Effectiveness of conditional cash transfers for uptake and retention in HIV prevention of mother-to-child transmission services in low- and middle-income countries: a systematic review and meta-analysis.

Objective: The objective of this systematic review was to synthesize the best available evidence on the effectiveness of conditional cash transfers for the uptake and retention in the prevention of mother-to-child transmission (PMTCT) services in pregnant and/or breastfeeding women with HIV infection in low- and middle-income countries (LMIC).

Introduction: Regardless of the effectiveness of PMTCT services, uptake, and retention in such services remains poor in LMIC. Conditional cash transfers are considered an important strategy to improve the uptake of preventive services in pregnant women and children. This review evaluated the effectiveness of conditional cash transfers in improving uptake and retention in the PMTCT services for pregnant and/or breastfeeding women with HIV infection.

Inclusion criteria: Studies that compared the impact of conditional cash transfers on uptake and retention in the prevention of mother-to-child services with standard care or with another intervention in pregnant and/or breastfeeding women with HIV were considered for inclusion. The primary outcomes of this review were retention and uptake of pregnant women with HIV in PMTCT programs, reported as the percentage of pregnant and/or breastfeeding women with HIV enrolled in antiretroviral therapy; and the number of facility-based deliveries. The secondary outcomes included the percentage of infants completing post-exposure HIV testing at 4 to 6 weeks after birth or early infant diagnosis; the percentage of infants exposed to HIV testing positive for HIV; and the percentage of infants exposed to HIV with health defects (eg, neural tube defects, heart defects, major limb malformations).

Methods: Databases searched included: Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, Embase (Ovid), and CINAHL (EBSCOhost). Sources of unpublished studies/gray literature included ProQuest Dissertations and Theses, OpenGrey, WHO International Clinical Trials Registry Platform, and Clinical-Trials.gov. Studies published in English since 2000 were considered. The JBI Critical Appraisal Checklist for Randomized Controlled Trials was used to assess the methodological quality of the included studies. Data were extracted from the included studies and studies were pooled in a statistical meta-analysis. Effect sizes were presented as odds ratios (OR) and CI (95%) were calculated. The standard χ2 and I2 tests were used to assess heterogeneity statistically. Statistical analyses were conducted using fixed effects based on established guidance.

Results: Two randomized controlled studies were included in this review with a total of 950 participants. Two outcomes were pooled and assessed for the effects of conditional cash transfer: facility-based delivery and early infant diagnosis. Conditional cash transfer has significant positive effects on both outcomes compared to standard care. The OR for facility-based delivery was 1.53 (95% CI, 1.15-2.04; P=0.004) while it was 1.89 (95% CI, 1.38-2.59; P<0.001) for early infant diagnosis. Heterogeneity (I2) was 0% for facility-based delivery and 30% for early infant diagnosis.

Conclusion: This review summarizes the available evidence on the effectiveness of conditional cash transfer on the uptake of and retention in the PMTCT services in LMIC. It is possible that conditional cash transfer increases facility-based delivery and it may result in an increase in early infant diagnosis.