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Objective. To determine whether recent changes in the process of care in PMTCT clinics in central Mozambique have resulted in increased proportions of eligible women starting HAART. Introduction ? Specific Aims. To quantify ?process of care' at PMTCT clinics with varying health systems characteristi
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1. Optimizing Prenatal HAART in Mozambique Research in Progress – March 4, 2009
Christian B. Ramers, MD
ramers@u.washington.edu
2. Objective To determine whether recent changes in the process of care in PMTCT clinics in central Mozambique have resulted in increased proportions of eligible women starting HAART
3. Introduction – Specific Aims To quantify ‘process of care’ at PMTCT clinics with varying health systems characteristics
To describe demographic/clinical characteristics of PMTCT attendees in central Mozambique
To assess the effect of decentralization of HIV/CD4 testing & HAART services on rates of initiation of HAART and on ARV’s for PMTCT among pre-natal clinic attendees in Mozambique
4. Background – What is Operations Research? “Use of systematic research techniques for program decision-making to achieve a specified outcome.”
Population Council, 2006
“How can I make my health program better?”
Mark Micek, MD, MPH 2009
5. Background – What is PMTCT?
6. Background – Leveraging PMTCT Abrams EJ, et al 2007 AJOG; 197(3); S1: S101-S106
7. Background – Mozambique Population – 19.2 million
78% live on < $2/day
Life expectancy 45 yrs
Adult HIV prevalence 12.5%
1.65 million PLWHA
~300,000 eligible for HAART
60% women
150,995 HIV+ births in 2007
8. HAART/PMTCT in Mozambique MOH developed HAART roll-out plan in 2003
HAI, Clinton Foundation, PEPFAR, MSF
7,710 people on HAART in first year (2004)
88,200 people on HAART (April 1, 2008)
83% of women have at least 1 ante-natal visit
35% of HIV+ women received PMTCT drugs
9. Methods – study design Quasi-experimental, retrospective, longitudinal
Step Wedge Time Series
Target population: PMTCT attendees
Subgroups: HIV+, HIV+ HAART-eligible
10. Methods – study design Interventions
Decentralization of ART from larger ‘day hospitals’ to the surrounding PMTCT clinics
Greater availability of CD4 testing at local level
Variables
Independent: pre- vs. post-intervention, clinic, clinical stage, CD4 count
Dependent: % on HAART, % PMTCT drugs, % with timely CD4 testing, % lost to follow-up, %
Denominators: # HIV+ women, # HIV+ HAART eligible women
11. Study Design – Stepped Wedge Time Series Time
Clinic 1 - T1 T2 T3 T4 T5 T6 T7 T8
Clinic 2 - T1 T2 T3 T4 T5 T6 T7 T8
Clinic 3 - T1 T2 T3 T4 T5 T6 T7 T8
Clinic 4 - T1 T2 T3 T4 T5 T6 T7 T8
Clinic 5 - T1 T2 T3 T4 T5 T6 T7 T8
12. Study Design – Stepped Wedge Time Series Time
Clinic 1 - T1 T2 x T3 T4 T5 T6 T7 T8
Clinic 2 - T1 T2 T3 x T4 T5 T6 T7 T8
Clinic 3 - T1 T2 T3 T4 x T5 T6 T7 T8
Clinic 4 - T1 T2 T3 T4 T5 x T6 T7 T8
Clinic 5 - T1 T2 T3 T4 T5 T6 x T7 T8
13. Study Design – Stepped Wedge Time Series Time
Clinic 1 - T1 T2 x T3 T4 T5 T6 T7 T8
Clinic 2 - T1 T2 T3 x T4 T5 T6 T7 T8
Clinic 3 - T1 T2 T3 T4 x T5 T6 T7 T8
Clinic 4 - T1 T2 T3 T4 T5 x T6 T7 T8
Clinic 5 - T1 T2 T3 T4 T5 T6 x T7 T8
17. Methods – data collection Routine data available from PMTCT clinic monthly reports
Clinic-level data (# pts, #HIV+, # on HAART)
Patient-level data (CD4, stage, HAART, sdNVP)
Cross-referenced with lab records
Date range roughly 2006-2008
Entered into Access database (PW protected)
18. Methods – study design Main Outcome: Proportion of HIV+ HAART-eligible women on HAART
20. Methods – Analysis [dummy table] Percentage of eligible women on HAART
21. Methods – Analysis [dummy table] ‘Table 1A’ – HIV + PMTCT Attendees
22. Methods – Analysis [dummy table] ‘Table 1B’ – Site Characteristics
23. Methods – Analysis [dummy table]
24. Limitations Retrospective Quasi-experimental design
Selection Bias
Historical Bias
Limited by ‘real-life’ setting (n = 9, 18)
Many simultaneous process changes – difficult to differentiate CD4 testing from on-site ART
Sample size and power not under my control
Uncertainty regarding data quality
25. Timeline
26. Dissemination & Policy Impact Plan Results are to be communicated directly back to Mozambique MoH officials & HAI staff to inform policy & resource allocation
May identify underperforming clinics
May lead to further ‘case control’ analyses comparing high-performing and low performing clinics
Published manuscript may be applicable to PMTCT clinics in other settings
27. Muito Obrigado!