rosalind carter, phd epidemiologist, pmtct, pediatrics and mtct plus initiative program
DESCRIPTION
Evaluating ICAP-supported Prevention of Mother to Child Transmission (PMTCT) Programs in 7 countries: . Rosalind Carter, PhD Epidemiologist, PMTCT, Pediatrics and MTCT Plus Initiative Program Monitoring, Evaluation and Research Unit, ICAP NY. Roadmap. Description of transmission timing - PowerPoint PPT PresentationTRANSCRIPT
Evaluating ICAP-supported Prevention of Mother
to Child Transmission (PMTCT) Programs in 7 countries:
Rosalind Carter, PhDEpidemiologist, PMTCT, Pediatrics and
MTCT Plus Initiative ProgramMonitoring, Evaluation and Research Unit, ICAP NY
Roadmap• Description of transmission timing• ICAP PMTCT model of care (MOC)• M & E indicators and data collection • Overview of PMTCT program in 7 countries• Results • Summary• Next steps
Timing of Mother to Child Transmission
Pregnancy
Labor & Delivery
Breast Feeding
Antenatal clinicCare & Treatment Maternity
Care and Treatment, Exposed Infant follow-up
PMTCT Model of CareCounseling and HIV testing: Identifying HIV+
pregnant women early in pregnancy Assessing maternal health status and HAART eligibility with CD4 testing/Clinical evaluationProvide multi-drug ART prophylactic regimens to
women not eligible for HAART and infants Follow-up care for HIV-exposed infants: early HIV
testing and cotrimoxazole
ICAP approach
Use pregnancy as the entry point to engage women and their families in life long care
# women tested/positive# documented CD4# receive Sd-NVP# receive AZT + Sd-NVP#partners tested
#known positive#tested/positive#mothers receive ART#infants receive ART
#eligible who initiate HAART#enrolled in comprehensivecare and treatment
#initiating cotrimoxazole #PCR tested#confirmed HIV diagnosis
Challenges to collecting PMTCT indicators
• Measure activities in 4 areas of care system: – ANC – Care and Treatment– Maternity– Exposed infant follow-up
• Missing data: If women receive CD4 testing at ART clinic, is data relayed to ANC?
• Services delivered over time, not at a single visit • Linking infant outcome to mother’s ANC care
M&E: Focus on populations
Clinical: Focus on patient
0
100
200
300
400
0
50,000
100,000
150,000
200,000
250,000
Jan 07 Apr 07 July 07 Oct 07 Jan 08 Apr 08
1st ANC tested Facilities reporting
Mozambique, Ethiopia, Rwanda, Nigeria, Tanzania
Lesotho Cote d’Ivoire
Cumulative enrollment in ICAP-supported PMTCT programs (n=378 sites) in 7 countries
248,742 1st ANC visits
217,890 counseled, tested and received results
Num
ber o
f pat
ient
sN
umber of facilities
*Tanzania data not included; cannot distinguish 1st ANC from followup visits
Seroprevalence in 7 ICAP countries Apr -Jun 08
COUNSELING AND HIV RAPID TESTING
Identification of HIV-infected women in Antenatal Care Clinics
Use of group pre-test counseling and provider-initiated approach improved the proportion of women receiving HIV testing at first ANC visit
Pregnant women counseled, tested and received ART prophylaxis in ICAP-supported PMTCT programs,
January 2007 – June 2008
0
50,000
100,000
150,000
200,000
250,000
Num
ber o
f wom
en 1st ANCCounseledTestedHIV positiveART prophylaxis
TZ data not included because they cannot distinguish 1st visit and followup visits to ANC
239,193 (96%)
217,184 (87%)
14,317 (7%) 11,433
(75%)
248,742
Counseling and Testing: across countries and over time, Jan 07-Jun 08
• Overall, excellent counseling and testing coverage in ANC
• Improvement over time:– % women counseled: from 93% to 96%– % tested: from 72% to 87%
• Ethiopia: most improvement – % counseled: 72% to 93%– % tested: 48% to 87%
CD4 TESTING Clinical evaluation of HIV-infected women in ANC
Evaluating CD4 testing
• Reviewed “# of HIV+ women with documented CD4 count” (recorded in CD4 logbook)
• Restricted analysis to sites that reported at least one woman with documented CD4 – only 161 (43%) of 378 sites reported CD4
Proportion of HIV+ women with documented CD4 testing by country (n=5102 at 161 sites),
mean vs. most recent quarter
CD4 data: Program issues• Where CD4 testing is available, >50% of women get
CD4 but why not 100%?• CD4 still not available at many sites
– PMTCT programs located in rural Health Centers where CD4 not feasible/accessible
• Even if machine is available, or have system to transport samples to off-site lab for CD4 testing, reagent stockouts and broken machines remain a problem
HAART ELIGIBILITY AND INITIATION
Among women receiving CD4 testing, who is eligible for HAART and do they initiate treatment during pregnancy?
Measuring eligibility and HAART initiation
• Indicator for “# women eligible for HAART” allows for variation in ART guidelines across countries.
• Both “# eligible” and “# initiating HAART” underreported in PMTCT
• If services delivered in Care & Treatment, information may not be recorded in ANC register
• “# initiating HAART”: measuring referrals to ART clinic? Or confirmed ART start date?
Jose Macamo Model Center Mozambique
Jan-Jun06
Jul-Dec 06
Jan-Jun 07
Jul-Dec 07
Jan-Jun 08
0
20
40
60
80
100
120
140
ART Eligibility and ART Initiation
Eligible for ART based on CD4Initiated ART
Hired PMTCT counselor to work in ART clinic
July07-Sept07 Oct07-Dec07 Jan-March08 Apr-Jun08 -
50
100
150
200
250
136 135
196
163
2839
82
60
28 (100%) 28 (72%) 25 (30%)
39 (65%)
# of HIV-positive pregnant women who received their CD4 test results# HIV+ with CD4 < 350 cells/mm3# (%) of pregnant women who iniated therapeutic HAART during pregnancy
HAART initiation during pregnancy among HIV+ pregnant women with CD4 count be-low 350 cells/mm3 in 23 ICAP supported PMTCT sites in Rwanda
(July 07- June 08)
ART PROPHYLAXIS IN ANCProviding ART prophylaxis to mothers before delivery
Proportion of HIV+ women receiving ART prophylaxis in ANC by country, Jan 07 - Jun 08
n=6659 n=4634 n=1207 n=415 n=96n=1052 n=3414
Mean: 75%
ART regimen among HIV+ women who received ART prophylaxis at ANC, Jan 07 – Jun 08
n=921 n=5657 n=3405 n=993 n=412n=11433 n=45 n=1674
Changes in ARV regimen over time for Maternal prophylaxis: Ethiopia, Jan 07-Jun 08
0.0
20.0
40.0
60.0
80.0
100.0
120.0
Jan_07 Apr_07 Jul_07 Oct_07 Jan_08 Apr_08
Perc
enta
ge
SDNVP only
SDNVP+AZT
HAART
New national ART prophylaxis guidelines implemented
HIV TESTING, ART
PROPHYLAXIS IN MATERNITY
Identifying HIV-infected women and providing prophylaxis to mother and infant in Labor and delivery
Counseling and testing in Maternity 223,412 deliveries at 240 sites,
Jan 07-Jun 008
Known Positive: 10, 769 (6%)
Known Negative: 157,164 (94%)
Not Tested: 17,520 (32%)
Tested: 37,959 (68%) Tested Positive: 2018 (5%)
Maternity results• Many women receive HIV testing in ANC• But for women presenting with unknown status,
counseling and testing coverage approx 70%• Of note:
– Ethiopia: >50% women in maternity need testing– Maternity seroprevalence ranges from
• <1% (RW, TZ, CDI) to 10% (MZ) and 39% (LS)• In general, seroprevalence in maternity is lower
than ANC
Prophylaxis coverage to mothers and infants in Maternity, Jan 07 – Jun 08
Tanzania Ethiopia Lesotho Mz Nigeria Rwanda0
500100015002000250030003500400045005000
HIV+ Maternal ART prophylaxisInfant ART prophylaxis
73%
60%
90%
75%
71%
105%
Infant ART prophylaxis coverage: what is the appropriate denominator?
Number of HIV-exposed infants receiving any prophylaxis N=7,102
# HIV+ women in maternity N=8,706
#HIV+ women in ANCN=10,038
#HIV+ women in ANC AND women testing positive in maternity
N=11,330
82%
71%
63%
% receiving prophylaxis
Type of infant prophylaxis regimen by type, Jan 07-Jun 08
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Ethiopia Lesotho Mozambique Nigeria Rwanda Tanzania
Perc
enta
ge
SDNVP only SDNVP+AZT
Changes in ARV regimen for infant prophylaxis: Ethiopia, Apr 07-Jun 08
0.0
20.0
40.0
60.0
80.0
100.0
120.0
Apr_07 Jul_07 Oct_07 Jan_08 Apr_08
Perc
enta
ge
SDNVP only
SDNVP+AZT
New national ART prophylaxis guidelines implemented
HIV EXPOSED INFANT FOLLOWUP
Cotrimoxazole prophylaxis, PCR and HIV antibody testing
CTX prophylaxis and HIV testing for HIV- exposed infants, 7 countries,
Jan 07-Jun 08 14305
6510
4739
7461347
200 579
0
2000
4000
6000
8000
10000
12000
14000
HIV+ women in
ANC
CTX PCR testing (any age)
PCR testing (6-8 weeks)
HIV antibody testing
Confirmed positive
Confirmed negative
Num
ber o
f HIV
exp
osed
infa
nts
Jan-Mar 07 Apr-Jun 07 Jul-Sept 07 Oct-Dec 07 Jan-Mar 08 Mar-Jun 08 TOTAL0
200
400
600
800
1000
1200
# of HIV exposed infants expected at 6 weeks visit for CPT initia-tion
# of HIV exposed infants that are initiating CPT by 6 weeks of age
# of HIV exposed infants tested with DNA-PCR at 6-weeks of age698
Initiation of Cotrimoxazole Preventive Therapy (CPT) and EID among HIV-exposed infants by 6 weeks of age, ICAP
supported sites (n=23), Rwanda, Jan 07-Jun 08
10541128
Linking mothers and infants
Using paper-based system to evaluate Mother-Infant Pairs at Zimpeto HC, MZ
– Reviewed PMTCT Register, Post Partum Register and CCR Register (no maternity or C&T)
– Sampled 11 women in PMTCT• 7 (63%) mother-infant pairs found in PP and CCR using
PMTCT Code as link across services• 5 of 7 infants were tested using PCR and all had
documented results (100%)
Timing of Mother to Child Transmission
Pregnancy
Labor & Delivery
Breast Feeding
Antenatal clinicCare & Treatment Maternity
Care and Treatment, Exposed Infant follow-up
Mother-Infant Unit
Report cardCD4 and ART initiation: B-/B1. Increase # PMTCT sites offering
CD4 testing2. Aim for >70% HIV+ women
obtaining CD4 where testing available
3. Improve data collection for HAART eligibility and initiation
ART prophylaxis: B+1. Support implementation of
more effective ART regimens in ANC in TZ, ETH, NG at Health Center level.
Counseling and testing: AKeep up the good work!
Care for HIV exposed infants: D+1. Prophylaxis in maternity good2. Improve follow-up of HEI3. Improve data collection and
linkage between infant outcomes and mothers
Next steps• Review and revise current ICAP PMTCT indicators to
simplify reporting and capture new situations• Address missing infant care piece:
– Propose new HIV-exposed infant indicators as a separate reporting module
• In order to evaluate PMTCT efficacy: we need to try new approaches to link mothers and infant outcomes
• How effective is our paper system in tracking mother/infant across health system?
• Improve use/accessibility of PMTCT data at site level– Measuring PMTCT SOCs with URS data
Many thanks to…..
• ICAP-Rwanda– Landry Tseague
Suzue SaitoSteve ShermanDenis NashFatima TsiourisElaine AbramsVictoria NankabimaMaria Lopez