Uganda is consistently one of the highest burden countries for mother-to-child transmission of HIV (MTCT). This study assessed Uganda's progress toward elimination of MTCT and factors associated with MTCT. Mother-infant pairs (MIP) were recruited at immunization clinics at randomly sampled public and private health facilities in Uganda during 2017-2019. Using a multistage sampling method, a nationally representative sample of MIP aged 4-12 weeks were recruited and followed longitudinally for 18 months or until the infant acquired HIV. Early MTCT was defined as an infant with confirmed HIV infection at study enrollment and was calculated using logistic regression to estimate adjusted odds ratios (aOR) and 95% confidence intervals (95% CI) for associated factors. Poisson regression was used to estimate incidence rate and incidence rate ratio (IRR) for infants acquiring HIV at any time during the study after enrollment (late MTCT) and associated factors. Early MTCT was 2.2% (95% CI: 1.3-3.6) and late MTCT rate was 5.2 per 1000 person-years (95% CI: 2.5-10.9). In the adjusted model, only detectable maternal HIV viral load (≥ 1,000 copies/mL) was significantly associated with early MTCT (aOR: 6.8, 95% CI: 2.3-19.9). Similarly, ever having a detectable viral load (at any visit) was significantly associated with late MTCT (IRR: 6.2, 95% CI: 1.2-31.7). Uganda's program has made large strides to eliminate MTCT. Identifying and addressing elevated maternal HIV viral load, especially during pregnancy and the early breastfeeding period could further reduce the number of new childhood infections in Uganda.

BACKGROUND: Early infant diagnosis (EID) facilitates early initiation into HIV care for identified HIV-positive infants. According to the Uganda Ministry of Health, EID testing algorithm, testing for infants exposed to HIV (IEH) should occur at <6 weeks, 9 and 18 months of age, and 6 weeks after stopping breastfeeding. Uganda has faced challenges with loss to follow-up (LTFU) of IEH for EID. We assessed complete testing coverage (CTC) to the EID algorithm for IEH and associated factors. METHODS: We analyzed data from the 'Impact of the National Program for the Prevention of Vertical Transmission (PVT) of HIV in Uganda (2017-2019)' study. Mothers living with HIV whose infants tested HIV-negative at 4-12 weeks were enrolled in a prospective cohort (2017 - 2018) and followed until the IEH tested positive, died, was LTFU, or reached 18 months of age. We computed the proportion of IEH tested according to the EID algorithm among surviving infants. CTC was defined as undergoing HIV tests at three designated time points (excluding the 6 weeks after breastfeeding cessation) if HIV negative. IEH who were diagnosed with HIV but were tested at all recommended tests until that point were also considered to have CTC. We evaluated factors associated with CTC using modified Poisson regression. RESULTS: Among 1,804 IEH, 912 (51%) were male. Of the 1,804 IEH at baseline, 27 (1%) died. Among the 1,777 IEH included in the primary outcome analysis, 1,282 (72%) completed the study and 941 (53%) infants had CTC according to the EID testing algorithm including 40 (2%) who tested HIV-positive. Perceived discrimination due to HIV status [RR = 0.77, 95%CI (0.65-0.92)], having fewer pregnancies [RR = 0.97, 95%CI (0.68-0.99)], and reporting sexual violence [RR = 0.82, 95%CI (0.73-0.93)] by the mother of IEH were associated with non-CTC. CONCLUSION: About half of IEH were tested at the recommended time points. Interventions to address stigma and sexual violence for mothers may improve CTC for the EID algorithm. Investigations are needed to explore associations between sexual violence, parity, and CTC for the EID algorithm.

BACKGROUND: Saving Mothers, Giving Life (SMGL) is a 5-year initiative implemented in participating districts in Uganda and Zambia that aimed to reduce deaths related to pregnancy and childbirth by targeting the 3 delays to receiving appropriate care: seeking, reaching, and receiving. Approaches to addressing the third delay included adequate health facility infrastructure, specifically sufficient equipment and medications; trained providers to provide quality evidence-based care; support for referrals to higher-level care; and effective maternal and perinatal death surveillance and response. METHODS: SMGL used a mixed-methods approach to describe intervention strategies, outcomes, and health impacts. Programmatic and monitoring and evaluation data-health facility assessments, facility and community surveillance, and population-based mortality studies-were used to document the effectiveness of intervention components. RESULTS: During the SMGL initiative, the proportion of facilities providing emergency obstetric and newborn care (EmONC) increased from 10% to 25% in Uganda and from 6% to 12% in Zambia. Correspondingly, the delivery rate occurring in EmONC facilities increased from 28.2% to 41.0% in Uganda and from 26.0% to 29.1% in Zambia. Nearly all facilities had at least one trained provider on staff by the endline evaluation. Staffing increases allowed a higher proportion of health centers to provide care 24 hours a day/7 days a week by endline-from 74.6% to 82.9% in Uganda and from 64.8% to 95.5% in Zambia. During this period, referral communication improved from 93.3% to 99.0% in Uganda and from 44.6% to 100% in Zambia, and data systems to identify and analyze causes of maternal and perinatal deaths were established and strengthened. CONCLUSION: SMGL's approach was associated with improvements in facility infrastructure, equipment, medication, access to skilled staff, and referral mechanisms and led to declines in facility maternal and perinatal mortality rates. Further work is needed to sustain these gains and to eliminate preventable maternal and perinatal deaths.