1. Population HIV-free survival among HIV-exposed children in four African countries: the PEARL community survey CBCHB and EGPAF (Cameroon) U. Bordeaux – PAC-CI (Cote d’Ivoire) University of Cape Town (South Africa) UAB – CIDRZ (Zambia) Pius Tih, David Coetzee, Didier K. Ekouevi, Kathryn Stinson, Elizabeth Stringer, Tracy Creek, Mark Giganti, Thomas Welty, Namwinga Chintu, Benjamin H. Chi, Francois Dabis, Cathy Wilfert, Nathan Shaffer, Jeff Stringer

2. The PEARL Study 4-Country PMTCT effectiveness study Facility-based evaluations – Cord Blood Surveillance – Facility Survey Community-based evaluations – Household Survey

3. The PEARL Study 4-Country PMTCT effectiveness study Facility-based evaluations – Cord Blood Surveillance – Facility Survey Community-based evaluations – Household Survey

4. Our Objective To estimate HIV-free survival among HIV-exposed infants under 2 years of age

5. Two-stage sampling method Stage 1: Facilities – 25 sites* were chosen randomly in the 4 countries Stage 2: Communities – The catchment area of each site was identified and household surveys conducted within it We only included sites that were providing PMTCT services *some “sites” comprised clusters of small facilities

6. Household eligibility Households were eligible if child born within it in the past 24 months

7. Questionnaire Adapted from the Demographics and Health Survey (DHS) Primary respondent was the mother of the eligible child or caregiver if mother deceased or not available

8. Specimen collection for HIV testing Informed consent obtained Mothers – Blood drawn in the home – In-home results (Cameroon) – Referral slip for results (RSA, ZM, CI) Infants – Whole blood dried blood spots (DBS) – HIV DNA PCR if mother antibody positive or deceased

9. Analysis Eligible children in the sample (< 2 years) were classified as: – HIV-exposed – HIV unexposed If HIV-exposed, further classified as: – dead – alive and HIV infected – alive and HIV uninfected 2 year HIV-free survival was estimated with a Weibull regression model

10. 9,120 Children < 2 yrs Study Schema (May 2008 – April 2009)

11. 9,120 Children < 2 yrs 7,667 (84%) Complete maternal and child data Study Schema 1,453 Maternal and/or child lab data not collected 381 refused participation 609 refused maternal test 40 refused child test 43 mother dead 150 mother not home 114 maternal test result not available 16 maternal test result unknown / indeterminate 50 child test result not available (May 2008 – April 2009)

12. 9,120 Children < 2 yrs 7,667 Complete maternal and child data 1,002 (13%) Children < 2 yrs with HIV exposure 1,453 Maternal and/or child lab data not collected Study Schema 6,665 Unexposed children (May 2008 – April 2009)

13. 9,120 Children < 2 yrs 7,667 Complete maternal and child data 1,002 Children < 2 yrs with HIV exposure 844 HIV (-) 105 HIV (+) 53 Dead 1,453 Maternal and/or child lab data not collected Study Schema 6,665 Unexposed children (May 2008 – April 2009)

14. HIV-free survival (at 2 years among exposed infants) EstimateHIV-free survival (95% CI) Cameroon68% (56%, 78%) South Africa78% (72%, 82%) Ivory Coast81% (65%, 90%) Zambia82% (78%, 87%) Overall79% (76%, 82%)

16. Conclusions Population HIV-free survival can be measured in the community This study provides community-level evidence that more potent PMTCT regimens result in measurably better outcomes National decision makers should consider incorporating the PEARL methodology into ongoing DHS and/or AIDS indicator surveys

17. Acknowledgements Cameroon Pius Tih Tom Welty Cote d’Ivoire Francois Dabis Didier Ekouevi Serge Kahon South Africa Andrew Boulle David Coetzee Kathryn Stinson Zambia Zambian MOH Max Bweupe Ben Chi Namwinga Chintu Mark Giganti Jeff Stringer Wendy Mazimba Centers for Disease Control Mark Bulterys Tracy Creek Nathan Shaffer EGPAF Allison Spensley Christophe Grundmann Cathy Wilfert Others Cameroon Baptist Health Convention Elliott Marseille Mary Louise Newell MOH Cote d’Ivoire

18. THANK YOU