Acknowledgements---2
Table of contents---3
Abbreviations---5
Tables & figures---6
Abstract---8
Résumé (Français) ---9
1. Background---11
1.1. HIV infection epidemic---12
1.2. Prevention of mother-to-child transmission of HIV---13
2. Hypotheses & Objectives---15
2.1. Research question---15
2.2. Hypotheses---16
2.3. Objectives---18
3. Methods---19
3.1. Systematic review of health care systems strengthening and coverage Maternal health services in Rwanda---19
3.2. Prospective cohort study in Muhima health centre---20
3.3. Ethical considerations---21
3.4. Study funding---21
4. Results & Discussion---24
4.1. Impact of health systems strengthening on coverage of maternal health services in Rwanda (2000-2010) ---24
4.2. Incidence & socio-economic, clinical and biological risk factors for mother-to-child transmission of HIV-1---49
4.3. Implementing primary health care –based PMTCT interventions: Operational perspectives from Muhima cohort analysis---79
4.4. Links between the three papers---105
5. Conclusions, Implications & Recommendations---107
References References Background/Hypotheses/Objectives & Methods---22
References paper 1---44
References paper 2---72
References paper 3---98
Appendix A: Data collection form---111
Appendix B: Consent form---119
Appendix C: Publications---122
LIST OF TABLES
Table1b: Rwanda maternal-newborn health and family planning:
major policy events, 1999–2010---26 Table2b: Studies reviewed on the impact of health systems strengthening
on coverage of maternal health services in Rwanda. ---32 Table3b: Levels of coverage (% of women surveyed) for four maternal health indicators, DHS data, 2000, 2005, 2010, Rwanda. ---36 Table1c: Background characteristics of mothers and infants meeting inclusion criteria in the study. Muhima health centre cohort, Kigali/Rwanda, 2007 – 2010---58 Table2c: Univariate analysis of factors associated with mother-to-child transmission of HIV-1 at 6 weeks and at 6 months of life. Muhima health centre cohort,
Kigali/Rwanda, 2007 – 2010. ---62
Table3c: Multivariable logistic regression analysis of risk factors associated with mother-to- child transmission of HIV at 6 weeks and at 6 months of life.
Muhima health centre cohort, Kigali/Rwanda, 2007 – 2010---64
Table1d: Background characteristics of mothers meeting inclusion criteria
in the Muhima cohort study---87
Table2d. Univariate analysis of PMTCT service use–related coverage indicators by infant HIV-1 status at 6 weeks of life among participants in Muhima cohort study---90 Table3d. Multivariate analysis of PMTCT service use–related indicators of MTCT of HIV-1 at 6 weeks of life---91
LIST OF FIGURES
Figure1a: Conceptual model for socio-economic, clinical and biological risk factors for mother – to – child transmission of HIV-1---18 Figure1b: Trends in selected maternal health indicators, 2000–2010---37 Figure1c: Muhima health centre cohort profile: Mothers and infants meeting
inclusion criteria in the study. Kigali/Rwanda, 2007-2010---60 Figure2c: Path diagram for mediation effect of HIV status disclosure.
Mothers and infants meeting inclusion criteria in the study.
Muhima health centre cohort, Kigali/Rwanda, 2007-2010---66
Figure1d: Muhima study cohort profile - infants at 6 weeks of life,
2007 – 2010 (Rwanda) ---89