Transcript Monitoring and Evaluation Results Pyramid

What happens to the babies? Factors
associated with PMTCT outcomes among a
community sample of HIV-exposed infants
from Zimbabwe
Frances M Cowan, Raluca Buzdugan, Sandra I McCoy,
Tyler E Martz, Constancia Watadzaushe, Jeffrey Dirawo,
Angela Mushavi, Agnes Mahomva, Nancy S Padian
PMTCT in Zimbabwe
• Overall Goal: Virtual
elimination of
paediatric HIV
• Follow-up and care
of HIV-exposed
infants is critical to
– prevent new HIV
infection (HIV-free
survival)
– decrease mortality
and morbidity in HIVexposed infants
IAS Poster MOPE113
The magnitude of loss to follow-up of HIV-exposed infants
along the PMTCT continuum of care: a systematic
literature review and meta-analysis
E.L. Sibanda1,2 , I.V.D Weller2, J.G. Hakim3, F.M. Cowan1,2
1 Zimbabwe AIDS Prevention Project-University of Zimbabwe, Harare, Zimbabwe
2 University College London, London, United Kingdom
3 Department of Medicine, University of Zimbabwe College of Health Sciences
Contact: Euphemia Sibanda; [email protected]
Introduction
Although Prevention of Mother to Child
Transmission (PMTCT) programs have been widely
implemented there is concern that many children do
not benefit from them because of loss to follow-up
(LTFU). We conducted a systematic review to
determine the magnitude of infant/baby LTFU at
each step in the PMTCT cascade.
Methods
Publications were eligible if they met the following
criteria:
• Reports from real-life PMTCT programs i.e. not
intervention or research studies
• Reporting on LTFU of HIV exposed infants at
any point along the PMTCT cascade
Literature searches were conducted in Medline,
Embase, Web of Knowledge, CINAHL Plus, and
Maternity and Infant Care on 06 August 2012.
Data were extracted in duplicate. Extracted data
included setting, methods of follow-up, PMTCT
regimens and proportion and timing of LTFU.
LTFU of infants by age three months
Fifteen studies reported on LTFU of infants soon
after delivery; the infants typically did not return to
the health care centre for HIV testing at six weeks,
fig 2.
LTFU of infants by age 3 months
Author
Country
% LTFU (95% CI)
Azcoaga-Lorenzo 2011
Kenya
19.30 (16.50, 22.09)
Black 2008
South Africa
38.74 (34.44, 43.04)
Ciampa 2011
Mozambique
74.40 (69.70, 79.09)
Cook 2011
Mozambique
75.17 (71.15, 79.19)
Ferguson 2011
Ireland
4.15 (2.89, 5.41)
Geddes 2011
South Africa
18.31 (15.44, 21.18)
Ginsburg 2007
Many
91.15 (90.97, 91.32)
Lussiana 2012
Angola
19.27 (14.03, 24.50)
Manzi 2005
Malawi
4.85 (1.92, 7.79)
Mirkuzie 2011
Ethiopia
47.96 (41.38, 54.55)
Moses 2008
Malawi
65.51 (63.85, 67.16)
Namukwaya 2011
Uganda
50.80 (49.39, 52.21)
Nlend 2012
Cameroon
17.55 (14.47, 20.62)
Panditrao 2011
India
19.61 (16.81, 22.41)
Sam 2003
United Kingdom
25.96 (17.54, 34.39)
Overall (I-squared = 99.7%, p = 0.000)
29.65 (23.89, 36.80)
with estimated predictive interval
.
1
10
20
40
100
(11.79, 74.55)
Simulation of cumulative LTFU of
exposed infants - SSA
100
90
80
70
60
50
40
30
20
10
HIV positive women at Infants delivered at Infants tested for HIV Infants remaining in
ANC registration
facility
(EID)
follow-up after HIV
testing
Impact Evaluation
• Impact evaluation of Zimbabwe MoHCW’s
accelerated PMTCT program (WHO Option A)
• External evaluators: University of California
Berkeley, CeSHHAR Zimbabwe and University
College London
• Funding: Children’s Investment Fund
Foundation
Impact Evaluation Design
• Serial cross-sectional community-based
surveys in 157 health facilities
• Pre-post design with the facility
catchment area as unit of analysis
– Baseline – 2012; endline – 2014/5
• Primary outcomes: MTCT rate & HIVfree infant survival at 9-18 months
Methods I
• Cross-sectional data from baseline survey of
the impact evaluation of Zimbabwe’s
accelerated implementation of the 2010 WHO
PMTCT guidelines
• The accelerated program was initiated in 2011
by the Zimbabwe Ministry of Health and Child
Welfare (MOHCW) with the Elizabeth Glaser
Pediatric AIDS Foundation (EGPAF).
Survey Sample
Random sample of women living in
catchment areas of 157 randomly
selected health facilities offering
PMTCT services in:
1. Mashonaland West
2. Mashonaland Central
3. Harare
4. Matabeleland South
5. Manicaland
1
2
3
5
4
Methods II
• Eligible women were ≥16 years old and biological
mothers of infants (alive or deceased) born 9-18
months prior.
• Participants were interviewed about health service
utilization during pregnancy and HIV status and
had DBs taken for HIV testing.
• Here we use self-reported HIV status and service
uptake.
• Factors associated with reported infant ARV
prophylaxis and infant HIV testing respectively
were examined.
IAS Poster TUPE424
Baseline Enrolment
• 9087 mother-infant pairs (98.9% of those
eligible) from 157 facility catchment areas
• 9019 alive infants (99.3%)
• 997 (11.5%) mothers reported positive HIV
status before or during delivery
• 16 HIV-exposed babies (1.6%) were deceased
• Average infant age:
– All infants: 412 days
– HIV-exposed infants: 407 days
[IAS Poster TUPE425]
Results: Maternal PMTCT Cascade:
All women (n=8662)
HIV-positive women (n=997)
100%
9000
1200
94%
8000
100%
92%
1000
77%
7000
No. women
92%
67%
6000
5000
800
600
4000
400
3000
12%
2000
200
1000
0
0
Total
≥1 ANC
visit
Tested or Received Institutional
HIV
knew HIV+ results or
delivery
positive,
knew HIV+
ANC or
L&D
Total HIV+
Maternal
ARV or
ART
Step in the PMTCT Cascade
No. HIV positive women
10000
Results: Uptake of postnatal services
100
90
80
70
60
50
40
30
20
10
0
94
96
98
98
80
66
Not tested
Negative
Positive
Attended postnatal visit
Immunization visit
Results: Uptake of Infant PMTCT Services
(997 biological mothers who self-reported HIV positive status)
683
[66%]
[62%]*
610
[58%]
516
[52%
(85%)]
33
[3.3%
(6.4%)]
Infant ARV
Infant CTX
prophylaxis at prophylaxis
delivery
Infant HIV
tested
28
[2.8%
(86%)]
Received HIV HIV positive Infant on ART
results
infant
* Among mothers who delivered at health facilities
Which infants received ARV prophylaxis?
Maternal
characteristics
Before
pregnancy
During
pregnancy
Mother received ARV prophylaxis
Infant delivered at home
Mother visited health facility for
herself (last year)
Mother found out
she is HIV+…
PR
95% CI
p
value
1.00
1.16 1.07 1.26 <0.001
4.29 2.99 6.15 <0.001
0.52 0.42 0.64 <0.001
1.17 1.06 1.30 0.003
Note: Poisson regression (n=981), outcome: infant ARV prophylaxis;
controlling for education and marital status; PR=prevalence ratio
Which infants were HIV tested?
Maternal & infant characteristics
No ARVs
Maternal ARVs
only
Infant ARVs only
Both maternal &
infant ARVs
Mother visited health facility for
herself (last year)
Infant was hospitalized
Mother/ infant on
ARV prophylaxis
PR
95% CI
1.00
p
value
<0.001
5.86
6.29
3.80 9.02
3.93 10.06
7.11
4.54 11.14
1.17
1.13
1.05 1.30 0.006
1.02 1.26 0.024
Note: Poisson regression (n=995), outcome: infant HIV testing; controlling for
age and whether living with mother in law; PR=prevalence ratio
Limitations
• Data are cross-sectional
• Uptake of health services is based on self
reports
• HIV status during ANC and at delivery was
based on self-report
• Data are not representative of all regions
in Zimbabwe.
Conclusions
• High rates of attrition at key stages along the
cascade of services for HIV-exposed infants
• Strong association between maternal & infant
ARV prophylaxis
• Strong association between ARV prophylaxis &
infant HIV testing
• Cost effective interventions to reduce LTFU
required
Other IAS Posters/ Presentations
based on this study
• Food insecurity – barrier to PMTCT service uptake
– Presentation MOAD0204
• Feasibility of population-based cross-sectional
surveys for estimating vertical HIV transmission: data
from Zimbabwe – Poster -TUPE424
• Uptake of Prevention of Mother-to-Child HIV
Transmission (PMTCT) Services Among Women
With a Recent Birth in Zimbabwe – Poster TUPE425
• Role of fees in the demand for PMTCT services Poster WEPE631
Acknowledgements
Ministry of Health and Child
Welfare
UC Berkeley
EGPAF Zimbabwe
CeSHHAR Zimbabwe
• Survey team
• Reuben Musarandega
The Children’s Investment Fund
Foundation (CIFF) funded the
baseline impact evaluation survey.
• Maya Petersen