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ADD LOGO TRACPLUS and MOH

HIV-free survival at 9-24 months among children born to HIV infected mothers in the National Program for the prevention of mother-to-child transmission of HIV in Rwanda: a household survey.

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ADD LOGO TRACPLUS and MOH

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  1. HIV-free survival at 9-24 months among children born to HIV infected mothers in theNational Program for the prevention of mother-to-child transmission of HIV inRwanda: a household survey N. Shema1, L. Tsague2, J.D.D. Bizimana3, P. Mugwaneza1, A. Lyambabaje3, E. Munyana2, J. Condo3, J.C. Uwimbabazi4, E. Rugigana3, J. Muita2 1- TRACPlus/Ministry of Health; Kigali, Rwanda; 2- UNICEF – Rwanda; 3- National University of Rwanda, School of Public Health; 4 - National Reference Laboratory ; Kigali, Rwanda REPUBLIC OF RWANDA ADD LOGO TRACPLUS and MOH MINISTRY OF HEALTH

  2. Maternal and Child Heath Indicators, Rwanda, (DHS 2005, Mini DHS 2008) • Fertility rate • 6.1→ 5.5 children per woman • At least 1 ANC visit uptake • 94% → 96% • Delivery assisted by trained health care worker • 24% → 63% • Immunization coverage in children • 94.8% for DPT1 ( DHS 2008)

  3. Rwandan National PMTCT program Millestones (1999-2009) 2005-2006 2007– 2008 1999 - 2000 2001 2002-2004 4. - More Efficacious ARV regimens and early infant diagnostic using DBS-PCR introduced; - PMTCT and ART program Scale-up (GF, PEPFAR) • 6. – Transition to MER-ARV; • Impact study of national PMTCT program • Adaptation of 2009 WHO ARV recommendations for PMTCT 2. TRAC defines National PMTCT program based on Sd-NVP regimen 2009– • 5 – Initial expansio of early infant HIV diagnostic (DBS-PCR) • Expansion of More Ef-ARV • PMTCT Acceptability study 3. Initial sites expansion (GF, MAP) 1. PMTCT pilot project (Kicukiro)

  4. Package of services for Mother-infant pair in the PMTCT program, Rwanda, 2009 HIV+ pregnant women HIV exposed infants • Routine opt-out counseling and HIV testing (Promotion of couple counseling and testing) • Laboratory investigation: FBC, CD4 count , routine pregnancy check-up, liver function • Routine pregnancy medications: Malaria prevention (Bed nets), anemia prevention (Iron/Folic acid), etc.. • ARV prophylaxis • HAART for women eligible • Bi-prophylaxis (AZT+SdNVP; Tail AZT/3TC) • Sd-NVP ; Tail AZT/3TC (discordant couple, labor room CT) • Safe practices delivery • Infant feeding counseling and support • Family planning services • Psychosocial and adherence support • Post-exposure ARV prophylaxis • Sd-NVP + AZT (4 weeks) • Drug package (CTX prophylaxis) • CTX starts at 6 weeks • Clinical monitoring • Growth monitoring • Symptoms of early HIV infection • Early Infant diagnostic (DBS-PCR) • DNA-PCR • PCR1: at 6 weeks • PCR2: 6 weeks before end of BF • Serology • 9 months (1rst) • 18 months (2nd)

  5. Study Objectives • Evaluate the effectiveness of the national PMTCT program in Rwanda 8 years after its inception. • The outcome variables were: • Prevalence of HIV infection among 9-24 month old exposed children • Risk of dying by 9 months among HIV exposed children • HIV-free survival at 9 months

  6. Methods (1) • Design:Cross-sectional household survey between February - May 2009 • Population: HIV+ and HIV- mothers who were expecting a child between March 2007 and June 2008 and have used antenatal services in Rwanda and their 9-24-month-old children. • Sampling strategy: Two-stage cluster sampling (Health facilities; pregnant women in ANC) • Ethical considerations: Study protocol was approved by the Rwanda National Ethics Committee and the National Institute of Statistics. • Statistical analysis: Quantitative data was analyzed in Stata 10.1.

  7. Results

  8. Socio-demographic characteristics of the respondents by HIV status

  9. Socio-demographic characteristics of the respondents by HIV status

  10. Among HIV+ mothers, having completed at least four ANC visit is associated with delivering at the health centers

  11. 24 months Child survival by maternal HIV status, Rwanda National PMTCT program , 2009 • Kaplan-Meier survival analysis shows that children whose mothers are HIV negative are more likely to survive longer than children born to HIV+ mothers (p<0.001). • Between 0-6 months, child survival is comparable. • Note that survival deteriorates between 6-18 months among children born to HIV positive mothers.

  12. 24 months Child survival by maternal ANC visits, Rwanda National PMTCT program , 2009 • Kaplan-Meier survival analysis shows that children whose mothers attended less than 4 ANC visits had poorer survival than children whose mothers attended more ANC visits (p=0.02). • This factor seems to be associated to early child mortality (0-6 months). • Survival deteriorates further between 6-18 months among children born to HIV positive mothers.

  13. 9-24 month HIV-free survival in National PMTCT program, Rwanda, 2009 • 2.75% exposed children died by the age of 9 months • 3.96% among the 1340 exposed children alive were HIV infected. • HIV-free survival was estimated at 93.26 %( 95%CI: 92.05%-94.47%) at 9-24 months • The risk of death in children born to HIV+ mothers is 3.5 times higher as compared to children born to HIV- mothers (aHR: 3.51, 95% CI: 1.73-7.10) independently of child HIV status.

  14. Multivariate analysis of determinants of HIV infection or death among HIV exposed children, National PMTCT program, Rwanda, 2009 • Children whose mothers received highly active antiretroviral therapy (HAART) were 50% less likely to be infected by HIV and/or died compared to children whose mothers did not receive any ARV during pregnancy (adjusted Odd Ratio (aOR): 0.49, 95%CI:0.28-0.86). • Being a member of an association of people living with HIV (PLWH) (aOR=0.61, 95%CI: 0.39-94) was also associated with a 39% reduced likelihood of HIV infection or death in children.

  15. Conclusions • HIV free-survival among HIV exposed children is high (93.3%) by 9-24 months in Rwanda, • However, survival among children born to HIV infected mothers decreases overtime as compared to the one of children born to HIV- mothers. Survival deteriorates further after 6 months of age among HIV exposed infants. • The risk of death in children born to HIV+ mothers is 3.5 times as higher as in children born to HIV- mothers (aHR: 3.51, 95% CI: 1.73-7.10) independently of child HIV status. • The key determinants of HIV free-survival in the national PMTCT program include maternal initiation of highly active antiretroviral therapy (HAART) during pregnancy (adjusted Odd Ratio (aOR): 0.49, 95%CI:0.28-0.86) and being a member of an association of people living with HIV (PLWH) (aOR=0.61, 95%CI: 0.39-94).

  16. Acknowledgments LABORATOIRE NATIONAL DE REFERENCE NATIONAL REFERENCE LABORATORY School of Public Health • All mothers and family who participated in the study • All staff from the selected sites • Staff at the National Reference Laboratory • All HIV&AIDS implementing partners • National University of Rwanda School of Public Health • UNICEF for technical and financial support

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