Evaluation of Sierra Leones Elimination of Mother-to-child Transmission of HIV Program, 2024: The Need for a Life Course Approach to Triple Elimination

BackgroundThe elimination of Mother-to-Child Transmission (eMTCT) Cascade Analysis is a key intervention to understand the effectiveness and gaps in national HIV prevention programs for pregnant women and their infants. This comprehensive evaluation aimed to assess the step-by-step processes of eMTCT services, from the entry points at antenatal care (ANC) to outcomes for HIV-exposed infants (HEI) and propose actionable recommendations using the life course approach to improve maternal and child health outcomes in Sierra Leone. MethodsWe used a retrospective cohort study to understand the entry of HIV-positive pregnant women into the eMTCT program and the outcome of their infants. The assessment was conducted in June 2024 across 118 selected health facilities nationwide. Data was analysed using Microsoft Excel to assess the steps from entry into the eMTCT program to HIV testing outcomes and delivery process for infants, including final infant/child outcomes for HIV-positive pregnant and breastfeeding women. ResultsOf the 80,264 pregnant women attending their first ANC visit between January and December 2022, 74,401(92.7%) received HIV tests. Of the 2,083 newly diagnosed HIV-positive pregnant women, 1,612 (77.4%) were initiated on antiretroviral therapy (ART) at their first ANC visit, highlighting a critical gap where 22.6% missed early treatment initiation. Only 753 (36.1%) HIV-positive women had documented facility-based delivery, indicating significant drop-offs in retention and continuity of care. Among 761 HEIs, 671 (88.2%) received ART for prophylaxis within 72 hours of birth; however, only 466 (61.2%) underwent their first virological test within 6-8 weeks of birth, and 176 (24.1%) received a second virological test 12 weeks after cessation of breastfeeding. ConclusionWhile Sierra Leones eMTCT program has made substantial progress in ANC attendance and HIV testing, critical gaps persist in ART initiation, facility delivery of HIV-positive women and retention in care. Adopting a life course approach is critical to address these gaps through targeted interventions, improved data quality, and enhanced follow-up care.