over the last decade , progress observed in sub - saharan african countries in increasing pmtct service coverage and in reducing new hiv infections among children is promising .
for example , in the 21 global plan priority countries in sub - saharan africa , coverage of antiretroviral medicines for pregnant women living with hiv to prevent mother - to - child transmission has nearly doubled in 2012 as compared to the 2009 level , increasing from 34% in 2009 to 65% in 2012 .
this increased coverage has contributed to reducing new hiv infections among children by 38% in 2012 as compared with 2009 levels . in this
regard , botswana , ethiopia , malawi , namibia and zambia have demonstrated a 50% or more decline on new hiv infections among children . on the other hand , angola , chad ,
cote divoire , democratic republic of congo , lesotho and nigeria showed slow declines in averting new hiv infections among children .
specifically , nigeria , which accounts more than one - quarter of new hiv infections among children in the region , pmtct coverage was very low ( 17% in 2012 ) and consequently , the decline in hiv infection aversion among children has been less effective .
such slow progress in high burden countries such as nigeria also affects achievement of regional targets .
the main purpose of this paper is to share the evidence on a major factor that may impede scale - up of pmtct service coverage and thereby advocate for integration of pmtct and maternal and child health services , fundamental for achieving the global plan and global fast - track commitments of zero transmission and to improve maternal and child health in general .
the paper specifically analyses disparities across income in the use of antenatal care services in sub - saharan african countries .
it also analyses the extent to which use of antenatal care services differentiated by women s wealth status explains variations in pmtct service coverage in the region .
all sub - saharan african countries that conducted demographic and health survey ( dhs ) between 2008 and 2015 have been selected for analysis . if countries conducted two or more dhs surveys , the most recent survey has been considered .
the dhs are nationally - representative household surveys ( with large sample sizes ranging between 5000 and 30,000 ) that provide a wide range of data in the areas of population , health , and nutrition .
the dhs surveys are normally implemented approximately every five years . from the dhs survey results , unicef pooled data on anc coverage and released the results in february 2016 . for this analysis
, anc use refers to least four antenatal care visits to a health facility or health personnel during the last pregnancy . on the other hand ,
the most recent pmtct coverage data have been pooled from the unaids dataset released in 2016 .
using spss , linear regression analysis were conducted to assess the disparity in the use of anc that are associated with income ; and to understand how much the disparity in anc use could explain pmtct service coverage .
wealth quintiles , as measured by dhs , refer to household income classified into five categories using principal component analysis .
thirty - one sub - saharan african countries with complete data on anc use by wealth quintile and pmtct service coverage . have been identified .
the complete dataset extracted from unicef and unaids 2016 online datasets are presented in supplementary table s1 .
the anc use ( at least four visits ) in the lowest and highest wealth quintiles , in their respect , average 42% and 69% .
this implies that in the 31 sub - saharan african countries , women in the highest wealth quintile are about 3 times more likely to use anc services ( at least four visits ) as compared to those in the lowest wealth quartile ( 95%ci : 1.7 - 5.7 , p<0.000 ) . the pmtct service service coverage in these countries ranges between 3% in madagascar and 95% in mozambique , namibia , swaziland , togo , and uganda ; while the average pmtct coverage is about 71% ( table 1 ) .
a regression analysis shows that the disparity in anc use associated with income ( i.e. , between women in the highest and lowest wealth quintiles ) is a statistically significant predictor of pmtct service coverage ( p<0.05 ) .
also , the analysis shows that disparity in anc use associated with income can explain nearly a quarter of the variation on pmtct service coverage in sub - saharan african countries ( p<0.05 ) .
the analysis and graph bellow show that the higher the disparity in anc use associated with income , the lower the pmtct service coverage ( figure 1 ; see also supplementary table s2 for more details on the output of the regression analysis ) .
sub - saharan africa accounts the highest burden of hiv / aids world wide . in this regard , by the end of 2012 , about 69% of people living with hiv globally were in this region , where nearly 1 in every 20 adults ( 4.9% ) were living with hiv .
similarly , over 90% of the children who acquired hiv infection in 2011 lived in sub - saharan africa . however , there are also encouraging results that are being observed , specifically over the last decade . in this regard , for example , new hiv infection in the region
has declined by one - quarter ; i.e. , from 2.4 million in 2001 to 1.8 million in 2011 . also , in the global plan s 21 priority countries in sub - saharan africa , the number of children newly infected fell by 38% ; i.e. , from 340,000 new infections in 2009 to 210,000 in 2012 .
but , achieving the global target of eliminating new hiv infections among children and keeping their mothers alive requires taking the full advantages of the advancements in the biomedical field on pmtct .
advancements in biomedical interventions have created huge opportunities by reducing the risk of mother - to - child transmission ( mtct ) of hiv from 35% to 2% . however , translating such advancements into practice is faced with programmatic barriers specifically in sub - saharan africa ; one of such challenges being lack of integration of pmtct with other maternal and child health services .
the world health organization strategic directions for scaling - up quality and effective pmtct calls for integration of hiv prevention , care and treatment services with maternal , new - born and child health and reproductive health programs as one of the critical approaches for reaching zero new infections among children . in most of the sub - saharan african countries , anc use ( at least four visits )
therefore , reaching women who are already using anc service is a low hanging fruit for expanding pmtct services .
while maternal health and pmtct service coverage are generally low and at varying levels in sub - saharan africa , access to services by the poorest women is worse , which has major impact on national and regional level achievements . in this regard , for example
, the relatively wealthiest women are three times more likely to use anc services as compared to the poorest women in the region ( p<0.05 ) ( table 1 ) . also , the higher the disparity across income in using anc services , the lower the pmtct service coverage at the national level ( p<0.05 ) .
the impact of health inequality in the region is beyond pmtct and anc . in this regard , in sub - saharan african countries , while there is no association between national poverty rate and hiv prevalence , a systematic review of studies shows existence of clear and significant association between income inequality ( measured with gini coefficient ) and hiv prevalence across countries ; i.e. , countries with greater income inequality have higher hiv prevalence .
the specific factors as to why women in the lower wealth quintile have lower access to health services might require further in - depth research . however , available studies on the general population might also enlighten some of the potential factors that need to be considered when designing maternal and pmtct programs .
it is also important to note that the anc use disparity across income only explains about a quarter of the variation on pmtct service coverage ( supplementary table s2 ) . in this respect , there remain many other factors that determine access / utilization of pmtct and other maternal health services . for example
, a study in holeta town of ethiopia shows that anc attendance is significantly associated with demographic , socio - economic and health related factors including age at last birth , literacy status of women , average monthly family income , media exposure , attitude towards pregnancy , knowledge on danger signs of pregnancy and presence of husband approval on anc .
studied women s practice of disclosing their hiv status to their partners in four sub - saharan africa countries - burkina faso , kenya , malawi and uganda .
disclosure has important effect for hiv positive women s desires to access pmtct services . according to hardon et al .
, rates of disclosure to partners in the four countries varied between 32.7% and 92.7% ; the lowest being in malawi .
a similar study in tanzania showed that six in ten hiv positive pregnant women had not disclosed their results of the hiv test to their partners .
an important reason for not disclosing was women s economic dependency on their partners and hence fear of being expelled from house .
such findings suggest the importance of also targeting male patterns in pmtct and maternal health programs . a cross - sectional study conducted in southeast nigeria shows limitations of women s knowledge / awareness about available maternal and child health services at the different service delivery points in their areas , which potentially leads to lack of trust and wastage of their time and other resources by unknowingly traveling to facilities where services are not available . in these regards ,
pmtct and maternal health program planning processes need to further look into the factors , validate those that deem most important and earmark resources on how to break the barriers for women ( especially to those in the poorest wealth category ) for accessing the services .
ameur et al . emphasized on the importance of eliminating user fees for maternal health services , specifically at the time of delivery , in order to address issue of maternal health inequity .
in this regards , while the study by ameur et al . focused on burkina faso , they also cited the positive outcomes in ghana after the country introduced exception policy making delivery care free . in this respect , 18 months after user fees were abolished in ghana , the greatest increase in health facility use was by the poorest segment of the population .
analysis of data from 269 sites in 20 pmtct programs and 15 sub - saharan countries from 2002 to 2005 showed two important factors that can increase pmtct coverage 
higher knowledge about pmtct and higher government investment on health . in order to address the maternal health disparities across income through integrated service delivery ,
other potential areas to be considered are : introducing routine hiv testing for women and their partners ( e.g. , through provider initiated testing and counselling - pict ) ; supporting alternate models of care delivery ( such as shifting basic tasks from physicians to nurses ) ; and providing incentives for service providers as well as clients ( e.g. , incentive for health workers for agreeing to relocate to rural areas if necessary ; or outreach pregnant women in neighboring villages ; and reimbursing pregnant women for the cost of transportation to the clinic ) .
the goal of the global plan was to move towards eliminating new hiv infections among children by 2015 and keeping their mothers alive .
the plan focused on reaching pregnant women living with hiv and their children , from the time of pregnancy until the mother stops breastfeeding .
the global fast - track commitments to end aids by 2030 also aims to eliminate hiv infections among children by 2020 . in this
regards , one of the principles for reaching these goals is leveraging synergies , linkages and integration for improved sustainability , i.e. , national plans leverage opportunities to strengthen synergies with existing programmes for hiv , maternal health , new - borns and child health , family planning , orphans and vulnerable children , and treatment literacy .
pmtct is more than the simple administration of arvs ; and the full set of its intervention components should be implemented as an integral component of essential maternal , neonatal and child health services . on the other hand
, funding is critical , there is never enough money for global health ; never enough for any one intervention ; and this creates a double rationale for support . while the hiv / aids and maternal health challenges in sub - saharan africa are immense , the gains ( especially over that last decade ) are also promising . in these regards , achieving the global plan target and global fast - track commitments of eliminating new hiv infections among children and keeping their mothers alive would definitely require strategic approaches by building on existing health - care delivery systems / structures and specifically integrating the service deliveries with other maternal and child health services ; and with deliberate effort to reach women who are most disadvantaged .
 about 69% of people living with hiv globally and over 90% of the children who acquired hiv infection are in sub - saharan africa . despite this , 
 promising results have been observed , especially over the last decade  for example , a 25% decline in new hiv infections as compared to 2001 and a 38% decline in the number of children newly infected by hiv in 2012 as compared to 2009 . 
 however , the global plan and the global fast - track commitments of eliminating new hiv infections among children require addressing impediments to service expansion . in this regard 
 , this paper attempts to draw attention to the extent to which disparities across income in using antenatal care ( anc ) services may constrain the prevention of mother - to - child transmission ( pmtct ) service expansion in sub - saharan africa . 
 the analysis is based on anc service coverage data from demographic and health surveys conducted between 2008 and 2015 in 31 sub - saharan african countries ; and pmtct coverage data from unaids datasets released in 2016 . 
 our analysis found that women in the highest wealth quintile are about three times more likely to frequently use anc services ( at least four visits ) as compared to those in the lowest wealth quintile ( 95%ci : 1.7 - 5.7 , p<0.0001 ) . 
 a regression analysis shows that one - quarter of the pmtct service coverage can be explained by the disparity in anc use associated with income ; and the higher the disparity in anc use , the lower the pmtct service ( p<0.05 ) . 
 the findings suggest that achieving the ambitious plan of zero new hiv infections among children while keeping their mothers alive will require on - going pmtct / anc service integration and ensuring that programs reach women who are most in need ; specifically those in the poorest income categories . 
Introduction
Materials and Methods
Results
Discussion
Conclusions