1. International Guidance on Methods to Measure PMTCT Impact Chika Hayashi Strategic Information, HIV Department WHO

2. Towards the Elimination of New Paediatric HIV Infection among Children by 2015 and Keeping Their Mothers Alive, Global Plan 2011-2015 Launched June 2011 2015 Targets in the Global Plan: 90% reduction in new child HIV infections 50% reduction in HIV-related maternal deaths <5% MTCT (final transmission) Other targets for all 4 prongs of PMTCT E-MTCT Targets

3. Where are we with MTCT? 2005 2010 2015: MTCT<5% UNGASS 33% 27% Modelled

4. How should we measure progress in achieving E-MTCT ? ~Global and National Level~ Outcomes of Interest and Definition Methods Baseline and Measurement Frequency Plan from now to 2015

5. Goal is to Assess Population-Level Outcome Outcomes of interest: MTCT at different timepoints, new child HIV- infection, HIV-free survival, survival Directly ascertain outcome. Some loss-to-follow-up is inevitable and thus need to couple with assumptions on outcomes in population not captured.

6. Short Guide: Methods to Measure PMTCT Impact Modelling (and better data for it) Immunization Clinic Survey and Follow-Up Population-based surveys Cohort/Follow-up Data Analysis of EID Data For each approach (3-5pages): 1. Brief description of method 2. Questions it can answer 3. Suitable setting 4. Pros and cons 5. Steps and Tips 6. Budgeting for It Generic Protocol for Each Approach outlines what needs to be done step-by-step, with key country decision options for steps that should be adapted to the country context.

7. Summary of Methods MethodDescriptionPros & Cons Modelling ●Estimation of population MTCT and new paediatric HIV infections, based on PMTCT ARV coverage and transmission assumptions. Other outcomes (e.g. deaths) can be modelled too. ●Transmission rates for Option A/B updated in 2011 Spectrum. Pros:Easy to implement Cons: Quality of input data and asumptions. ARV data input not necessarily accurate reflection of adherence. Transmission assumptions based on clinical trials. Immuniza -tion Clinic Survey ●Cross-sectional facility-based survey testing for HIV exposure and infection in infants attending DPT1 visit around 6 weeks. PMTCT intervention uptake history linked with transmission outcome. ●Can be an entry point to FU study of identified HIV-exposed child for later/final outcomes. Pros: Captures infants with unknown HIV exposure status. Cons: Bias from immunization seeking behaviour. Survival bias.

8. MethodDescriptionPros & Cons Cohort/ Follow-Up Data ●Intensive cohort follow-up; retrospective data linking, extraction and tracing. ●Significant attrition is the reality in many settings so need to make assumptions for those not captured in data. Pros: Ideal to get full picture. Cons: Loss to follow-up is inevitable. Hawthorne effect. Resource intensive. Population- based surveys ●Population-based household survey that includes HIV testing in children (and mothers). Provides survival and HIV status among all children born in a defined time period. ●Can collect intervention uptake and other data at the same time. Pros: Captures child deaths. Nationally representative. Cons: Large sample size required and only practical in very high prevalence countries. Expensive. Analysis of EID and Testing Data ●Analyze routinely collected EID data for positivity rate. ●Need to be coupled with estimating number/% of children with no HIV test and their outcomes, to get a national estimate. Pros: EID lab database usually exists. Cons: Unless PITC in all children, EID data is not representative. Bias from health seeking behaviour. Survival bias. EID alone does not address final transmission. Triangulate multiple methods for validation

9. Next Steps One national M&E system M&E Working Group of IATT PMTCT and other experts. Short guide finalized over the next month to be available for COP and GF-R11. We welcome your input! Generic protocols underway, finalize with experts and field-experience Field-test multiple methods in a few countries Collective effort to scale-up PMTCT impact evaluations PMTCT Impact Assessment Guide