Table 1

Characteristics of included studies 

location in country)
InterventionComparisonEPOC intervention 
Participants (n)Participant 
Ezeanolue, 2015PatientMixed methods including small cluster RCTNigeria (Enugu State)Self-identified pregnant women ≥18 years who attended any church site.Monthly baby showers offered health education and onsite laboratory testing including HIV testing, and mama packs for essential items during pregnancy.Usual care.
  • Outreach services.

40 churches,
3002 patients.
  • % HIV-positive: 2% overall.

  • Maternal age (mean): I=29.3, C=29.7.

  1. ART during pregnancy.

  2. Retention in care at 6–8 weeks post partum.

Reynolds, 2010PatientCluster RCTKenya (Coast, Rift Valley and Western provinces)HIV-positive pregnant women ≥18 and at least 32 weeks’ gestation.PMTCT providers trained to prepare and counsel women on how to store and administer take-home nevirapine infant dose.Usual care.
  • Self-management.

  • Educational outreach.

10 clusters, 160 patients.
  • Maternal age (mean): I=27.4, C=28.4.

  1. Infant ART prophylaxis at birth.

Weiss, 2014PatientRCTSouth Africa (Gert Sibande and Nkangala districts)HIV-positive pregnant women, 24–30 weeks’ gestation, and ≥18 years of age, recruited and asked to invite their male partner to enrol as a couple.4 successive weekly sessions employed a cognitive-behavioural approach and addressed HIV, safer sex, sexual negotiation and PMTCT issues. Sessions were closed, structured, of gender-concordant groups, led by trained gender-matched facilitators and conducted in ANCs.Time-matched health education sessions.
  • Group (couple) vs individual care.

12 clusters, 478 couples.
  • % HIV-positive: at postintervention, 35% (n=82) of female participants were HIV-positive.

  • Maternal age (mean): I=28.3, C=28.1.

  1. ART detected in mothers’ blood samples at birth.

  2. ART detected in infants’ blood at birth.

  3. Infant HIV-positive rate at 6 weeks.

Yotebieng, 2016PatientRCTDemocratic Republic of Congo (Kinshasa)Newly diagnosed HIV-positive women, ≤32 weeks’ gestation, registering for ANC.Participants received small, escalating cash payments, starting at US$5 and increasing by US$1 each visit, if attended scheduled clinic appointments and completed recommended actions. Incentive reset to its original value if mother failed to complete any actions required at a specific visit.Usual care.
  • Conditional cash transfer.

433 women.
  • Maternal age (median): I=29.5, C=29.0.

  1. Retention in care at 6 weeks post partum.

  2. Uptake of PMTCT services through to 6 weeks post partum.

  3. Infant HIV- positive rates at 6 weeks.

Richter, 2014Patient/ProviderCluster RCTSouth Africa (KwaZulu-Natal)HIV-positive women, ≥18 years of age and <34 weeks pregnant.8-session intervention conducted by peer mentors (4 antenatal, 4 postnatal) to support HIV-positive women through pregnancy and early motherhood. HIV-positive women recruited, trained and certified as peer mentors prior to implementation; inperson supervision was provided weekly.Usual care.
  • Role expansion or task shifting.

  • Educational meetings.

8 clusters, 1200 patients.
  • Maternal age (mean): I=26.5, C=26.5.

  1. ART from the 28th week of pregnancy (AZT or HAART).

  2. ART during labour (AZT or HAART.

  3. NVP or HAART during labour.

  4. Infant NVP at birth.

  5. AZT dispensed for infant and medicated as prescribed.

Kieffer, 2011ProviderCluster RCTSwazilandAll pregnant women presenting for delivery at participating maternity facilities.1-day training course provided to nurse- midwives to increase knowledge and skills in provision of PMTCT and to enhance confidence and counselling skills.Usual care.
  • Educational meetings.

6 clusters, 2444
  • % HIV-positive at enrolment: 33% overall.

  1. NVP in cord blood.

Dryden-Peterson, 2015Provider/SystemStepped-wedge cluster RCTBotswana (Gaborone)ART-naïve, HIV-positive women registering at antenatal clinic before 26 weeks’ gestation.2-hour clinical staff education sessions on protocols for CD4 testing; open-source platform permitting automated SMS to monitor/deliver CD4 results between central labs and clinics; longitudinal support for tracing women eligible for ART initiation.Usual care.
  • The use of information and communication technology.

  • Educational meetings.

19 clusters, 336 women.
  • % HIV-positive: I=(47.6%), C=(44.6%).

  • Maternal age (median): I=28, C=29.

  1. ART initiation by 30 weeks’ gestation.

Mwapasa, 2017Provider/System3-arm, cluster RCTMalawi (Salima and Mangochi districts)HIV-positive pregnant women initiated on option B+ regimen.MIP: integration of HIV/ANC, routine tracing.
MIP+SMS: integrated HIV/ANC care, SMS sent to community health worker to trace if appointment missed.
Usual care: non-integrated care, routine tracing as for MIP.
  • Integration.

  • The use of information and communication technology.

30 clusters, 1350 women.
  • Maternal age (median): MIP=29.5; MIP+SMS=29.2; SOC=29.4.

  1. Maternal retention in care at 12 months postpartum trial data.

  2. Infant retention in care at 12 months postpartum trial data.

  3. Maternal retention in care at 12 months using MOH definition

  4. Infant retention in care at 12 months using MOH definition.

Oyeledun, 2017Provider/SystemCluster RCTNorthern Nigeria (Benue and Kaduna states)HIV-positive, women, gestational age ≤34 weeks, who were ART-naive and agreed to start lifelong ART.QI teams established, visits by coaches and collaborative meetings.Routine MOH support.
  • Continuous quality improvement.

32 clusters (6 later excluded), 532 women (21 withdrew, leaving 511 in total).
  • Maternal age (median): I=27, C=27.

  1. ART initiated within 2 weeks of enrolment.

  2. Retention in care at 6 months.

  3. Infants starting prophylaxis within 72 hours.

  4. Infant HIV testing at 6–10 weeks.

Phiri, 2017Provider/System3-arm, cluster RCTMalawi (SE, SW and Central West Zones)Pregnant and breastfeeding HIV-positive women and their infants. Up to three male sex partners could be enrolled per patient.FBPS: women received SOC and met with ‘mentor mothers’, HIV-positive women who had recently completed PMTCT and were on ART. Mentor mothers provided one-on-one support at each clinic visit, led weekly clinic-based support groups and contacted women within 1 week of a missed appointment.
CBPS: women received SOC and met with ‘expert mothers’, HIV-positive women who recently completed PMTCT and were on ART. Expert mothers conducted routine home visits to provide HIV education and clinic visit reminders, and led monthly community-based support group meetings. Expert mothers were responsible for contacting women in the community within 1 week of a missed clinic visit.
SOC facilities provided routine HIV care according to Malawi MOH guidelines.
According to national guidelines, women who fail to attend the clinic within 60 days of a missed appointment are supposed to be traced. However, this rarely occurs in the routine programme.
  • Role expansion or task shifting

  • Outreach services.

  • The use of information and communication technology.

21 clusters, 1269 women.
  • Maternal age (median across all 3 arms): 27.

  1. ART uptake.

  2. Retained in care at 1 year.

  3. Retained in care at 2 years trial data.

  4. Retained in care at 2 years MOH definition.

  5. Infant HIV tested at 6 weeks

  6. Infant HIV- positive at 6 weeks.

Tomlinson, 2014Provider/SystemCluster RCTSouth Africa (Umlazi)Pregnant women aged ≥17 and their newborns residing in the clusters during the recruitment period.CHWs were trained to carry out structured home visits using motivational interviewing for breastfeeding counselling. Women were scheduled to receive seven home-based visits during pregnancy and postdelivery. Low birthweight neonates received two extra visits within the first week.In control clusters, CHWs provided information and support on accessing social welfare grants and conducted three home-based visits: during pregnancy and postdelivery.
  • Role expansion or task shifting.

  • Outreach services.

30 clusters, 3957 women.
  • Maternal age (median): I=23, C=23.

  1. Infant HIV testing by 6 weeks.

  2. Infant HIV- positive at 12 weeks.

Aliyu, 2016SystemCluster RCTRural north-central Nigeria (Niger State)HIV-positive women and their infants, presenting for ANC or delivery who met one of the following criteria: unknown HIV status at presentation; history of ART prophylaxis or treatment, but not receiving ARTs at presentation; or known HIV status but had never received treatment.Integrated package of PMTCT services that included point-of-care CD4 cell count or percentage testing, transition of decentralised PMTCT tasks to trained midwives, integrated mother and infant care services, active influential family member (male partner) participation, and community involvement (male community peer champions providing outreach, education and linkage of male partners to key referral services).SOC included health information, opt-out HIV testing, infant feeding counselling, referral for CD4 cell counts and treatment, ART prophylaxis, and early infant diagnosis.
  • Role expansion/task shifting 

  • Integration.

  • Packages of care.

12 clusters, 369 patients.
  • Maternal age (median): I=26, C=28.

  1. Maternal ART initiation.

  2. Maternal–infant retention in care at 6 weeks post partum.

  3. Maternal–infant retention in care at 12 weeks post partum.

Geelhoed, 2013SystemCluster RCTMozambique (Tete Province)Public primary health facilities providing maternal child health and PMTCT services.
Mothers and their children up to 5 years of age.
Reorganised services to deliver integrated consultations and services for mothers and their children up to 5 years of age.Usual care.
  • Integration.

  • Educational meetings.

6 clusters.Not available.
  1. ART in labour.

  2. Infants receiving prophylaxis within 48 hours.

  3. Infant HIV- positive.

Killam, 2010SystemStepped-wedge cluster RCTZambia (Lusaka)ART-eligible pregnant women presenting at participating clinics.Integration of ART care into ANC. Women already receiving ART at the general ART clinic encouraged to continue receiving their services in the general ART clinic.Usual care.
  • Integration.

8 clusters, 31 536 patients.
  • % HIV-positive: I=21.8%, C=22.2%.

  • Maternal age (mean): I=27.5, C=27.3.

  1. ART initiation during pregnancy.

Odeny, 2014SystemRCTKenya (Nyanza region)HIV-positive women attending antenatal or HIV care, ≥18 years of age, between 28 weeks’ gestation and delivery, enrolled in PMTCT, access to mobile phone.Custom-built, automated software to send and receive text messages. Sent 14 text messages, up to 8 sent during pregnancy, and weekly for the first 6 weeks after delivery.Usual care.
  • The use of information and communication technology.

388 patients.
  • % HIV-positive: 29.3% (388/1324).

  • Maternal age (mean): I=30.8% 18–24, 56.9% 25–34, 12.3% 35+; C=33.7% 18–24, 57.5% 25–34, 8.8% 35+.

  1. Maternal postpartum clinic attendance to 8 weeks.

  2. Infant HIV testing by 8 weeks.

Rotheram-Borus, 2014SystemCluster RCTSouth Africa (Cape Town)Pregnant women ≥18 years of age from Cape Town townships.Antenatal and postnatal home visits by CHW in addition to standard clinic-based care.Usual care.
  • Role expansion or task shifting.

  • Outreach services.

26 clusters (2 later removed), 1144 eligible women.
  • % HIV-positive: I= (25.5%), C=(26.7%).

  • Mean maternal age: I=26.5, C=26.3.

  1. ART prior to labour.

  2. AZT or HAART during labour.

  3. NVP or HAART at onset of labour.

  4. Infant prophylaxis within 24 hours of birth.

  5. AZT dispensed for infant and medicated as prescribed.

  6. Infant HIV test at 6 weeks.

Rustagi, 2016SystemCluster RCTCote d’Ivoire, Kenya, MozambiquePublic and non-profit health facilities with PMTCT services. Pregnant women presenting for antenatal care.A five-step, facility-level systems analysis and improvement intervention designed to maximise effectiveness of PMTCT service delivery by improving understanding of inefficiencies.Usual care.
  • Continuous quality improvement.

36 clusters, 1876 patients.Not available.
  1. ART in pregnancy.

  2. Infants HIV tested by 6–8 weeks.

Turan, 2015SystemCluster RCTKenya (Nyanza Province)Pregnant HIV-positive women ≥18, not enrolled in HIV care at baseline and their infants.Integrated clinics provided PMTCT and HIV care and treatment services within existing ANC services, starting prenatally and continuing until a definitive paediatric HIV diagnosis was obtained or the child reached 18 months of age.Non-integrated ANC clinics provided routine PMTCT services and referred HIV-positive pregnant women to a separate HIV clinic at the same facility.
  • Integration.

12 clusters, 1172 women.
  • % HIV-positive: I=48.5%, C=51.5%.

  • Maternal age (mean): I=25.0, C=24.8.

  1. ART during pregnancy.

  2. ART during labour.

  3. ART after birth.

  4. Infant ART after birth.

  5. ART use throughout all 3 PMTCT periods.

  6. Infant HIV testing by 3 months.

  7. Infant HIV testing at 9 months.

  8. Infants HIV tested by 6 weeks.

  9. Infants HIV- positive at 6 weeks.

  10. Infants HIV tested by end of study (up to 12 months).

  11. Infants HIV-positive at 9 months.

  • ANC, antenatal care; ART, antiretroviral therapy; AZT, zidovudine; C, control; CHW, community health worker; EPOC, Effective Practice and Organisation of Care; FBPS, facility-based peer support; HAART, highly active antiretroviral therapy; I, intervention; MIP, methods routine paper; MOH, ministry of health; NVP, nevirapine; PMTCT, prevention of mother to child transmission; RCT, randomised controlled trial; SE, south east; SMS, short message service; SOC, standard of care; SW, south west.