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IAS 2011, Rome, July 17 to 20

Impact of the National PMTCT Program Measured at Six Weeks Postpartum in South Africa, 2010 Thu-Ha Dinh, MD., MS., US CDC/GAP Ameena Goga, MD., MS., MRC/HSRU, South Africa Debra Jackson, PhD., RN., UWC, MRC/HSRU, South Africa and other co-authors. IAS 2011, Rome, July 17 to 20.

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IAS 2011, Rome, July 17 to 20

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  1. Impact of the National PMTCT Program Measured at Six Weeks Postpartum inSouth Africa, 2010Thu-Ha Dinh, MD., MS., US CDC/GAP Ameena Goga, MD., MS., MRC/HSRU, South Africa Debra Jackson, PhD., RN., UWC, MRC/HSRU, South Africaand other co-authors IAS 2011, Rome, July 17 to 20

  2. Overview of Presentation • Background • Objectives • Methods • Findings • Conclusions

  3. Background • Live-birth: 1 mil/yrs • 1st immunization (DPT) at 6 weeks • Coverage >98% in 2010 • Antenatal HIV prevalence: 29% (range: 17-40) • National PMTCT started in 2002 • 2010: • PMTCT at > 98% of facilities • Decentralized ARV provision, nurse initiates ARV

  4. Background: PMTCT guidelines 2008: • Mothers: • CD4 > 200  AZT from 28 wks + sd NVP in labour • CD4< 200  ART/HAART • Infant: sd NVP + AZT (7 - 28 days) • DNA PCR at 4-6 weeks of age - 1st immunization 2010: • Mothers • CD4 > 350  AZT from 14 wks + sd NVP + TDF/FTC in labour • CD4< 350  ART/HAART • Infant: NVP throughout breastfeeding 2008 – present: DNA PCR at 4-6 weeks of age at the 1st immunization

  5. Objectives Primary objectives • To estimate national and provincial perinatal MTCT rates in 2009 and early 2010 • To identify associated factors with the MTCT Secondary questions • To estimate number of HIV acquisition during pregnancy (poster # MOPE300; Mon 12.30 – 14:30) • To describe and identify re PMTCT missed opportunities – PMTCT cascade (poster # TUPE285 , Tue 12:20-14:30)

  6. Methods • A cross-sectional facility-based survey • Sampling: Multi stage, PPS and systematic sampling methods  national and provincial estimates • 565 facilities in all 9 provinces (range, 34-78/province) • A total of 9915 eligible caregiver-infant pairs enrolled • Data collection: Using cell-phone technology  real time data collection (interview) • Duration: Data collection: Jun 2010 to Dec 2010  establish a baseline to measure impact of Option A in South Africa (SA 2010 guidelines)

  7. Methods: Laboratory • HIV Exposed Infants identified using biomedical marker • ELISA test (Genscreen HIV antibody assay) for Infant HIV Exposure •  HIV ELISA test positive  HIV DNA PCR • Automated Ampliprep/Taqman v2.0 technology (Roche) • All HIV tests were done at NHLS HIV ELISA test

  8. Findings • Weighted for population live-birth in 2008 • Survey analysis using SAS 9.2

  9. Survey Profile Caregiver-infants - 4-8 wk old infant attending 1st DPT (10 820) • Refused to participate, 84 (0.8%) • No or insufficient infant-DBS 821 (7.6%) Caregiver-infants interviewed & infant-DBS* (9915, 92%) HIV not exposed, 6912 (69.7%) HIV exposed (3003; 30.3%) No PCR test result, 35 (1.2%) • Inclusion: 4-8 week old attending clinic for 6wk immunization • Exclusion: Severely ill infants needing emergency care HIV exposed infants with PCR test result (2958; 98.5%)

  10. Mother’s characteristics by HIV-exposure status

  11. Weighted perinatal MTCT Rate

  12. Factors associated with perinatal MTCT

  13. Limitations • Selection bias • Representative population attending primary health care • Excluded sick infants needing emergency care • Potential recall bias  bias associated factors • Sample realization in 3 provinces <75%  estimates were not stable in that 3 provinces (NC, EC and LP)

  14. Conclusions • Nationally, the perinatal MTCT rate was < 4% in South Africa • C-section and having birth attendant as a doctor may not be optimal options to reduce MTCT • Mixed feeding is a strong indicator to increase MTCT in this population • No breast-milk feeding to exposed infants (62%) can reduce MTCT but will increase mortality • HIV test uptake in infant was high (92%) if offered to all infants at routine immunisation services “The findings and conclusions on this report are those of the authors and do not necessarily present the official position of the US Centers for Disease Control and Prevention”

  15. Provincial Departments of Health • University of the Western Cape: • WondwossenLerebo • UNICEF (SA): • Siobhan Crowley • CDC: • Katherine Robinson • Jeff Klausner • Thurma Goldman • Infant Diagnosis: • Gayle Sherman • Adrian Puren • Technical Advisors: • Mickey Chopra (UNICEF) • Nathan Shaffer (WHO) Caregiver-infant pairs Acknowledgements Nurse Data collectors Routine health workers Medical Research Council: Carl Lombard (Statistician) Selamawit Woldesenbet Wesley Solomon Vundli Ramokolo Nothemba Kula Tanya Doherty National Department of Health: Yogan Pillay, Nonhlanhla Dlamini Thabang Mosala

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