HIV positive pregnant women not accessing drugs include:

Challenges faced by PMTCT programmes

Even where PMTCT services are available, not all women receive the full benefit. Reasons for HIV positive pregnant women not accessing drugs include:

• Not being offered an HIV test
• Refusing to take an HIV test
• Not returning for follow up visits
• Not adhering to self-administered drugs

HIV testing is critical because women who do not know they are HIV positive cannot benefit from interventions. In 2009 an estimated 26% of the estimated 125 million pregnant women in low and middle-income countries received an HIV test.²¹ However some women refuse to be tested because they fear learning that they have a life-threatening condition; because they distrust HIV tests; or because they do not expect their results to remain confidential, and fear stigma and discrimination following a positive result.

Women having tested negative early in pregnancy can become infected during pregnancy; without returning to clinics for retesting treatment is not accessed²² . Sometimes women who test HIV positive do not return to clinics for follow up visits, or fail to take the drugs they have been given. This can happen because they have had negative experiences interacting with clinic staff, fear or stigma or disclosure and because they did not receive adequate HIV counseling. because they have been poorly informed about HIV transmission and how it can be prevented. Fear of disclosure is a common reason why women are reluctant to return to their HIV clinic. In the words of a woman from Cote d'Ivoire:

"My husband might see me with the medicines, and he will want to know what they are for. That way he will find out about my [HIV positive test] result. Even the location bothers me, because everyone who comes to the clinic knows what goes on [at the programme]. As soon as a pregnant woman is seen coming here, it's known right away that she is seropositive."²³

One of the major problems in preventing mother-to-child transmission, it has been argued, is making the provision of ARV drugs the focus of PMTCT efforts. Access to other services such as counselling, care and treatment services, infant-feeding guidance, and in particular sexual and reproductive health is ignored as a result.²⁴ Therefore, it should not be assumed that the proportion of HIV-positive pregnant women who are receiving antiretroviral prophylaxis to prevent their child becoming infected - estimated at one-third in low and middle-income countries - are receiving comprehensive PMTCT services.²⁵

To achieve a high success rate, PMTCT programmes must have well-trained, supportive staff who take great care to ensure confidentiality. They must be backed up by effective HIV testing and counselling programmes and by good quality HIV/AIDS education, which is essential to eliminate myths and misunderstandings among pregnant women, and to counter stigma and discrimination in the wider community. Under these conditions, antiretroviral drugs have the potential to save many thousands of babies' lives.