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 evaluation

Provide 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

of p

atie

nts

Num

ber 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

Nu

mb

er o

f wo

me

n 1st ANC

Counseled

Tested

HIV positive

ART 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

Pe

rce

nta

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

500

1000

1500

2000

2500

3000

3500

4000

4500

5000

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

Pe

rce

nta

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

Nu

mb

er

of

HIV

ex

po

se

d in

fan

ts

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 age

698

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 testing

2. 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 good

2. Improve follow-up of HEI

3. 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 Saito

Steve Sherman

Denis Nash

Fatima Tsiouris

Elaine Abrams

Victoria Nankabima

Maria Lopez