The implementation gap: a national evaluation of Uganda's Prevention of vertical transmission retention package

Uganda has made progress in eliminating vertical transmission (VT) of HIV, but VT rates have plateaued in recent years. A major factor contributing to high VT rates is the loss of mother-baby pairs from HIV care. To improve retention, Uganda introduced a national Prevention of Vertical Transmission (PVT) retention package in 2015. This package included seven facility-based interventions: five core ones (appointment tracking, EDD/EID cohort monitoring, Bring-Back Mother-Baby initiative, color-coded DBS reminder stickers, birth cohort monitoring) and two additional interventions (point-of-care EID testing, FamilyConnect SMS reminders). We evaluated the implementation and fidelity of this package across Uganda from 2015 to 2020 and explored facilitators and barriers to uptake in routine care.

We conducted a cross-sectional mixed-methods study in 123 health facilities across Uganda's regions and levels of care. Adoption of each package component was assessed by asking PVT focal persons whether it was implemented ("Yes"/ "No"). Implementation fidelity was measured against national standards and categorized as "Yes" (adhered to all standards) or "No" (did not). Qualitative interviews with health workers and program managers explored facilitators and barriers. Retention information was extracted from DHIS 2.

Implementation varied widely. Simple, facility-based interventions had high adoption: appointment tracking (98%) and birth cohort monitoring (81%). More resource-intensive or community-linked components were poorly implemented: Bring-Back Mother-Baby (~ 50%), DBS reminder tracking stickers (26%), and point-of-care EID testing (23%). Fidelity followed adoption patterns-high for simple interventions (98% for appointment tracking) but lower for complex ones (77% for Bring-Back Mother-Baby). Facilitators included health worker skills and strong leadership. Barriers were systemic: workforce shortages, limited funding for community follow-up, poor data quality, and a lack of standardized tools.

Uganda's PVT package shows effective uptake of simple, low-cost interventions but struggles with complex, resource-demanding components vital for retention. To eliminate vertical transmission, Uganda must move beyond developing innovations, job aids, and the provision of data collection tools and toward strengthening health system capacities, especially investing in the workforce's continuous training, supportive supervision, and supporting community-facility linkages.