatment in an effort to eliminate babies born with HIV. This study, therefore, explored the experiences of HIV positive mothers who enrolled on PMTCT programme at Tonga hospital. The researcher explored the participants’ understanding of the programme prior to enrolment, the extent to which they experienced the programme, the nature of support and services they received while on the programme as well as challenges they faced. All this was done with the intention and commitment to strengthening the intervention strategies for the HIV pregnant women, thereby ensuring that they receive top quality services from a group of multi skilled professionals. To achieve this, the study applied a collective case study within a qualitative approach. The population for the study was HIV positive mothers who enrolled on the PMTCT programme between June 2011 and July 2012. The sample consisted of 12 HIV positive mothers who took part in the PMTCT programme at Tonga hospital. For data collection purposes, the researcher applied semi-structured interview. Informed by the findings, the study concluded that there is lack of knowledge and understanding of the programme in the community. It further established that the clinic is situated under the ward where HIV positive patients are treated and that psycho social services are not offered to the HIV positive pregnant women. It also concluded that the women’s husbands or partners are not encouraged to be part of the programme. Consistent with the above, the study recommended that the PMTCT programme should be provided in a holistic and well integrated manner, where all health care disciplines contribute as required to make the participants’ experiences on the programme more comfortable both socially and emotionally. There should be a way to get the male counterparts of the participants more involved in the programme so as to afford them the opportunity to get first-hand information about pregnancy and what is expected of them as partners. Each health worker’s role should be clearly defined and a referral system be developed so that all services are easily accessible. / Dissertation (MSW)--University of Pretoria, 2013. / am2014 / Social Work and Criminology / unrestricted

Globally, great strides have been made in developing essential strategies and knowledge necessary to prevent vertical transmission of HIV. Retention in the Prevention of Mother to Child Transmission (PMTCT) programme is essential for the achievement of this aspiration. The study applied Mixed Method Sequential Explanatory Design to explore the factors that underscored the retention decisions of newly diagnosed HIV positive pregnant women. The study was set in the PMTCT programme in the Takoradi Government Hospital, Ghana, a lower middle income country. PMTCT records were retrospectively reviewed. Subsequently, the Appreciative Inquiry process using the 4Is terminology was applied to unearth the experiences and aspirations of mothers (n=12), midwives and Community health nurses (CHNs) (n=12) engaged in the programme. Ethical approval was granted by University of Cape Town Faculty of Health Sciences Human Ethics Research Committee and Ghana Health Service Ethics Review Committee. Retention rate at six weeks postpartum was 67.4%. Retention stories of women enrolled in the PMTCT programme reflected a life-enhancing experience in the face of a life-threatening diagnosis. Four themes were generated: Transitioning to the ‘new’ woman, Journeying with committed companions, Glimpses of triumph and Tying up the loose ends: A daring new path. The study highlighted development of hope in a seemingly hopeless situation, supportive network of family, healthcare professionals and religious leaders, and the commitment and companionship of the midwives and CHNs that culminated in the successes of the programme. ‘Healthy’ HIV-infected mothers and ‘exposed’ infants who tested negative to HIV at the end of the mother-infant pair’s journey in the PMTCT programme was evidence of the diligence of mothers, midwives and CHNs. A collaborative discussion resulted in the development of action plans to improve service delivery, enhance clients’ experiences and improve retention. The study recommends that PMTCT services should be structured to promote hope and empowerment for the clients through shared clients and healthcare professionals’ designed improvement programmes, instituting programmes that promote the emotional health of the health practitioners to sustain the programme, and promptly addressing health system challenges that contribute to disengagement.

An estimated 33.0 million people are currently living with HIV/AIDS worldwide. Of these, 15.5 million are women, and 2.2 million children under the age of 5 years who have mainly been infected through mother-to-child transmission. Mothers and babies are increasingly infected and about 90% of these are in sub-Saharan Africa. The same trend can be identified in South Africa, which has one of the highest incidences and prevalence rates of HIV/AIDS in the world with 5-6 million people living with HIV/AIDS. Women of childbearing age constitute 55% of all HIV positive adults and a quarter of pregnant women (28%) in South Africa are HIV positive. The HIV/AIDS epidemic is overburdening hospital systems and it will continue to grow within the context of already massively overstretched public resources. This increase also impacts on health services in the North West Province which are facing an alarming increase in mothers and babies living with HIV/AIDS. One of the strategies that are implemented to reduce maternal deaths is the Prevention-of-Mother-to-Child Transmission (PMTCT) Programme and massive roll out of Antiretrovirals during puerperium. One of the goals of the PMTCT programme is to prevent transmission of HIV/AIDS from mothers to babies and reduce child, perinatal and neonatal morbidity and mortality. This strategy is integrated with Non-Governmental Organizations (NGOs) and community-based organizations (CBOs) in care of mothers and babies living with HIV/AIDS during puerperium. Successful implementation of this programme requires social support and community involvement because of short hospitalization during the postnatal period. Caregivers are trained to perform various tasks and fulfil certain roles due to lack of human resources. Caregivers implementing the PMTCT programme experience problems which lead to stress and one of the causes of this stress manifests in feelings of inadequacy and isolation. They are faced with problems pertaining to mothers not adhering to treatment, and poverty is an additional source of stress as it negatively affects the quality of the PMTCT services they need to provide. This research was conducted in the Bojanala region, Rustenburg Sub-District of the North West Province in South Africa. A descriptive, exploratory, qualitative research design was utilized to explore and describe the lived experiences of caregivers while implementing the PMTCT programme as well as perceptions of health workers coordinating the PMTCT programme in order to gain a more thorough understanding of the support needed by caregivers during puerperium. Two populations were used. In population one, purposive sampling was used to select caregivers. In population two inclusive sampling was used to select health workers. In-depth interviews were conducted with both populations with the aim to collect data. From the research findings similarities were identified between the two populations regarding support, namely: (a) Caregivers need personal support in the form of counselling as well as support networks to enable them to deal with the problems they are faced with. (b) Caregivers need financial support to afford basic essentials and better remuneration to meet their financial needs. (c) Caregivers need to be trained in areas in which they lack knowledge -continued development and empowerment is essential. They also need to be trained specifically in PMTCT and they need a PMTCT consultant to always be available to support them. (d) Improvement of the PMTCT services by providing transport to follow up mothers, protective resources to protect themselves against infections as they are at risk of infections, water is essential as a basic human right, provision with food parcels to mothers who are poverty stricken and the PMTCT health services to be intensified from the antenatal period. (e) Management to establish a caring environment by displaying a caring attitude, respecting them and providing them with rewards to improve morale and performance. Recommendations were made for the fields of nursing education, nursing research and community health practice with recommendations to establish a structure of support for caregivers to enhance the PMTCT programme during puerperium. These recommendations were discussed under the five themes presented above. / Thesis (M.Cur.)--North-West University, Potchefstroom Campus, 2010.

An estimated 33.0 million people are currently living with HIV/AIDS worldwide. Of these, 15.5 million are women, and 2.2 million children under the age of 5 years who have mainly been infected through mother-to-child transmission. Mothers and babies are increasingly infected and about 90% of these are in sub-Saharan Africa. The same trend can be identified in South Africa, which has one of the highest incidences and prevalence rates of HIV/AIDS in the world with 5-6 million people living with HIV/AIDS. Women of childbearing age constitute 55% of all HIV positive adults and a quarter of pregnant women (28%) in South Africa are HIV positive. The HIV/AIDS epidemic is overburdening hospital systems and it will continue to grow within the context of already massively overstretched public resources. This increase also impacts on health services in the North West Province which are facing an alarming increase in mothers and babies living with HIV/AIDS. One of the strategies that are implemented to reduce maternal deaths is the Prevention-of-Mother-to-Child Transmission (PMTCT) Programme and massive roll out of Antiretrovirals during puerperium. One of the goals of the PMTCT programme is to prevent transmission of HIV/AIDS from mothers to babies and reduce child, perinatal and neonatal morbidity and mortality. This strategy is integrated with Non-Governmental Organizations (NGOs) and community-based organizations (CBOs) in care of mothers and babies living with HIV/AIDS during puerperium. Successful implementation of this programme requires social support and community involvement because of short hospitalization during the postnatal period. Caregivers are trained to perform various tasks and fulfil certain roles due to lack of human resources. Caregivers implementing the PMTCT programme experience problems which lead to stress and one of the causes of this stress manifests in feelings of inadequacy and isolation. They are faced with problems pertaining to mothers not adhering to treatment, and poverty is an additional source of stress as it negatively affects the quality of the PMTCT services they need to provide. This research was conducted in the Bojanala region, Rustenburg Sub-District of the North West Province in South Africa. A descriptive, exploratory, qualitative research design was utilized to explore and describe the lived experiences of caregivers while implementing the PMTCT programme as well as perceptions of health workers coordinating the PMTCT programme in order to gain a more thorough understanding of the support needed by caregivers during puerperium. Two populations were used. In population one, purposive sampling was used to select caregivers. In population two inclusive sampling was used to select health workers. In-depth interviews were conducted with both populations with the aim to collect data. From the research findings similarities were identified between the two populations regarding support, namely: (a) Caregivers need personal support in the form of counselling as well as support networks to enable them to deal with the problems they are faced with. (b) Caregivers need financial support to afford basic essentials and better remuneration to meet their financial needs. (c) Caregivers need to be trained in areas in which they lack knowledge -continued development and empowerment is essential. They also need to be trained specifically in PMTCT and they need a PMTCT consultant to always be available to support them. (d) Improvement of the PMTCT services by providing transport to follow up mothers, protective resources to protect themselves against infections as they are at risk of infections, water is essential as a basic human right, provision with food parcels to mothers who are poverty stricken and the PMTCT health services to be intensified from the antenatal period. (e) Management to establish a caring environment by displaying a caring attitude, respecting them and providing them with rewards to improve morale and performance. Recommendations were made for the fields of nursing education, nursing research and community health practice with recommendations to establish a structure of support for caregivers to enhance the PMTCT programme during puerperium. These recommendations were discussed under the five themes presented above. / Thesis (M.Cur.)--North-West University, Potchefstroom Campus, 2010.

Master of Public Health - MPH / Two quantitative studies were carried out in randomly-selected facilities within all nine provinces of South Africa. First, a situational assessment of these randomly selected facilities was undertaken using key informant (health care personnel) interviews and record reviews to ascertain guidelines and procedures for early identification of HIV-exposed infants (HEI), the coverage of early infant diagnosis services, the human resource capacity of the health system, and existing linkage and referral system for antenatal and postnatal PMTCT services. This was followed by the South African national PMTCT survey (SAPMTCTE) which involved a collection of infant blood samples and maternal interview data from mother-infant pairs (infants age 4-8weeks) attending six weeks immunisation service points in the selected facilities. Interviews were conducted with mothers to assess antenatal and peripartum PMTCT services received and maternal intention to request for infant HIV testing at six weeks immunisation visits. Data on gestational age at birth, infant birth weight and HIV status was extracted from the road-to-health-card (RtHC). The HIV status of mothers was determined from maternal report or enzyme immunoassay (EIA) test conducted on infants dried blood spots (DBS). A weighted analysis (weighted for sample size realisation and population live births) was performed to assess uptake of services along the PMTCT cascade. Mothers who either self-reported an HIV-positive status or had an EIA positive infant were classified as HIV-positive mothers. Perinatal ARV regimen coverage was calculated from the total number of HIV-positive mothers who received maternal azidothymidine (AZT) or HAART for any duration during pregnancy plus infant nevirapine (NVP)/AZT received at birth. Descriptive methods were used to analyse national availability of EID services and approaches for identifying HEI at the six weeks immunisation visit. Logistic regression assessed key factors influencing maternal intention to receive EID. Logistic regression was also used to explore individual, health facility and provincial level factors that explain variability in mother-to-child-transmission rates.

The devastating consequences of HIV/AIDS have caused untold harm and human suffering globally. Over 33 million people worldwide are estimated to be living with HIV and AIDS and a majority of these are in sub-Saharan Africa. Women and children are more infected particularly in sub-Saharan countries. Globally, an estimated number of 370 000 children were newly infected in 2007, mainly through mother to child transmission (MTCT). Implementation of prevention of mother to child transmission (PMTCT) programmes has been introduced in many sub-Saharan countries during the last years. Operational research was conducted to study the demand and adherence of key components within a PMTCT Programme among women in rural Malawi. This study was carried out at Malamulo SDA Hospital in rural Malawi and employed a mixture of both quantitative and qualitative approaches. Data sources included antenatal care (ANC), PMTCT and delivery registers, structured questionnaires, in-depth interviews with HIV positive women in the programme and focus group discussions with community members, health care workers and traditional birth attendants. Over the three year period of the study (January 2005 to December 2007), three interventions were introduced in the antenatal care (ANC) at the hospital at different times. These were HIV testing integrated in the ANC clinic in March 2005, opt-out testing in January 2006 and free maternal services in October 2006. A steady increase of the service uptake as interventions were being introduced was observed over time. HIV testing was generally accepted by the community and women within the programme. However, positive HIV tests among pregnant women were also experienced to cause conflicts and fear within the family. Although hospital deliveries were recognised to be safe and clean, home deliveries were common. Lack of transport, spouse support and negative attitudes among staff were some of the underlying factors. Further study on the quality of care offered in the presence of increased service uptake is required. Community sensitisation on free maternal care and male involvement should be strengthened to enable full utilisation of services. Additionally, service providers at facility and community levels, policy makers at all levels and the communities should see themselves as co-workers in development to reduce preventable maternal and infant mortality including MTCT of HIV.

Magister Curationis - MCur / Background: In the South Africa, the number of HIV- positive pregnant women is rising and has resulted in more than 70,000 babies being born with HIV infection annually since the year 2000. In response to the escalating number of HIV-positive pregnant women, the Department of Health of South Africa, decided, in 2002, to implement the Prevention of Mother to Child Transmission (PMTCT) programme at 18 pilot sites in the country. An effective PMTCT programme could reduce the incidences of maternal and child mortalities in the country. An evaluation of the effectiveness of the PMTCT programme that was done in 2010 showed that, although the programme was rendered effectively during pregnancy and labour, there were still irregularities that appeared, especially during the postnatal period. Khayelitsha was the first pilot site in South Africa to provide Antiretroviral Therapy and initiate the Nurse Initiated Management of Antiretroviral Therapy (NIMART) at primary care level in the public sector. Midwives are the health professionals who render the PMTCT services to HIV-positive mothers and their babies until six weeks post-delivery. They have managed to test almost 100% of pregnant women during the antenatal period and the HIV-positive women were started on the PMTCT programme during their first visit. Aim: The aim of this study was to explore the challenges that midwives faced in rendering care to postnatal HIV-positive mothers enrolled in the PMTCT programme at the Khayelitsha Community Health Clinic in the Western Province of South Africa. Method: An exploratory design and qualitative approach was followed. The study population consisted of midwives who were rendering PMTCT services to HIV-positive mothers and their infants during the postnatal period. Purposive sampling was conducted until data saturation was reached. Six participants were included in the sample. The participants were informed about the study by means of an Information Sheet, advised that the study was voluntary and reminded that they could withdraw from the study at any time, without prejudice. In-depth, unstructured individual interviews were conducted with each of the participants. With the permission of participants, an audio tape recorder was used during the interviews to collect data, while the researcher took field notes to supplement and verify the voice recordings, after the interviews. The seven steps of Colaizzi were used to analyse the data. Six themes and sixteen sub-themes emerged during the data analysis. Trustworthinesswas maintained by using the criteria of Guba’s model, i.e. credibility, transferability, conformability and dependability. Permission to conduct the study was obtained from the appropriate ethical committees; the Department of Health, the Khayelitsha Community Health Clinic, as well as, the Senate Research Committee of the University of the Western Cape. Participants were asked to sign Informed Consent forms before participating in the study. The ethical principles of privacy, anonymity, withdrawal, confidentiality and consent were strictly adhered to. Findings: The study found several challenges faced by midwives while implementing the PMTCT programme during the postnatal period. These challenges included: the shortage of NIMART-trained staff attending to the high number of clients per day; the lack of manpower with data base systems to trace mothers who did not come back after delivery; and mothers who did not come back for postnatal appointments because of denial, non-disclosed HIV status and socioeconomic reasons. Furthermore, the participants also reported on midwives experiencing ‘burnout’ as a result of the hectic working environment at the Khayelitsha Community Health Clinic. Recommendations: There is an urgent need for all midwives in the MOU’s to be NIMART-trained. NIMART should be standardize and be the part of the curriculum that taught in all the tertiary institutions and be updated in a yearly basis as part of the in-service training or education for all practising midwives. The South African Government should introduce home visits in the PMTCT programme. Data-bases of all MOU’s and facilities that offer PMTCT services need to be synchronized and these MOU’s and facilities should all follow the same PMTCT guidelines. Further research should be done on the same topic at other clinics and MOU’s that render the PMTCT programme in the Western Cape.

Background: Prevention of unplanned pregnancy is a crucial aspect of preventing mother-to-child HIV transmission (PMTCT). However, we have little understanding of how HIV status and antiretroviral therapy (ART) may influence pregnancy planning. There are few data on pregnancy planning in HIV-infected South African women, and no comparative data with HIV-uninfected women. Methods: We conducted a cross-sectional study of 2105 pregnant women (1512 HIV-infected; 593 HIV-uninfected) ages 18-44 making their first antenatal clinic visit at a primary-level health care facility in Gugulethu, Cape Town. All women completed structured questionnaires including the London Measure of Unplanned Pregnancy (LMUP), a 6-item scale that categorizes pregnancies into planned, ambivalent and unplanned. Analyses examined LMUP results across 4 groups of participants: HIV-infected established on ART; known HIV-infected but not currently on ART; newly diagnosed HIV-infected; and HIV-uninfected. Results: Overall, the mean age was 29 years (SD: 5.63), 43% of women were married or cohabiting and 20% were nulliparous. The LMUP performed well across all groups (Cronbach's α=0.84). Levels of unplanned pregnancy were higher in HIV-infected versus HIV-uninfected women (50% vs. 33%, p<0.001); and highest in women not on ART. Overall, 69% of women reported contraceptive use in the year before pregnancy; this was strongly associated with unplanned pregnancy (p<0.001). Compared to HIV-uninfected women, HIV-infected women had significantly higher odds of unplanned pregnancy, even after adjusting for age, parity and cohabiting status. The odds were greatest among women newly-diagnosed with HIV and previously diagnosed but not on ART (OR: 1.43; 95% CI: 1.05-1.94 and OR: 1.56; 95% CI: 1.13-2.15, respectively). Increased parity and age <24 years were also associated with unplanned pregnancy (OR 1.83; 95% CI: 1.24-2.74 and OR 1.42; 95% CI: 1.25- 1.60 respectively). Conclusions: These data indicate high levels of unplanned pregnancy in a high HIV prevalence setting, highlighting missed opportunities for family planning and counselling services for HIVpositive women. Possible explanations for the high level of unplanned pregnancy observed include contraceptive failure and/or misuse thereof. Therefore, women living with HIV require additional support to avoid unplanned, particularly those who are younger and have one or more children.

MPH, Faculty of Health Sciences, University of theWitwatersrand, 2011 / Introduction: In South Africa, over 25% of all babies born each year are exposed to HIV. The high antenatal HIV sero-prevalence rates coupled with high levels of maternal morbidity and mortality advocate for high quality maternal and child health care, which should include resilient PMTCT programs. This study aimed to explore infant feeding practices selected by HIV-positive women enrolled on a PMTCT program and describe some of the reasons for their choices, within the first 6 months postpartum. The study also reports on infant feeding practice and HIV status of the infant. Methodology: The study was a cross-sectional study which was carried out within the Perinatal Research Unit at Chris Hani Baragwanath hospital in Soweto. A sample of 200 women enrolled in the PMTCT program was interviewed, using a semi-structured questionnaire, during April 2007 – June 2007. Results: The study revealed that 84.5% of the study population had received infant feeding counseling. There was a high rate of exclusive formula feeding (EFF=84.5%), with lower exclusive breastfeeding (EBF=14%) and mixed feeding (MF=1.5%) rates. The corresponding HIV transmission rates were EFF – 26% (n=44/169); EBF – 75% (n=21/28); MF – 100% (n=3/3). The study demonstrated that babies born to mothers who did not receive information on infant feeding were twice as likely to be HIV positive (OR=2.43), which was statistically significant. The study also showed that the timing of the counseling was critical – all mothers who received counseling 6 weeks or more after delivery had HIV-positive babies. The overwhelming majority of women (78%) indicated that they would breast feed their babies if they were HIV-negative. Conclusion: The study demonstrated the vital role of infant feeding counseling in antenatal care and PMTCT programs. It illustrated that it was critically important that all HIV-infected women receive infant feeding counseling as soon as possible after the HIV diagnosis is made, prior to delivery and highlighted the importance of reinforcement of infant feeding choice at every antenatal care visit, for every woman. 5 The key recommendations focus on the need for: • Improved Antenatal care for all pregnant women • Improved care for HIV-positive pregnant women • Improvements in infant feeding counseling for HIV positive women • Integration of Maternal, Child health and PMTCT programs • Intensification of ongoing prevention efforts • The need for further research to: o identify some of the reasons HIV positive women choose certain infant feeding modalities throughout the country, and the challenges associated with these; and o critically evaluate the training that health care workers and counselors receive, regarding infant feeding counseling.

L’objectif de cette thèse est de décrire la prise en charge en France des femmes enceintes infectées par le VIH à l’ère des multithérapies, de mesurer les écarts par rapport aux recommandations, d’identifier des facteurs liés à des prises en charge non optimales du point de vue du risque de transmission et d’améliorer les recommandations pour certaines situations minoritaires encore mal étudiées. Ce travail est issu des données de l’Enquête Périnatale Française (ANRS-EPF), la seule cohorte nationale et l’une des plus larges sur le plan international, avec 17 491 couples mères-enfants inclus depuis 1986.Actuellement, presque toutes les femmes sont traitées par multithérapie (96,5% en 2009) et le taux de transmission est inférieur à 1% (0,6% ; IC95% : 0,2-1,4). Les prises en charge non optimales du point de vue de la prévention de la transmission mère-enfant du VIH (PTME)(dépistage du VIH tardif, absence ou retard à l’initiation des traitements antirétroviraux pendant la grossesse, en perpartum ou en prophylaxie post-natale, échec virologique en fin de grossesse, accouchement par voie basse malgré une charge virale non contrôlée, allaitement maternel) sont de plus en plus rares en France (0,2% à 5,5% en 2009). Le taux de césarienne reste cependant nettement plus élevé qu’en population générale, du fait notamment d’un taux élevé de césariennes programmées malgré une charge virale contrôlée, ce qui n’est pas conforme aux recommandations. On n’observe pas pour autant un taux de transmission plus bas pour les césariennes programmées lorsque la charge virale est contrôlée.L’immigration en provenance d’un pays d’Afrique sub-saharienne est associée à un diagnostic du VIH plus tardif pendant la grossesse, mais l’accès à la PTME et l’observance semblent similaires à ceux des Françaises de métropole, une fois le diagnostic établi. La non divulgation du statut VIH maternel au père de l’enfant, plus fréquente chez les africaines, est associée à une PTME moins optimale, mais sans augmentation de la transmission mère–enfant du VIH.Nous avons également évalué les recommandations pour certaines situations minoritaires.Pour les femmes infectées par le VIH-2 (2,6% des femmes de la cohorte EPF), dont le risque de transmission mère-enfant est spontanément faible, nos résultats contribuent à justifier une prise en charge moins intensive que celles des femmes infectées par le VIH-1. Pour les femmes nécessitant une amniocentèse, associée à un risque accru de transmission mère-enfant avant l’ère des multithérapies, nos résultats ne montrent pas d’augmentation de risque chez les femmes traitées par multithérapie.Nos résultats sont globalement encourageants pour un système offrant un accès universel et gratuit aux soins pour le VIH, facilitant ainsi l’accès aux soins aux populations en situation de précarité, qui restent néanmoins les plus à risque de prises en charge non optimales. / The objective of this Ph.D thesis is to describe the care received by HIV-infected pregnant women in France in the era of multitherapy, to assess how actual practices differ from recommendations, to identify factors related to non optimal care for prevention of mother-to child HIV transmission (PMTCT) and to improve recommendations for some minority situations that have not been well evaluated.Work for this thesis was done using data from the French perinatal cohort ANRS-EPF, the only national multicenter cohort and one of the largest, having included 17 491 mother-child couples since 1986.Currently, almost all women are treated with multitherapy (96.5% in 2009) and the transmission rate is below 1% (0.6%; 95%CI: 0.2-1.4). Non optimal care for PMTCT (late HIV diagnosis, lack or late initiation of antiretroviral treatment during pregnancy, intrapartum and postnatal prophylaxis, virological failure at delivery, vaginal delivery despite uncontrolled viral load, maternal breastfeeding) has become increasingly rare in France (between 0.2% and 5.5% in 2009). The cesarean section rate is however clearly higher than in the general population, most notably due to a higher rate of elective cesarean section among women with a controlled viral load, which does not comply with the recommendations. And yet elective cesarean section performed on women with a controlled viral load does not result in a lower transmission rate.Migration from a sub-Saharan African country is associated with a later HIV diagnosis during pregnancy, but access to PMTCT and adherence seem similar once HIV infection is diagnosed. Failure for a mother to disclose her HIV status to the child’s father, which occurs more frequently with African women, is associated with less optimal PMTCT strategies but without any increase in MTCT rate.We have also evaluated the recommendations for some minority situations. For HIV-2infected women (2% of EPF cohort), who had a spontaneously lower MTC rate, our results contribute to justifying a less intensive PMTCT than for HIV-1 infected women. For women needing an amniocentesis, which, before the multitherapy era, was associated with an increased transmission rate, our results suggest that the transmission risk is no longer greater for women being treated by multitherapy.Our findings are encouraging as they demonstrate the effectiveness of a health care system which promoting free universal access to HIV care has succeeded in reaching out the most under privileged populations, thereby making it easier for them to receive optimal care although they remain at risk for non optimal PMTCT practices.