1. Impact of the National PMTCT Program Measured at Six Weeks Postpartum in South Africa, 2010 Thu-Ha Dinh, MD., MS., US CDC/GAP Ameena Goga, MD., MS., MRC/HSRU, South Africa Debra Jackson, PhD., RN., UWC, MRC/HSRU, South Africa and other co-authors IAS 2011, Rome, July 17 to 20

2. Overview of Presentation Background Objectives Methods Findings Conclusions

3. Background Live-birth: 1 mil/yrs 1 st immunization (DPT) at 6 weeks –Coverage >98% in 2010 Antenatal HIV prevalence: 29% (range: 17-40) National PMTCT started in 2002 2010: PMTCT at > 98% of facilities Decentralized ARV provision, nurse initiates ARV

4. 2008: –Mothers:  CD4 > 200  AZT from 28 wks + sd NVP in labour  CD4< 200  ART/HAART –Infant: sd NVP + AZT (7 - 28 days) –DNA PCR at 4-6 weeks of age - 1 st immunization 2010: –Mothers  CD4 > 350  AZT from 14 wks + sd NVP + TDF/FTC in labour  CD4< 350  ART/HAART –Infant: NVP throughout breastfeeding 2008 – present: DNA PCR at 4-6 weeks of age at the 1st immunization Background: PMTCT guidelines

5. Objectives Primary objectives To estimate national and provincial perinatal MTCT rates in 2009 and early 2010 To identify associated factors with the MTCT Secondary questions To estimate number of HIV acquisition during pregnancy (poster # MOPE300; Mon 12.30 – 14:30) To describe and identify re PMTCT missed opportunities – PMTCT cascade (poster # TUPE285, Tue 12:20-14:30)

6. Methods A cross-sectional facility-based survey Sampling: Multi stage, PPS and systematic sampling methods  national and provincial estimates –565 facilities in all 9 provinces (range, 34-78/province) –A total of 9915 eligible caregiver-infant pairs enrolled Data collection: Using cell-phone technology  real time data collection (interview) Duration: Data collection: Jun 2010 to Dec 2010  establish a baseline to measure impact of Option A in South Africa (SA 2010 guidelines)

7. HIV Exposed Infants identified using biomedical marker ELISA test (Genscreen HIV antibody assay) for Infant HIV Exposure  HIV ELISA test positive  HIV DNA PCR – Automated Ampliprep/Taqman v2.0 technology (Roche) All HIV tests were done at NHLS Methods: Laboratory

8. Findings Weighted for population live-birth in 2008 Survey analysis using SAS 9.2

9. Caregiver-infants - 4-8 wk old infant attending 1 st DPT (10 820) Caregiver-infants interviewed & infant-DBS* (9915, 92%) Refused to participate, 84 (0.8%) No or insufficient infant-DBS 821 (7.6%) HIV exposed (3003; 30.3%) No PCR test result, 35 (1.2%) HIV exposed infants with PCR test result (2958; 98.5%) HIV not exposed, 6912 (69.7%) Survey Profile Inclusion: 4-8 week old attending clinic for 6wk immunization Exclusion: Severely ill infants needing emergency care

10. Characteristics HIV exposed infant N=3003 HIV unexposed infant N=6912 %95% CI% Brought by mother96.896.2-97.497.996.4-97.7 Marital status of mother Single79.877.9-81.673.071.6-74.5 Married/cohabiting20.218.4-22.026.925.5-28.4 Feeding practice (last 8 days) Exclusively breast-feeding20.018.2-21.830.328.7-32.0 Mixed Feeding17.916.4-19.558.456.7-60.1 No breast-milk feeding62.059.8-64.211.210.5-12.0 Food insecurity (episode) Yes20.618.1-23.115.514.0-16.9 No79.076.5-81.584.082.5-85.4 Planned pregnancy Yes34.832.7-36.938.336.8-39.7 No62.059.9-64.258.456.9-59.8 Mother’s characteristics by HIV-exposure status

11. Weighted perinatal MTCT Rate Province Infant HIV exposure % (95% CI) N=2958 Perinatal MTCT % (95% CI) Eastern Cape30.0 (26.3-33.7)4.1 (1.7-6.3) Free State31.1 (28.9-33.3)6.0 (3.8-8.2) Gauteng30.2 (27.7-32.8)2.2 (1.2-3.2) KwaZulu-Natal43.9 (39.7-48.0)2.8 (1.7-4.0) Limpopo22.6 (20.4-24.8)3.5 (1.2-5.8) Mpumalanga36.2 (33.6-38.9)5.9 (4.3-7.6) Northern Cape15.6 (13.0-18.3)1.7 (0.1-4.2) Northwest30.9 (28.6-33.1)4.5 (2.9-6.1) Western Cape20.8 (16.8-24.9)3.3 (1.3-5.2) National31.4 (30.1-32.6)3.5 (2.9-4.1)

12. Factors associated with perinatal MTCT FactorsAdj OR95% CI ARV prophylaxis or ART/HAART Maternal ART (HAART)1.0-- Either maternal ARV OR infant ARV5.22.7-10.0 ≤10 week maternal ARV AND infant ARV2.41.2-5.1 11-30 week maternal ARV AND infant ARV1.70.9-3.5 Feeding practices (last 8 days) EBF or no breast-milk1.0-- Mixed breast-feeding1.61.0-2.5 Planned pregnancy Yes1.0-- No1.40.8-2.3 Delivery method C-section1.0-- Not C-section1.10.4-2.9 Birth attendant Non-doctor1.0-- Doctor1.20.5-2.9

13. Limitations Selection bias – Representative population attending primary health care – Excluded sick infants needing emergency care Potential recall bias  bias associated factors Sample realization in 3 provinces <75%  estimates were not stable in that 3 provinces (NC, EC and LP)

14. Conclusions 1.Nationally, the perinatal MTCT rate was < 4% in South Africa 2.C-section and having birth attendant as a doctor may not be optimal options to reduce MTCT 3.Mixed feeding is a strong indicator to increase MTCT in this population 4.No breast-milk feeding to exposed infants (62%) can reduce MTCT but will increase mortality 5.HIV test uptake in infant was high (92%) if offered to all infants at routine immunisation services “The findings and conclusions on this report are those of the authors and do not necessarily present the official position of the US Centers for Disease Control and Prevention”

15. Acknowledgements Nurse Data collectors Routine health workers Medical Research Council: Carl Lombard (Statistician) Selamawit Woldesenbet Wesley Solomon Vundli Ramokolo Nothemba Kula Tanya Doherty National Department of Health: Yogan Pillay, Nonhlanhla Dlamini Thabang Mosala Provincial Departments of Health University of the Western Cape: Wondwossen Lerebo UNICEF (SA): Siobhan Crowley CDC: Katherine Robinson Jeff Klausner Thurma Goldman Infant Diagnosis: Gayle Sherman Adrian Puren Technical Advisors: Mickey Chopra (UNICEF) Nathan Shaffer (WHO) Caregiver-infant pairs