1. THE 6 TH NATIONAL SCIENTIFIC CONFERENCE ON HIV/AIDS Late maternal HIV testing, HCMC 2007-2011 Chi K. Nguyen 1, Haily T. Pham 2, ThuVan T. Tieu 2, Chinh Q. Nguyen 3, Nhung T. Vu 4, Hao T. Duong 1, Binh T. Le 1, Michelle McConnell 1, Marta Ackers 1 Presenter: Nguyen Thi Kim Chi CDC 1 HHS/ CDC Vietnam, 2 Provincial AIDS Committee, Ho Chi Minh City, Vietnam, 3 Reproductive Health Center, Ho Chi Minh City, Vietnam, 4 Hung Vuong OB/GYN hospital, Ho Chi Minh City, Vietnam

2. The 6 th National Scientific Conference on HIV/AIDS Content 1.Background 2.Objectives 3.Methods 4.Results & Discussions 5.Conclusions 6.Recommendations 2

3. The 6 th National Scientific Conference on HIV/AIDS Background: PMTCT in HCMC City program started in 2004 120,000 pregnant women annually –30-40% from other provinces* –600-700 (0.5%) HIV+ pregnant women identified* MTCT rate: 4-7%* Late maternal ARV uptake or none at labor and delivery (L&D) high (30% in 2011)* To further reduce MTCT need to identify HIV+ women and provide ARVs earlier * HCMC PAC PMTCT program report 3

4. The 6 th National Scientific Conference on HIV/AIDS Objectives Identify proportion of women receiving late maternal HIV testing at labor and delivery Describe associations between maternal characteristics and late maternal testing Determine MTCT rate and risk factors for pediatric HIV infection Recommend solutions to improve program 4

5. The 6 th National Scientific Conference on HIV/AIDS Methods Retrospective cohort –HIV+ women who delivered live infants from 2007-2011 in HCMC and their HIV-exposed infants –Late maternal testing defined as HIV testing at labor and delivery (L&D) Data collection: –Chart abstraction from maternity medical records at 9 hospitals and 2 pediatric outpatient clinics Timing of maternal testing Pediatric HIV infection (documentation of PCR test results) –Linked maternal and infant data using the maternal HIV testing code 5

6. The 6 th National Scientific Conference on HIV/AIDS Data Analysis Descriptive analysis –Calculate proportions and mean (±sd) –Pearson’s Chi-square or Fisher’s exact test to compare proportions –t-test or ANOVA to compare means Multivariate logistic regression with adjusted odds ratios, aOR, and 95% confidence intervals (CI 95%), used to assess associations between maternal characteristics and late maternal testing or MTCT 6

7. The 6 th National Scientific Conference on HIV/AIDS Schematic of Study Participants HIV+ women delivering in 2007-2011 N=3,280 Women eligible n=3,066 Exposed infants n=3,077 No registration n=960 (31%) OPC registration n=2,117 (69%) One of twins n=11 Infants with PCR for analysis n=2,034 Unmatched maternal code/ PCR not available n=72 Excluded n=214 7

8. The 6 th National Scientific Conference on HIV/AIDS Characteristic of women n=3,066 26 years median maternal age, range 23-29 45% employed 37% residents of other provinces 57% with secondary school or better 7% IDU HIV testing –42% maternal testing at ANC –35% maternal HIV testing at L&D –23% before ANC 16% no ARVs for PMTCT 8

9. The 6 th National Scientific Conference on HIV/AIDS Timing of receipt of maternal HIV test, by year, HCMC (n= 3,066) n=521n= 622 n= 683 n= 666 n=574 25.4 weeks 21 weeks 9

10. The 6 th National Scientific Conference on HIV/AIDS Characteristics associated with late HIV testing (n=3,066) Timing of maternal HIV testing CharacteristicsAt L&D n=1,082 (35%) ANC or before n=1,984 (65%) OR (95%CI) Facility of delivery* OB/GYN hospital General & dist. hospital 893 (83%) 189 (17%) 1,811 (91%) 173 (9%) 1 2.21 (1.77-2.76) Maternal age category <19 20-24 25-29 30-34 >35 95 (9%) 374 (34%) 386 (36%) 172(16%) 55 (5%) 89 (5%) 624 (31%) 833 (42%) 354 (18%) 84 (4%) 1 0.56 (0.40 – 0.77) 0.43 (0.31 – 0.59) 0.44 (0.31 – 0.62) 0.61 (0.39 – 0.95) Residence* HCMC Other provinces 600 (56%) 479 (44%) 1,346 (68%) 638 (32%) 1 1.68 (1.45 – 1.96) *controlling for residence, education and facility of delivery aOR 3.06 (1.97-4.74) aOR 2.10 (1.72 – 2.54) 10

11. The 6 th National Scientific Conference on HIV/AIDS Characteristics associated with late HIV testing (n=3,066) Timing of maternal HIV testing CharacteristicsAt L&D n=1,082 (35%) ANC or before n=1,984 (65%) OR (95%CI) Employment Employed Unemployed Missing 414 (38%) 436 (40%) 232 (21%) 962 (48%) 844 (43%) 178 (9%) 1 1.21 (1.03 – 1.43) Education level* Primary Secondary High school or higher Missing 319 (30%) 332(31%) 127(12%) 304 (26%) 453(23%) 801(40%) 487(25%) 243 (12%) 1 0.58 (0.48 – 0.71) 0.37 (0.29 – 0.47) *multivariate aOR=0.65 (0.52 – 0.81) aOR=0.43 (0.32 – 0.57) 11

12. The 6 th National Scientific Conference on HIV/AIDS HIV testing and maternal ARV use (n=3,066) Timing of maternal HIV testing CharacteristicsAt L&D n=1,082 (35%) ANC or before n=1,984 (65%) p-value ARV use (n= 3,066) No ARV NVP at labor ARV prophylaxis at ANC HAART at ANC HAART before ANC 288 (27%) 794 (73%) 0 193 (9.7%) 0 1,197 (60.4%) 189 (9.5%) 405 (20.4%) <.001 12

13. The 6 th National Scientific Conference on HIV/AIDS MTCT, 2007-2011, HCMC YearNumber of HIV- exposed infants (%) Number of positive PCR infants (%) MTCT rate 2007204(10%)9 (11%)4.4% 2008443 (22%)18 (22%)4.0% 2009528 (26%)28 (35%)5.3% 2010480 (24%)14(17%)2.9% 2011379 (16%)12 (15%)3.2% Total2,034 (100%)81 (100%)3.9% p-value >0.05 13

14. The 6 th National Scientific Conference on HIV/AIDS Maternal risk factors for pediatric HIV infection (n=2,034) Risk factorsPCR PositiveNegativeOR (CI 95%) Year of delivery 2007 2008 2009 2010 2011 n= 81 9 (11.1%) 18 (22.2%) 28 (34.6%) 14 (17.3%) 12 (14.8%) n= 1,953 195(10%) 425(22%) 500(26%) 466(24%) 367(19%) 1 0.92 (0.41-2.08) 1.21 (0.56-2.62) 0.65 (0.28-1.52) 0.71 (0.29-1.71) Maternal ARV use* No ARV NVP at labor ARV prophylaxis at ANC HAART at ANC HAART before ANC n=81 22(15%) 37(46%) 13(16%) 6(7%) 3(4%) n= 1,953 235(12%) 383(20%) 871(45%) 146(7%) 318(16%) 9.92 (2.93 – 33.54) 10.24 (3.13 – 33.52) 1.58 (0.47 – 5.59) 4.35 (1.07-17.66) 1 Mother age group <19 20-24 25-29 30-34 >35 n=81 7 (9%) 22 (27%) 35 (43%) 13 (16%) 4 (5%) n= 1,953 105 (5%) 627 (32%) 783 (40%) 355 (18%) 83 (4%) 1 0.53 (0.22-1.26) 0.67 (0.29-1.55) 0.55 (0.21-1.40) 0.71 (0.20-2.55) * bivariate MTCT 8.6% 8.8% 3.4% 3.9% 0.9% 14

15. The 6 th National Scientific Conference on HIV/AIDS Conclusions Late maternal testing reduced but still 24% in 2011 –Residents of other provinces, low education level and delivery at a general/district hospital associated with late maternal testing –Women with late maternal testing, less likely to get most efficacious PMTCT ARV regimen MTCT rate unchanged over time Late or no ARV use significantly associated with pediatric HIV infection 15

16. The 6 th National Scientific Conference on HIV/AIDS Recommendations 1.Develop strategies to increase early HIV testing and ARV uptake, specifically targeting women at lower education levels and residents of other provinces 2.Strengthen documentation of HIV testing, linkage to ARV services, and communication of testing and treatment results among facilities 16

17. The 6 th National Scientific Conference on HIV/AIDS Limitations Early HIV testing data based on self-report –HIV + women may have been reluctant to disclose Missing information in medical records Other potential associations or risk factors could not be captured MTCT based only on PCR results from infants who enrolled in care at two hospitals –31% of infants did not enroll at 2 pediatric hospitals and their PCR results were not available 17

18. The 6 th National Scientific Conference on HIV/AIDS Acknowledgments HCMC PAC leaders and key staff Faculties of HCMC Medical & Phar. University MCH leaders Staff at PMTCT sites and Pediatric Outpatient Clinics US Centers for Disease Control and Prevention (CDC) 18

19. The 6 th National Scientific Conference on HIV/AIDS Thank you for your attention 19