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PMTCT program in Arua Uganda

PMTCT program in Arua Uganda. Lessons learned after 5 years of experience. Experts Roundtable 23-24 June 2008 Geneva . Arua PMTCT program (1). Started in January 2000 1 st ante-natal visit : HIV voluntary counselling & testing HIV+ enrolled in PMTCT program. Arua PMTCT program (2).

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PMTCT program in Arua Uganda

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  1. PMTCT program in Arua Uganda Lessons learned after 5 years of experience Experts Roundtable 23-24 June 2008 Geneva

  2. Arua PMTCT program (1) • Started in January 2000 • 1st ante-natal visit : HIV voluntary counselling & testing • HIV+ enrolled in PMTCT program

  3. Arua PMTCT program (2) • National PMTCT protocol (2000 to 2005) • Mother : NVP at labour onset • Infant : AZT (1 wk) or NVP (<72 h) • Follow-up • Cotri prophylaxis + feeding education • Infant formula (up to June 2004)

  4. Pregnant women in ANC n=30 536 HIV-test refused  Routine ANC n=3 088 (14%) Pre-test counseling n=22 105 (72%) HIV-tested n=19 017 (62%) HIV– n=17 980 (95%) HIV + n=1 037 (5%) Routine ANC n=520 (50.2%) PMTCT n=517 (49.8%) Arua PMTCT program (2) • National PMTCT protocol (2000 to 2005) • Mother : AZT from 36 wk or NVP at labour onset or ART • Infant : AZT (1 wk) or NVP (<72 h) • Follow-up • Cotri prophylaxis + feeding education • Infant formula (up to June 2004)

  5. Objectives Evaluate the performance of the PMTCT program of Arua by: • Describing characteristics of mothers & infants • Quantifying and describing reasons for loss to follow-up (LTFU) • Estimating HIV transmission

  6. Methods (1) • Retrospective cohort analysis • Inclusion: Women enrolled in PMTCT between July 2000-July 2005 • Description of infant outcomes • Active tracing of LTFU • Cross-sectional survey • Interview of caregivers (reasons for LFU) • Clinical examination and HIV testing for infants

  7. Methods (2) • Survival Analyses(Kaplan-Meier) • HIV transmission • HIV testing for children alive • HIV-related deaths*: • severe infection or persistent diarrhoea AND • > 1 HIV-related symptom at last MCH visit • Risk factors for HIV-transmission(multiple logistic regression) • * Ghent Int. Working Group on MTCT of HIV

  8. Results: PMTCT Program (July 2000 – July 2005) • Enrolled: • Mothers (N=517) • Infants (N=567) Infant outcomes (n=567)

  9. Results: PMTCT Program (July 2000 – July 2005) • Enrolled: • Mothers (N=517) • Infants (N=567) • Cross-sectional survey • Mothers(N= 327, 63%) • Infants(N= 368, 65%) Infant outcomes (n=567)

  10. Maternal characteristics at PMTCT enrolment (N=327) Median age (yr) [IQR] 28 [25-32] 4 (1) 72 (22) 233 (71) 18 (6) Trimester of pregnancy(%) First Second Third At/after birth WHO stage (%) Asymptomatic Stage I/II Stage III Stage IV 5 (2) 164 (50) 144 (44) 13 (4) Median CD4+ cells/ml; n=201 [IQR] 368 [200 -535] On ART 32 (10)

  11. Newborn characteristics (N=368)

  12. Follow-up characteristics of infants (N=368)

  13. HIV transmission • 8.3% (24 / 288) of children were HIV+ • Overall transmission = 15.5% (57 / 367)

  14. Mother Child Risk factors for MTC HIV transmission* *Among children tested for HIV (n=288)

  15. Infant survival • 33 / 72 deaths were HIV-related • Most frequent causes of death • Acute or chronic diarrhoea (34.7%) • Respiratory tract infections (20.8%) 0.81 (95% 0.77 – 0.85)

  16. Mother/baby pair LTFU • Median time at LTFU was 1 month (IQR : 0 – 5) • Reasons for LFU(n=197) • 30% mothers' ignorance of the importance of FU • 27 % infant death • 13 % discouraged by the partner • 12 % address change

  17. Discussion (1) Mothers • 40% women refused to be tested • Among the HIV +, 50% refused to be enrolled in the PMTCT • Among the enrolled women , 50% drop out • First visit in third trimester of pregnancy • 50% accessed ANC in earlier HIV disease • 21% home delivery

  18. Discussion (2) Infants • 18% did not receive PMTCT prophylaxis • HIV transmission rate reduced from 35% to 15.5% Mother/baby pairs LTFU • 53% LTFU before tracing • Main reasons for LTFU = mother’s ignorance of importance of FU & infant death BUT 30% of pairs untraced

  19. Recommendations • Improve the message delivered to mothers at enrolment • Increase resources for PMTCT (HR, logistics…) • Reconsider Feeding strategy • Early diagnosis and treatment for children

  20. Acknowledgments • Ugandan Ministry of Health in Arua and Kampala • MSF team in Arua and Kampala • Epicentre in Kampala and Paris • CDC laboratory in Entebbe (Ugandan Virus Institute)

  21. ARUA REFFERAL REGIONAL HOSPITAL PMTCT From May 2007 to end of February 2008

  22. Organigram Flow of patient ANC VCT HIV clinic Women became pregnant Mother 1year after delivery Child+ after 1 year PMTCT AN +HIV f/up Mother and child f/up until 1 year Home delivery Maternity ward Labour suite

  23. Treatment protocol

  24. Data from ANCfrom May 2007 to end of February 2008 • 63% women accept to be tested • 75% of mother tested HIV+ are enrolled in PMTCT • HIV prevalence at ANC is 4 % during the period

  25. Mothers enrolled in PMTCT May 2007 to End of February 2008 (1)

  26. Mothers enrolled in PMTCT May 2007 to End of February 2008 (2) • Median CD4 : 448 /mm3 85%

  27. Mothers enrolled in PMTCT May 2007 to End of February 2008 (3) • 8% are lost to follow-up • 40% are on ARVs (10% in 2000-2005) • 62% of the mothers enrolled in PMTCT are coming from HIV clinic

  28. Prophylaxis and treatment (1) 73% 57%

  29. Prophylaxis and treatment (2)

  30. Location of delivery May 2007 to End of February 2008

  31. Feeding Option PMTCT May 2007 to End of February 2008

  32. Outcome of children • Will need to wait 2009 regional meeting…. Thanks

  33. WHO stage & CD4 at PMTCT enrolment

  34. Maternal characteristics at follow-up (N=327) • Partner/family aware of HIV status : 297 (90.8%) • Partner aware of PMTCT enrolment : 242 (74.0%) • Participation in PMTCT • No problems : 279 (85.3%) • Separation/divorce : 22 (6.7%) • No male involvement/conflict : 15 (4.6%) • Family stigma/conflict : 9 (2.8%) • Other : 2 (0.6%)

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