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Evaluation report

2013 Liberia: Prevention of Mother-to-Child Transmission of HIV Impact Study Report

Executive summary

With the aim to continuously improve transparency and use of evaluation, UNICEF Evaluation Office manages the "Global Evaluation Reports Oversight System". Within this system, an external independent company reviews and rates all evaluation reports. Please ensure that you check the quality of this evaluation report, whether it is “Outstanding, Best Practice”, “Highly Satisfactory”, “Mostly Satisfactory” or “Unsatisfactory” before using it. You will find the link to the quality rating below, labelled as ‘Part 3’ of the report.


The first case of HIV in Liberia was reported in 1986 in Curran Hospital, Zorzor, Lofa County.  In response, the government established the National AIDS and STI Control Program (NACP) in 1987. However, the NACP could not fully implement strategies to prevent and control the spread of HIV insecurity lasting between 1989 and 2003.
Despite, being a low HIV prevalent country, Liberia has attracted support from NGOs and multilateral agencies to scale up and strengthen Prevention of Mother-to-Child Transmission (PMTCT) services. From early 2009, the use of PMTCT package became popular and was carried out in most sites in the country.

Prevalence of the general population was established at 1.5% (LDHS 2007). Statistics indicate a downwards trend of HIV prevalence. Prevalence amongst pregnant women dropped from 5.7% in 2006 to 2.6% in 2011 (ANC sentinel survey).  The scale up of PMTCT actually began from 2009 and has been increasing since then from 55 sites to 335 in September 2012.

NACP commissioned this study to evaluate the impact of the rapid scale-up and investment in PMTCT services. A previous PMTCT study failed to provide useful information on the effectiveness of service provision. The basis of this study was to provide critical information on patient attrition, reasons behind this attrition, and information on mother-to-child transmission rates in Liberia.

Further reasons for conducting this study was that significant amount of assistance from the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM), and other technical and funding partners have been available to Liberia and there is a rapidly increasing access to PMTCT for pregnant women.


The primary aim of the study was to assess the performance of PMTCT services in Liberia, as well as understand factors affecting pregnant women’s participation in PMTCT. Specifically, the study intended to accomplish the following three objectives:

1. Calculate national rate of HIV transmission from pregnant women to their children
2. Calculate attrition rates at each stage of the cascade of PMTCT services
3. Identify factors influencing or causing patient attrition at each stage of the cascade of PMTCT services


The method use for the study was a two-phase approach: a) from a quantitative standpoint, the study followed 1,778 HIV positive women who were pregnant during the eligibility period of January 1, 2009 to June 30, 2010 and subsequently delivered by March 31, 2011. Data was collected from 18 health facilities throughout the country that post-test counseled at least 20 HIV positive pregnant women at the antenatal clinics and at labor and delivery during the eligibility period.
Information from patient charts and facility registers were collected according to the NACP Standard Operating Procedures and then entered in Microsoft Excel; afterwards, data were analyzed using statistical software (MS Excel and Graph Pad Prism). Baseline patient demographics and critical treatment decisions were also collected.
The Clinton Health Access Initiative (CHAI) developed PMTCT and Pediatric HIV Impact Model, a Microsoft Excel-based, deterministic model was used. This model, used locally available data for each point along the cascade of services, from pregnancy through breastfeeding, and assumptions from the most recent scientific literature, helped in estimation of the transmission risk from mother to child. This model was used to estimate the vertical HIV transmission rates in Liberia.
From a qualitative point of view, b) semi-structured tools were used to interview respondents of various categories to obtain views on PMTCT services and tracing and interviewing pregnant women that had been found to be HIV positive from the period 2009 and testing their babies in the field.

The qualitative part of the study was conducted to obtain an in-depth understanding of reasons that lead to uptake or non-uptake of PMTCT services in order to explain the attrition rates obtained from the quantitative component. The qualitative part involved use of Focus Group Discussions (FGD) and individual exit poll interviews.

Findings and Conclusions:

Providing mother-baby pairs with antiretroviral drugs throughout pregnancy and breastfeeding can dramatically reduce vertical HIV transmission. Less than 40% of the HIV positive pregnant women in the cohort received antiretroviral drugs at any stage of the PMTCT cascade, while only 26% of HIV exposed infants received antiretroviral prophylaxis. Furthermore, less than 44% of mother-baby pairs received antiretroviral drugs at any stage of the PMTCT cascade. The PMTCT cascade can be broken down into “arms”, noted as pregnancy, labour delivery and breastfeeding. At all other facilities, of the mother-baby pairs receiving antiretroviral drugs, over 70% only received drugs during one arm of the cascade. Finally using a sophisticated PMTCT and Pediatric HIV Impact Model we determined the vertical HIV transmission rates within this cohort. Modelling vertical HIV transmission in the cohort found that when women received antiretroviral drugs the transmission rate was 3.7% at 6 weeks and 16.4% at the end of breastbeeding. After adjusting for all other factors, including the length of breastfeeding in the model, the weighted vertical transmission rate was 13.7%. A key factor responsible for the low uptake of PMTCT services is the fear of stigmatization. Men would not accept for their women to be HIV positive and  HIV positive tested women are afraid of being stigmatized in their community and abandoned  from their partners.

In general, most men and women are aware of PMTCT services, but the most commonly cited challenge of taking an HIV test with the possibility of being found to be positive by all mothers was stigma and discrimination. For women, the fear of breaking up their marriage or relationships if their partners should find out their HIV status also prevents many women from accepting to enrol into the PMTCT programme or to drop out even if they had initiated the process.


-  It is entirely possible to altogether eliminate new HIV infections through vertical HIV transmission in Liberia. Increasing the quality of PMTCT services through strong peer mentor programs, health care worker as well as patient commitment in the program and consistent provision of antiretroviral drugs throughout the PMTCT cascade as recommended by the most recent WHO guidelines, can considerably decrease vertical HIV transmission

-  Service providers must be well-trained, supportive staff who take great care to ensure confidentiality

-  More counselling needs to be done to enable women to handle and accept their test results, be able to disclose effectively to their men and to other relevant people

-  Conduct outreach efforts and massive sensitizations about HIV and AIDS to reach pregnant women. These include counselling, testing and conducting workshops at district and village levels.

-  Organize a mother peer to peer follow up system at facility level to enhance retention, increase treatment adherence and reduce the rate of follow up loss.

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Report information





National AIDS and STI Control Program (NACP)  and Ministry of Health and Social Welfare



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