1. 1Management Sciences for Health Stronger health systems. Greater health impact. More HIV positive infants and mothers identified through HIV testing in immunization clinics in Malawi Erik Schouten, Michele Sinunu, Nellie Wadonda, Enock Kajawo, Michael Eliya, Frank Chimbwandira, Scott Kellerman Management Sciences for Health, Ministry of Health Malawi 26 July 2012, 19 th International AIDS Conference, Washington

2. 2Management Sciences for Health Background Evaluation of Malawi´s national PMTCT program through an immunization clinic surveillance project designed to obtain population-based vertical transmission rates. The evaluation was carried out in August – November 2011, before the a newly implemented policy (option B+) could have effect.

3. 3Management Sciences for Health Methods Infants < 3 months old and their care-givers attending the first immunization visit 53 randomly-selected immunization clinics in 4 districts in Malawi Questionnaire Infant dried blood spots (DBS) were collected ELISA HIV test to determine maternal HIV-status ELISA positive tests were tested by DNA-PCR DNA-PCR positive HIV-infected infant ------------------------ = ------------------------ = vertical transmission ELISA (HIV) positive HIV-infected mother

4. 4Management Sciences for Health Evaluation Flow Diagram

5. 5Management Sciences for Health Methods (2) One of the research questions: What is the additional number of infants and mothers in need of HIV care that could be identified if HIV testing was introduced in immunization clinics? Mothers' responses about previous HIV testing were compared with ELISA (HIV) test results

6. 6Management Sciences for Health Testing history of mother Number of mothers (% of total) Never tested 179 (3%) Negative HIV test before this pregnancy 277 (5%) Negative HIV test result during the pregnancy 4,353 (79%) Positive HIV test (any time) 607 (11%) Don't know 45 (1%) No answer83 (1%) Total 5,544 (100%)

7. 7Management Sciences for Health Testing history of mother Number of mothers (% of total) Positive HIV ELISA result in infant (% with pos result) Never tested 179 (3%)17 (9.5%) 207 Negative HIV test before this pregnancy 277 (5%)19 (6.9%) Negative HIV test result during the pregnancy 4,353 (79%)171 (3.9%) Positive HIV test (any time) 607 (11%)561 (92.4%) Don't know 45 (1%)11 (24.4%) No answer83 (1%)15 (18.1%) Total 5,544 (100%)794 (14.3%)

8. 8Management Sciences for Health Testing history of mother Number of mothers (% of total) Positive HIV ELISA result in infant (% with pos result) Never tested 179 (3%)17 (9.5%) 207 Negative HIV test before this pregnancy 277 (5%)19 (6.9%) Negative HIV test result during the pregnancy 4,353 (79%)171 (3.9%) Positive HIV test (any time) 607 (11%)561 (92.4%) 207/561=37% Don't know 45 (1%)11 (24.4%) No answer83 (1%)15 (18.1%) Total 5,544 (100%)794 (14.3%)

9. 9Management Sciences for Health Testing history of mother Number of mothers (% of total) Positive HIV ELISA result in infant (% with pos result) Never tested 179 (3%)17 (9.5%) Negative HIV test before this pregnancy 277 (5%)19 (6.9%) Negative HIV test result during the pregnancy 4,353 (79%)171 (3.9%) Positive HIV test (any time) 607 (11%)561 (92.4%) 207/4,809=4.3% Don't know 45 (1%)11 (24.4%) No answer83 (1%)15 (18.1%) Total 5,544 (100%)794 (14.3%)

10. 10Management Sciences for Health Testing history of mother Number of mothers (% of total) Positive HIV ELISA result in infant (% with pos result) Never tested 179 (3%)17 (9.5%) 207 Negative HIV test before this pregnancy 277 (5%)19 (6.9%) Negative HIV test result during the pregnancy 4,353 (79%)171 (3.9%) Positive HIV test (any time) 607 (11%)561 (92.4%) Don't know 45 (1%)11 (24.4%) No answer83 (1%)15 (18.1%) Total 5,544 (100%)794 (14.3%)

11. 11Management Sciences for Health Results An additional 207 (37%) mother/infant pairs were identified among women that had never been tested or tested HIV- negative before or during the pregnancy Yield of testing all 4,809 women/children who were never tested before, or tested negative before or during the pregnancy is 207/4,809 = 4.3% A reported HIV-positive test result could not be confirmed in (100-92.4 =) 7.6% of patients with a reported HIV-positive status. Vertical transmission was 67/794 = 8.4% (at 6 weeks)

12. 12Management Sciences for Health Possible reasons 1.HIV incidence in pregnancy (estimated at 1% according to a recent study in Malawi *)) 2.False negative or false positive HIV test results 3.Recall bias *) Keating et al. HIV Incidence and Sexual Behavior Change among Pregnant Women in Lilongwe, Malawi: Implications for the Risk of HIV Acquisition. PLoS ONE 7(6): e39109. doi:10.1371/journal.pone.0039109

13. 13Management Sciences for Health conclusions 1.HIV testing in immunization clinics can help to identify an important number of HIV-infected-exposed mother-infant pairs 2.We need to critically look at the quality of HIV testing 3.Base-line can be repeated as part to evaluate Option B+ (test and treat for pregnant and breastfeeding women)

14. 14Management Sciences for Health Stronger health systems. Greater health impact. Saving lives and improving the health of the world’s poorest and most vulnerable people by closing the gap between knowledge and action in public health.