1. Nomsa Mulima 17 th July 2011 Effectiveness of the PMTCT program in Swaziland

3. Country background Country Population 1,018,449 (M=481428; F=537021) Pop 0-4 yrs=127859 (13%) Pop 15-49 yrs= 510738 (50%) HIV Prevalence (Extreme) Generalized epidemic in all 4 regions Pregnant women (41.1%) General population (19%) 15-49 age group (26%) MMR =589 IMR= 78 in 1997 to 107 in 2007 Under 5 MR= 106 in 1997 to 167 in 2007

4. PMTCT in Swaziland- country Information PMTCT program implementation & expansion PMTCT Implementation since 2003 4 Sites initially; increase to 73 by 2005; 137 by 2008 and 150 (88%) by 2010 Expansion in sites providing treatment including ART ART implementation since 2003 6 sites initially; 17 in 2005; 70 by 2008 and 116 (43%) by 2010 EID Started in late 2007 Increase from 58 sites in 2008; 107 end of 2009 &127/157 (81%) of CW clinics by 2010 DBS done centrally- 1 DNA-PCR machine Some tests done in South Africa due to insufficient capacity

6. PMTCT Country background Cont....... EID Coverage: Policy= test all exposed infants >6wks (for HIV+ initiate ART immediately) Estimated exposed infants=11,528 Tested within 2 mnths= 4,902(42%) still most infants test after 2 mnths. Improvement compared to previous years (as graph shows)

7. EID Coverage(HIV prevalence vs time DBS done) Decline in % infants testing HIV+ (from estimated 21%- +- 14%) Within <8wks (4%) Notable difference for those testing>8wks (unknown causes) Transmission through breast milk/that DBS confirms test for those testing HIV + through Antibody testing????

8. Existing data on PMTCT Impact _cont....... Currently available data PMTCT program data-improvement in access to ARVs & EID uptake Gaps 1. Still Impact of PMTCT is unknown (country relies on modelling _ not country specific_ generalized to regional assumptions No linkages btwn ANC & CWF data (cannot link and measure transmission rates)

9. Current PMTCT impact evaluation: Methods Evaluation of the effectiveness of the national PMTCT programme at 6 – 8 weeks post-partum in Swaziland Protocol submitted and approved nationally Awaiting approval from IRB/CDC Method chosen and why: Immunization clinics survey (+83% EPI-DPT1 coverage) Mother-infant-pairs to be recruited from a random sample of about 55 child welfare clinics providing EID, All mother-infant pairs attending selected facilities during the 4-month data collection period will be offered an opportunity to participate in the evaluation. Consenting mothers will be interviewed using a structured questionnaire to obtain demographics, uptake of ANC and PMTCT interventions-Testing & ARVs.

10. Method chosen and why cont..... Why the study & method selection? Country target: reduction of MTCT to 5% by 2014 (country specific Baseline not available) Program data not of good quality CWF register already in cohorts, but issues of LTF (infants <6wks in 1 st visit not coming back) No link of CWF data to mom’s regimen/ PMTCT intervention Current STD: Infants tested if mother’s HIV+ status known> all infants selected will be tested regardless of mom’s HIV status Data triangulation done on infant mortality, declines noted but not clear of attributing factors

11. Other proposed studies Follow-up of breastfeeding infants To be part of the above mentioned study –Evaluation of the effectiveness of PMTCT program Follow-up selected infants whose DNA is negative at 6-8wks until cessation of breast milk to determine late HIV transmission (breast milk) Still to develop protocol NVP Adherence for infants- study to assess routine collection of adherence data to assess uptake of new PMTCT guidelines and use as input to adjust model ( WHO collaboration) DHS 2012 to consider infant/child testing Triangulation of PMTCT programme scale-up and infant mortality Continuous triangulation to determine impact of PMTCT