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AbstractIntroductionFindings from biomedical, behavioural and implementation studies provide a rich foundation to guide programmatic efforts for the prevention of mother‐to‐child HIV transmission (PMTCT).MethodsWe summarized the current evidence base to support policy makers, programme managers, funding agencies and other stakeholders in designing and optimizing PMTCT programmes. We searched the scientific literature for PMTCT interventions in the era of universal antiretroviral therapy for pregnant and breastfeeding women (i.e. 2013 onward). Where evidence was sparse, relevant studies from the general HIV treatment literature or from prior eras of PMTCT programme implementation were also considered. Studies were organized into six categories: HIV prevention services for women, timely access to HIV testing, timely access to ART, programme retention and adherence support, timely engagement in antenatal care and services for infants at highest risk of HIV acquisition. These were mapped to specific missed opportunities identified by the UNAIDS Spectrum model and embedded in UNICEF operational guidance to optimize PMTCT services.Results and discussionFrom May to November 2019, we identified numerous promising, evidence‐based strategies that, properly tailored and adopted, could contribute to population reductions in vertical HIV transmission. These spanned the HIV and maternal and child health literature, emphasizing the importance of continued alignment and integration of services. We observed overlap between several intervention domains, suggesting potential for synergies and increased downstream impact. Common themes included integration of facility‐based healthcare; decentralization of health services from facilities to communities; and engagement of partners, peers and lay workers for social support. Approaches to ensure early HIV diagnosis and treatment prior to pregnancy would strengthen care across the maternal lifespan and should be promoted in the context of PMTCT.ConclusionsA wide range of effective strategies exist to improve PMTCT access, uptake and retention. Programmes should carefully consider, prioritize and plan those that are most appropriate for the local setting and best address existing gaps in PMTCT health services.

IntroductionIntegration of HIV into child survival platforms is an evolving territory with multiple connotations. Most literature on integration of HIV into other health services focuses on adults; however promising practices for children are emerging. These include the Double Dividend (DD) framework, a new programming approach with dual goal of improving paediatric HIV care and child survival. In this commentary, the authors discuss why integrating HIV testing, treatment and care into child survival platforms is important, as well as its potential to advance progress towards global targets that call for, by 2020, 90% of children living with HIV to know their status, 90% of those diagnosed to be on treatment and 90% of those on treatment to be virally suppressed (90–90–90).DiscussionIntegration is critical in improving health outcomes and efficiency gains. In children, integration of HIV in programmes such as immunization and nutrition has been associated with an increased uptake of HIV infant testing. Integration is increasingly recognized as a case‐finding strategy for children missed from prevention of mother‐to‐child transmission programmes and as a platform for diffusing emerging technologies such as point‐of‐care diagnostics. These support progress towards the 90–90–90 targets by providing a pathway for early identification of HIV‐infected children with co‐morbidities, prompt initiation of treatment and improved survival. There are various promising practices that have demonstrated HIV outcomes; however, few have documented the benefits of integration on child survival interventions. The DD framework is well positioned to address the bidirectional impacts for both programmes.ConclusionsIntegration provides an important programmatic pathway for accelerated progress towards the 90–90–90 targets. Despite this encouraging information, there are still challenges to be addressed in order to maximize the benefits of integration.

AbstractIntroductionHIV continues to devastate the adolescent population in sub‐Saharan Africa (SSA). The complex array of interpersonal, social, structural and system‐level obstacles specific to adolescents have slowed progress in prevention and treatment of HIV in this population. The field of implementation science holds promise for addressing these challenges.DiscussionThere is growing consensus that enhanced interactions between researchers and users of scientific evidence are important and necessary to tackle enduring barriers to implementation. In 2017, the Fogarty International Center launched the Adolescent HIV Prevention and Treatment Implementation Science Alliance (AHISA) to promote communication and catalyse collaboration among implementation scientists and implementers to enhance the cross‐fertilization of insights as research advances and the implementation environment evolves. This network has identified key implementation science questions for adolescent HIV, assessed how members' research is addressing them, and is currently conducting a concept mapping exercise to more systematically identify implementation research priorities. In addition, AHSA pinpointed common challenges to addressing these questions and discussed their collective capacity to conduct implementation science using the shared learning approach of the network. Specifically, AHISA addresses challenges related to capacity building, developing mentorship, engaging stakeholders, and involving adolescents through support for training efforts and funding region‐/country‐specific networks that respond to local issues and increase implementation science capacity across SSA.ConclusionsInnovative platforms, like AHISA, that foster collaborations between implementation science researchers, policymakers and community participants to prioritizes research needs and identify and address implementation challenges can speed the translation of effective HIV interventions to benefit adolescent health.

IntroductionMother‐to‐child transmission of HIV can be reduced to<5% with appropriate antiretroviral medications. Such reductions depend on multiple health system encounters during antenatal care (ANC), delivery and breastfeeding; in countries with limited access to care, transmission remains high. In Lesotho, where 28% of women attending ANC are HIV positive but where geographic and other factors limit access to ANC and facility deliveries, a Minimum PMTCT Package was launched in 2007 as an alternative to the existing facility‐based approach. Distributed at the first ANC visit, it packaged together all necessary pregnancy, delivery and early postnatal antiretroviral medications for mother and infant.MethodsTo examine the availability, feasibility, acceptability and possible negative consequences of the Minimum PMTCT Package, data from a 2009 qualitative and quantitative study and a 2010 facility assessment were used. To examine the effects on ANC and facility‐based delivery rates, a difference‐in‐differences analytic approach was applied to 2009 Demographic and Health Survey data for HIV‐tested women who gave birth before and after Minimum PMTCT Package implementation.ResultsThe Minimum PMTCT Package was feasible and acceptable to providers and clients. Problems with test kit and medicine stock‐outs occurred, and 46% of women did not receive the Minimum PMTCT Package until at least their second ANC visit. Providing adequate instruction on the use of multiple medications represented a challenge. The proportion of HIV‐positive women delivering in facilities declined after Minimum PMTCT Package implementation, although it increased among HIV‐negative women (difference‐in‐differences=14.5%, p=0.05). The mean number of ANC visits declined more among HIV‐positive women than among HIV‐negative women after implementation, though the difference was not statistically significant (p=0.09). Changes in the percentage of women receiving≥4 ANC visits did not differ between the two groups.ConclusionsIf supply issues can be resolved and adequate client educational materials provided, take‐away co‐packages have the potential to increase access to PMTCT commodities in countries where women have limited access to health services. However, efforts must be made to carefully monitor potential changes in ANC visits and facility deliveries, and further evaluation of adherence, safety and effectiveness are needed.

The global HIV response is leaving children and adolescents behind. Because of a paucity of studies on treatment and care models for these age groups, there are gaps in our understanding of how best to implement services to improve their health outcomes. Without this evidence, policymakers are left to extrapolate from adult studies, which may not be appropriate, and can lead to inefficiencies in service delivery, hampered uptake, and ineffective mechanisms to support optimal outcomes. Implementation science research seeks to investigate how interventions known to be efficacious in study settings are, or are not, routinely implemented within real-world programmes. Effective implementation science research must be a collaborative effort between government, funding agencies, investigators, and implementers, each playing a key role. Successful implementation science research in children and adolescents requires clearer policies about age of consent for services and research that conform to ethical standards but allow for rational modifications. Implementation research in these age groups also necessitates age-appropriate consultation and engagement of children, adolescents, and their caregivers. Finally, resource, systems, technology, and training must be prioritized to improve the availability and quality of age-/sex-disaggregated data. Implementation science has a clear role to play in facilitating understanding of how the multiple complex barriers to HIV services for children and adolescents prevent effective interventions from reaching more children and adolescents living with HIV, and is well positioned to redress gaps in the HIV response for these age groups. This is truer now more than ever, with urgent and ambitious 2020 global targets on the horizon and insufficient progress in these age groups to date.