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Rosalind Carter, PhD Epidemiologist, PMTCT, Pediatrics and MTCT Plus Initiative Program

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

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Rosalind Carter, PhD Epidemiologist, PMTCT, Pediatrics and MTCT Plus Initiative Program

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  1. 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

  2. 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

  3. Timing of Mother to Child Transmission Care and Treatment, Exposed Infant follow-up Antenatal clinic Care & Treatment Maternity Pregnancy Labor & Delivery Breast Feeding

  4. PMTCT Model of Care Counseling 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

  5. ICAP approach Use pregnancy as the entry point to engage women and their families in life long care

  6. #known positive #tested/positive #mothers receive ART #infants receive ART # women tested/positive # documented CD4 # receive Sd-NVP # receive AZT + Sd-NVP #partners tested #eligible who initiate HAART #enrolled in comprehensive care and treatment #initiating cotrimoxazole #PCR tested #confirmed HIV diagnosis

  7. 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

  8. M&E: Focus on populations Clinical: Focus on patient

  9. Cumulative enrollment in ICAP-supported PMTCT programs (n=378 sites) in 7 countries Number of patients 248,742 1st ANC visits Mozambique, Ethiopia, Rwanda, Nigeria, Tanzania Number of facilities 217,890 counseled, tested and received results Lesotho Cote d’Ivoire *Tanzania data not included; cannot distinguish 1st ANC from followup visits

  10. Seroprevalence in 7 ICAP countries Apr -Jun 08

  11. Identification of HIV-infected women in Antenatal Care Clinics Counseling and HIV rapid testing

  12. Use of group pre-test counseling and provider-initiated approach improved the proportion of women receiving HIV testing at first ANC visit

  13. Pregnant women counseled, tested and received ART prophylaxis in ICAP-supported PMTCT programs, January 2007 – June 2008 248,742 239,193 (96%) 217,184 (87%) 14,317 (7%) 11,433(75%) TZ data not included because they cannot distinguish 1st visit and followup visits to ANC

  14. 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%

  15. Clinical evaluation of HIV-infected women in ANC CD4 testing

  16. 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

  17. Proportion of HIV+ women with documented CD4 testing by country (n=5102 at 161 sites), mean vs. most recent quarter

  18. 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

  19. Among women receiving CD4 testing, who is eligible for HAART and do they initiate treatment during pregnancy? HAART eligibility and initiation

  20. 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?

  21. Jose Macamo Model Center Mozambique Hired PMTCT counselor to work in ART clinic

  22. Providing ART prophylaxis to mothers before delivery art prophylaxis in ANC

  23. Proportion of HIV+ women receiving ART prophylaxis in ANC by country, Jan 07 - Jun 08 n=1052 n=6659 n=4634 n=1207 n=415 n=96 n=3414 Mean: 75%

  24. ART regimen among HIV+ women who received ART prophylaxis at ANC, Jan 07 – Jun 08 n=11433 n=921 n=5657 n=3405 n=993 n=412 n=45 n=1674

  25. Changes in ARV regimen over time for Maternal prophylaxis: Ethiopia, Jan 07-Jun 08 New national ART prophylaxis guidelines implemented

  26. Identifying HIV-infected women and providing prophylaxis to mother and infant in Labor and delivery HIV testing, art prophylaxis in maternity

  27. Counseling and testing in Maternity 223,412 deliveries at 240 sites, Jan 07-Jun 008 Not Tested: 17,520 (32%) Tested: 37,959 (68%) Tested Positive: 2018 (5%) Known Positive: 10, 769 (6%) Known Negative: 157,164 (94%)

  28. 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

  29. Prophylaxis coverage to mothers and infants in Maternity, Jan 07 – Jun 08

  30. Number of HIV-exposed infants receiving any prophylaxis N=7,102 # HIV+ women in maternity N=8,706 82% #HIV+ women in ANC N=10,038 #HIV+ women in ANC AND women testing positive in maternity N=11,330 71% 63% Infant ART prophylaxis coverage: what is the appropriate denominator? % receiving prophylaxis

  31. Type of infant prophylaxis regimen by type, Jan 07-Jun 08

  32. Changes in ARV regimen for infant prophylaxis: Ethiopia, Apr 07-Jun 08 New national ART prophylaxis guidelines implemented

  33. Cotrimoxazole prophylaxis, PCR and HIV antibody testing HIV exposed infant followup

  34. CTX prophylaxis and HIV testing for HIV- exposed infants, 7 countries, Jan 07-Jun 08

  35. 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 1128 1054

  36. Linking mothers and infants

  37. 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%)

  38. Timing of Mother to Child Transmission Care and Treatment, Exposed Infant follow-up Antenatal clinic Care & Treatment Maternity Pregnancy Labor & Delivery Breast Feeding Mother-Infant Unit

  39. Report card CD4 and ART initiation: B-/B • Increase # PMTCT sites offering CD4 testing • Aim for >70% HIV+ women obtaining CD4 where testing available • 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. Care for HIV exposed infants: D+ • Prophylaxis in maternity good • Improve follow-up of HEI • Improve data collection and linkage between infant outcomes and mothers Counseling and testing: A Keep up the good work!

  40. 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

  41. ICAP-Rwanda Landry Tseague Suzue Saito Steve Sherman Denis Nash Fatima Tsiouris Elaine Abrams Victoria Nankabima Maria Lopez Many thanks to…..

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