Objective: Examine the uptake of services and behaviors in the prevention of mother-to-child HIV transmission (PMTCT) cascade in Zimbabwe and determine factors associated with MTCT and maternal antiretroviral therapy (ART) or antiretroviral (ARV) prophylaxis.

Design: Analysis of cross-sectional data from mother-infant pairs.

Methods: We analyzed baseline data collected in 2012 as part of the impact evaluation of Zimbabwe's Accelerated National PMTCT Program. Using multi-stage cluster sampling, eligible mother-infant pairs were randomly sampled from the catchment areas of 157 facilities in five provinces, tested for HIV infection, and interviewed about PMTCT service utilization.

Results: Of 8,800 women, 94% attended >=1 antenatal care (ANC) visit, 92% knew their HIV serostatus during pregnancy, 77% delivered in a health facility, and 92% attended the 6-8 week postnatal visit. Among 1,075 (12%) HIV-infected women, 59% reported ART/ARV prophylaxis and 63% of their HIV-exposed infants received ARV prophylaxis. Among HIV-exposed infants, maternal receipt of ART/ARV prophylaxis was protective against MTCT (adjusted prevalence ratio (PRa): 0.41, 95% confidence interval (CI): 0.23, 0.74). Factors associated with receipt of maternal ART/ARV prophylaxis included >=4 ANC visits (PRa: 1.18, 95%CI: 1.01,1.38), institutional delivery (PRa: 1.31, 95%CI: 1.13, 1.52), and disclosure of serostatus (PRa: 1.30, 95%CI: 1.12, 1.49).

Conclusions: These data from women in the community indicate gaps in the PMTCT cascade prior to the accelerated program, which may have been missed by examination of health facility data alone. These gaps were especially noteworthy for services targeted specifically to HIV-infected women and their infants, such as maternal and infant ART/ARV prophylaxis.