1. www.aids2014.org Operational challenge: Linkages from prevention of mother-to-child transmission services to care and treatment services in Zambia S. Okawa, M. Chirwa, N. Ishikawa, F. Pande, H. Kapyata, C. Msiska, K. Komada, H. Miyamoto, A. Mwango ▪Chongwe District Community Health Office ▪Ministry of Health Zambia - Japan International Cooperation Agency SHIMA project, Lusaka, Zambia

2. www.aids2014.org Background  Great success in scale-up of the PMTCT program in Zambia  PMTCT ARV coverage: 97% (UNAIDS, 2012)  There is a need to take advantage by referring all HIV-positive women from PMTCT to HIV care/treatment  Few studies on linkages between PMTCT and HIV care/treatment in Zambia

3. www.aids2014.org Study design  Design: Prospective cohort study  Period: ▶ Enrolment: June 2011 – May 2012 ▶ Follow up: June 2011 – January 2014  Site: Chongwe district, Lusaka province ▶ Referral health center ▶ 5 rural health centers (RHCs) with ART services ▶ 5 RHCs without ART services  WHO 2010 guidelines Option A  Participants: 195 mothers newly diagnosed as HIV- positive in PMTCT program

4. www.aids2014.org Data Collection  Face-to-face interview ‒ Basic characteristics of mothers  Review of clinical record and electronic database of clients on HIV care/treatment ‒ Date of enrolment in HIV care/treatment ‒ Date of ART initiation ‒ Date of the last visit to the services

5. www.aids2014.org Analysis  Probability of enrolment in HIV care/treatment  Kaplan-Meier survivor function  Predictors of enrolment in HIV care/treatment  Cox proportional hazards model  Observation time:  Entry point: from HIV diagnosis at antenatal clinic  End point: enrolment in HIV care/treatment  Censored point: 20 January 2014

6. www.aids2014.org Results

7. www.aids2014.org Participants Characteristics Characteristics N% Age Median (IQR)27(22-32) ≤ 20 2713.9 21-3010453.3 ≥ 31 6432.8 Education (years) None178.9 1-710554.7 ≥8≥87036.5 Marital status Married/Cohabit15982.0 Not married3518.0 Parity Primigravida3518.4 1-310957.4 ≥4≥4 4624.2

8. www.aids2014.org Participants Characteristics cont. N% Paid work of partner No4925.3 Once in a while3417.5 Part of the year178.8 Throughout the year9448.5 Time to access heath facility (minutes) ≤ 29 2814.6 30 - 595327.6 60 - 1196935.9 ≥1204221.9 Perception on taking ARVs Positive15076.9 Negative4523.1 Place of receiving PMTCT service Referral health center7940.5 RHCs with HIV care/treatment5528.2 RHCs without HIV care/treatment 6131.3

9. www.aids2014.org Linkage from PMTCT to HIV care/treatment 195 Newly diagnosed in PMTCT program 92 enrolled in HIV care/treatment (47.2%) 48 initiated ART (24.6%) 44 not initiated ART (22.6%) 103 not enrolled (52.8%) As of 20 January, 2014

10. www.aids2014.org Probability of enrolment in HIV care/treatment Time from HIV diagnosisProbability95%CI at 6 months0.320.26-0.40 at 12 months0.420.35-0.50 at 18 months0.440.37-0.52

11. www.aids2014.org From HIV Diagnosis to ART initiation 195 newly diagnosed 87 tested CD4 48 CD4<350 27 started ART 21 not started ART 39 CD4 ≥350 11 started ART 28 not started ART 108 not tested CD4 (No data) 10 started ART 98 not started ART As of 20 January 2014 *108/195 (55.4%) *21/48 (43.8%)

12. www.aids2014.org Predictors for enrolment in HIV care/treatment PredictorsHazard ratio 95% CI Age ≤200.260.09-0.71† 21-301.00 ≥310.790.44-1.42 Education None1.00 1-70.800.32-2.00 ≥8≥81.590.62-4.08 Marital status Married/Cohabit1.00 Not married0.650.29-1.44 Parity Primigravida1.00 1-30.930.41-2.12 ≥4≥41.21 0.43-3.46

13. www.aids2014.org Predictors for enrolment in HIV care/treatment (cont.) PredictorsHazard ratio 95% CI Paid work of partner No1.00 Once in a while1.450.63-3.35 Part of the year1.030.40-2.61 Throughout the year0.600.29-1.24 Time to access heath facility (minutes) ≤291.00 30 - 591.360.63-2.96 60 - 1191.470.67-3.23 ≥1200.960.37-2.44 Perception on taking ARVs Positive1.170.67-2.05 Negative1.00 Place of receiving PMTCT service Referral health center1.00 RHCs with HIV care/treatment1.390.76-2.54 RHCs without HIV care/treatment0.51 0.27-0.96†

14. www.aids2014.org Summary

15. www.aids2014.org Poor linkage from PMTCT to HIV care/treatment ▪53% of new HIV-positive mothers have not enrolled in HIV care/treatment ▪55% of new HIV-positive mothers were not tested CD4 count after diagnosis of HIV ▪44% of mothers with CD4<350 have not started ART

16. www.aids2014.org Risk factors for not enrolled in HIV care/treatment ▪Younger maternal age ▪Attending rural health centers not providing HIV care/treatment

17. www.aids2014.org Conclusion Strengthening linkage between PMTCT and HIV care and treatment services needed - Option B+ implementation (Apr 2014-) - Treatment is offered to HIV + partners regardless of CD4 count - Future evaluation of Option B+ implementation needed

18. www.aids2014.org Acknowledgements  Study participants  Ministry of Health, Zambia  Ministry of Community Development, Mother and Child Health, Zambia  Japan International Cooperation Agency (JICA)  National Center for Global Health and Medicine, Japan (NCGM)  The University of Tokyo  Midwives and community-based volunteers at study sites

19. www.aids2014.org Thank you very much for your attention For further information: shimaproject@gmail.com