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Problem Zimbabwe has one of the highest rates of HIV seroprevalence in the world. In 2001 only 4% of women and children in need of services for prevention of mother to child transmission of HIV were receiving them. Design Pilot implementation of the first programme for prevention of mother to child transmission of HIV in rural Zimbabwe. Setting 120 bed district hospital in Buhera district (285 000 inhabitants), Manicaland, Zimbabwe. Key measures for improvement Programme uptake indicators monitored for 18 months; impact of policy evaluated by assessing up-scaling of programme. Strategies for change Voluntary counselling and testing services for HIV were provided in the hospital antenatal clinic. Women identified as HIV positive and informed of their serostatus and their newborn were offered a single dose antiretroviral treatment of nevirapine; mother-child pairs were followed up through routine health services. Nursing staff and social workers were trained, and community mobilisation was conducted. Effects of change No services for prevention of mother to child transmission of HIV were available at baseline. Within 18 months, 2298 pregnant women had received pretest counselling, and the acceptance of HIV testing reached 93.0%. Of all 2137 women who had an HIV test, 1588 (74.3%) returned to collect their result; 326 of the 437 HIV positive women diagnosed had post-test counselling, and 104 (24%) mother-child pairs received nevirapine prophylaxis. Lessons learnt Minimum staffing, an enhanced training programme, and involvement of district health authorities are needed for the implementation and successful integration of services for prevention of mother to child transmission of HIV. Voluntary counselling and testing services are important entry points for HIV prevention and care and for referral to community networks and medical HIV care services. A district approach is critical to extend programmes for prevention of mother to child transmission of HIV in rural set... [ABSTRACT FROM AUTHOR]