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 ICAP PMTCT model of care (MOC) M & E indicators and data collection Overview of PMTCT program in 7 countries Results Summary Next steps

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

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

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

Maternity HIV Care and Treatment Exposed infant followup ANC # women tested/positive # documented CD4 # receive Sd-NVP # receive AZT + Sd-NVP #partners tested #known positive #tested/positive #mothers receive ART #infants receive ART #eligible who initiate HAART #enrolled in comprehensive care and treatment #initiating cotrimoxazole #PCR tested #confirmed HIV diagnosis

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

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

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

Seroprevalence in 7 ICAP countries Apr -Jun 08

COUNSELING AND HIV RAPID TESTING Identification of HIV-infected women in Antenatal Care Clinics

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

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

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%

CD4 TESTING Clinical evaluation of HIV-infected women in ANC

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

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

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

HAART ELIGIBILITY AND INITIATION Among women receiving CD4 testing, who is eligible for HAART and do they initiate treatment during pregnancy?

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?

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

ART PROPHYLAXIS IN ANC Providing ART prophylaxis to mothers before delivery

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

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

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

HIV TESTING, ART PROPHYLAXIS IN MATERNITY Identifying HIV-infected women and providing prophylaxis to mother and infant in Labor and delivery

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

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

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

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

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

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

HIV EXPOSED INFANT FOLLOWUP Cotrimoxazole prophylaxis, PCR and HIV antibody testing

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

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

Linking mothers and infants

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%)

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

Report card Counseling and testing: A Keep up the good work! Counseling and testing: A Keep up the good work!

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

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