effectiveness of the national pmtct program in rwanda
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Effectiveness of the National PMTCT Program in Rwanda. By Dr Alexandre LYAMBABAJE, School of Public Health/ National University of Rwanda Dr Placidie MUGWANEZA, Institute of HIV Diseases Prevention and Control (IHDPC/RBC), Rwanda. - PowerPoint PPT PresentationTRANSCRIPT
Effectiveness of the National PMTCT Program in Rwanda
By
Dr Alexandre LYAMBABAJE, School of Public Health/ National University of Rwanda
Dr Placidie MUGWANEZA, Institute of HIV Diseases Prevention and Control (IHDPC/RBC), Rwanda
16%
26%33%
53%
63%
78%84%81%
0%
20%
40%
60%
80%
100%
2003 2004 2005 2006 2007 2008 2009 2010
Male partner HIV counseling and testing, during ANC, Rwanda PMTCT program,
2005-2010
Population Coverage, HIV+ preg. Women receiving ARV, Rwanda PMTCT program,
2005-2010
2005 2006 2007 2008 2009 20100%
20%
40%
60%
80%
100%
100% 100%
16% 8% 8% 10%
0.637240650191622 0.51981205
95144880.48719043
5525192 0.329410307234887
0.103475617814193 0.21331245
10571660.210788499857672 0.37797324
0832508
0.103872076119995 0.19075959
27956150.224167378309138
0.196110009910803
HIV+ pregnant women receiving HAART for life
HIV+ pregnant women receiving HAART prophylaxis
HIV+ pregnant women receiving Dual ARV prophylaxis
HIV+ pregnant women receiving NVP only
Transitioning from Sd-NVP to Efficacious ARV regimens, Rwanda PMTCT program, 2005-2010
Aim: HIV prevalence and key determinants among exposed children in the Rwanda PMTCT program.
Methods◦ Study design: cross sectional
◦ Inclusion criteria: 9-24 months children with their mother
◦ Sampling frame: Stratified 2-stage cluster sampling (1st unit: sites; 2nd unit: ANC mothers).
◦ Both HIV+ and –ves mothers were included to ensure community is blind about status of participants.
◦ Data collection: Interview with mothers at household, HIV testing of all children (rapid test and PCR)
1st PMTCT Program Effectiveness Study- Household Survey (2008-2009)-
Key findings -
Recall bias: 9 to 24 months is a long period after birth. Some mothers could not recall exactly events and treatments during pregnancy and delivery periods
End point measurement: Wide interval (9-24 months) making it difficult to interpret the HIV free-survival rate, as we could not rule out exposure to breastfeeding
Adherence to PMTCT regimens: Registries could not provide exhaustive information about the adherence of the mothers to PMTCT regimens.
Limitations of the 1st PMTCT effectiveness study
Primary Objective◦ To periodically measure rates of early mother-to-child transmission (MTCT)
of HIV at 6-weeks postpartum
Secondary Objectives◦ To periodically estimate the national coverage of key PMTCT interventions,
◦ To estimate the association between early MTCT rate and maternal, infant and health system factors.
Endpoints: ◦ 6-week infant HIV prevalence
◦ 6-week infant MTCT rate (Overall, PMTCT mother, non-PMTCT mother, Serodiscordant couples)
2nd PMTCT 6-week Impact Study Facility-based, 2010-2012
Design: Cross-sectional Two-stage Stratified Cluster sampling design
◦ Primary units: Health facilities Stratified by (rural vs urban; PMTCT vs Non-PMTCT site)
Probability proportional to size sampling: size estimated using historical DTP1 data (previous year)
o Secondary units: Mother-infant pairs
Sample size◦ 161 sites (36 non-PMTCT sites; 20 urban)
◦ 2,000 pairs (exposed infant, mother or legal caregiver)
6-week facility based PMTCT Impact Study - Design
Age group: 6-10 weeks Where: Facility-based at MCH/EPI unit How: enrollment at DTP1 immunization visit By Who: Health facility personnel Main steps
◦ Screening based on standard algorithm (exposed infant)◦ Interviews of mother or caregiver◦ Blood sample collection (using DBS)
Data collection started in June 13th 2011 Final results expected by May 2012
6-week facility based PMTCT Impact Study - Data collection
Evaluation of the Effectiveness of the National Prevention of Mother-to-Child Transmission (PMTCT) Programme on Infant HIV at 6 weeks Postpartum in South Africa.
IRB identifier: FWA00002753 Cooperative Agreement no. CDC U2G/PS001137·01 Version 1.2 (23 November 2009) Figure 8 outline the overall approach and conceptual framework for this evaluation.
ALL caregiver- infant pairs attending for their six- week immunization (1st
DTP Dose) to Sampled HF
Screening – consent if Eligible
HIV+ mother
DBS Infant + Quest
PCR on DBS at NRL
NRL
send
s inf
ant
resu
lt ba
ck to
HF
& SP
H
Mother Knows Her HIV Status Mother Status Unknown
Discordant PartnerUnknown Status
Mother Rapid test
HIV - mother
Quest+Inf DBS
Not Enrolled
Mother Not Available or
Mother Refuses HIV Testing
Mother Available &
Accepts HIV Testing HIV - partner
Mother HIV -Mother HIV +DBS Infant + Quest
Infant DBS Elisa
Infant DBS Elisa -
Infant DBS Elisa +
6-week facility based PMTCT Impact Study - Screening Algorithm for enrollment
Outreach Immunization strategy◦ How to integrate screening for the study?◦ How to administer the questionnaire?◦ Who will manage the transfer of potential eligible mothers and
infants to Health facilities for further screening?
Reaching the hardest to reach populations: do not participate in immunization campaigns (Beliefs, Ignorance, hard to reach areas)
Long period for data collection (7 months) Health Center Personnel mobility
Challenges and Potential Bias
Advantages◦ Low cost for blood samples collection and testing◦ Zero risk for non-exposed children◦ Capacity building for health facilities and better
sustainability◦ Better coverage by including recruitment from outreach
immunization strategy
Disadvantages◦ Difficult screening phase to identify exposed children◦ Long period for data collection (7 months)◦ Mobility of trained personnel and need to retrain new
people for data collection
Advantages and Disadvantages compared to MRC Generic Protocol
Thank You For Your Attention - MURAKOZE
Acknowledgements
Rwanda School of Public Health
NNRLR
L
Rwanda Biomedical Center/Institute of HIV, Diseases Prevention and Control (RBC/IHDPC)