In the past, the incidence of HIV in Iran was higher among addicted women or those married to injecting drug users who were mainly from low-income socioeconomic groups, but the disease pattern is changing in the country. Based on the results, the educational level of mothers with HIV is now higher than the educational level of previously diagnosed cases, which indicates an increase in the prevalence of HIV among people with a higher educational level. The majority of new cases are often due to unprotected sexual contacts, indicating the importance of the integration of the PMTCT program into the health program in the country. The pilot phase of the PMTCT program in Iran is one of the strengths in the integration of this program into PHC.
In the pilot phase, HIV infection was confirmed only in 56.7% of the cases with a positive result in the HIV rapid test. The fourth generation of ELISA test was used in the pilot phase pf the program in Iran. The sensitivity and specificity of this test is over 99% . However, it seems that this test was not used in a standardized manner in the pilot phase. Nevertheless, the problems have been solved during the implementation of this phase. In order to reduce false positives, it is very important to keep compliance with the protocol when performing these tests in the program. In line with a similar study in Uganda , 69.4% of eligible people in the pilot phase underwent HIV rapid test, which could be due to lack of training for the personnel, lack of tools for the rapid test at a specific point of time (because of sanctions imposed by the USA), and custom-made practices by the personnel in some cases. It is of great importance to ensure the sustainability of people’s access to rapid test at the integration stage, and it is necessary to conduct the rapid test for all pregnant women in order to achieve the goals of EMTCT.
In 75% of cases, the test was performed before the 18th week of gestation. Rapid diagnosis of and counseling for HIV in the first trimester of pregnancy is one of the key points in preventing the transmission of disease from mother to child, because during that time the treatments can be more effective . In the pilot phase, some of the studied pregnant women were in the last weeks of gestation and some of them were diagnosed at the end of pregnancy; this problem will be resolved at the integration phase. According to different studies, from 1.2–40% [6, 8, 9] of pregnant women are tested and diagnosed in the first trimester of pregnancy. Since a very high percentage of pregnancies in small towns and rural areas are recorded at the early stages in health centers, it is expected that, after the initiation of the integration phase, a high percentage of pregnant women will be tested in the first trimester of pregnancy.
In 75% of cases, the time interval between reactive testing and definitive diagnosis was less than three days and the median time interval between the definitive test and the start of treatment was seven days. These time intervals do not cause a program failure in the first trimester of pregnancy, but when the test is performed in the third trimester, these short time intervals can be problematic. Therefore, strong efforts should be made to conduct the rapid test in the first trimester of pregnancy for all pregnant women. In this study, CD4 test and blood Viral Load (VL) test were performed only for a low percentage of cases. This will impede the monitoring of the treatment, and before integrating the program it is necessary to adopt the required measures for conducting these tests and increase the level of access to the mentioned tests. The implementation of USA sanctions against Iran is one of the main reasons for the shortage of a Viral Load testing device in Iran, which should be considered when running the program. In various studies in different countries, it has been reported that between 30% and 100% of women diagnosed with HIV had underwent CD4 testing [10, 11]. After the treatment, the mean level of CD4 was significantly higher than before, and the level of VL was also increased. In Ethiopia , the mean CD4 at the time of the initiation of ART was about 302, which reached 404 after the treatment, and in Uganda , the median CD4 was 368.
Given that in Iran the PMTCT program is implemented as Option B+, it is expected that all mothers with HIV use ART for a lifetime. ART during pregnancy was not fully used in 13% of cases, which is a risk to the program. However, there was a proper reduction in the percentage of viral load in patients and the lifetime treatment was properly started after the delivery. One of the reasons for the lack of full and regular adherence to the medication is the patients’ fear of disclosing their illness to the family, which is a serious problem that must be addressed properly. Of all eligible women with HIV, 30.6% in Uganda , 77% in Côte d'Ivoire , and almost 100% in China  received ART from the early time of diagnosis. HIV infection in spouse, high level of education, availability of services in health centers, the presence of knowledgeable staff during childbirth, and maternal training have been reported to be effective in the acceptance of ARV by mothers .
Counseling was performed only for 75% of the spouses of the studied patients; the low rate of counseling is also due to the same cultural problem and stigma. Furthermore, 25% of the spouses refused undergoing HIV testing, and 50% of them had previously been diagnosed with HIV, indicating that care services was poorly provided for the patients. Thus, it is necessary to fundamentally review and modify processes at the Voluntary Counselling and Testing (VCT) centers. Moreover, it can be concluded that the quality of counseling for HIV-positive men had been probably low and did not reduce the risk of transmission of HIV to their spouses. On the other hand, 39.5% of men who had been counseled and tested were diagnosed as new cases of HIV, indicating that the PMTCT program could also be very effective in detecting men with the disease. In Uganda , 91% of husbands were informed of their spouse's disease, which is higher than the rate observed in our study.
Since it is impossible to conduct viral load testing for all patients in Iran, it has been recommended to perform cesarean section for delivery; however, 5.4% of cases in this study had a normal delivery, which is a defect in the program. Of course, all of these cases were diagnosed during delivery; the late diagnosis of the disease, after the natural childbirth, might be attributed to the lack of awareness, inappropriate adherence to the standards in the processes, or the late request for the services by pregnant women, which increase the risks in the program. Prophylaxis was not considered in 3% of all newborns, but all of them had received powdered milk; moreover, the vaccination in 5.4% of them had some defects. These shortcomings in the program are also a risk factor for the transmission of HIV from mother to infant, which could disrupt EMTCT. According to the findings of other studies [6, 10], 96% of cases in African countries had a natural delivery while the majority of patients in China  had delivered via a cesarean section. Of all, 97.8% cases in Rwanda  and 87% in Ethiopia  were exclusively breastfed. However, taking into consideration the economic status of every country, it is advised to practice or do not practice breastfeeding; In Iran, it is not recommended to practice breastfeeding by mothers with HIV.
In Uganda , 14.2% of newborns did not receive prophylactic drugs at birth, and the rate of HIV transmission to the child was reported to be about 15%. Over a period of five years in Uganda , 18% of children born to HIV-infected mothers died. Of all children born to HIV-infected mothers, 6% in Ethiopia  and one out of 67 children in China  were infected with HIV. The prevalence of HIV infection among 6-week old children at risk of HIV exposure in South Africa , ranged from 0.3–2.4% in different regions. In a pilot study in the country, only one newborn was infected with HIV and no children died before the end of the pilot study, indicating that the treatment for pregnant women and prophylaxis for infants were effectively provided.