Impact of South Africa s PMTCT Programs on Perinatal HIV Transmission: Results of the 1st Year Implementing 2010 WHO Recommended Guidelines

Transcription

1 Impact of South Africa s PMTCT Programs on Perinatal HIV Transmission: Results of the 1st Year Implementing 2010 WHO Recommended Guidelines 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 4 th International workshop on Pediatric HIV, Washington DC, July 20 th -21 st, 2012

2 Overview of Presentation Background Objectives Case definitions Methods Findings Conclusions

3 Background: PMTCT guidelines : HIV-infected pregnant women CD4 > 200 AZT from 28 wks + sd NVP in labour CD4< 200 or WHO clinical stage 4 ART for life HIV-exposed infants: sd NVP + AZT (7-28 days) 2010-present: HIV-infected pregnant women CD4 > 350 AZT from 14 wks + sd NVP + TDF/FTC in labour CD4< 350 ART for life HIV-exposed infants Mother on ART or non-breastfed infants: 6 wks NVP Breastfed infant: NVP through out breastfeeding

4 Background HIV and pregnant women Antenatal HIV prevalence ( 10): 30.2% (95 CI, 29.4% -30.9%) Coverage of PMTCT service sites: > 98% of facilities Decentralized ARV provision: Primary health care facilities Nurse initiates ARV Maternal and Child health Live-births ( 10): 1,240,000 (incl. late registration) 1 st immunization (DPT, 6 wks) coverage ( 10): >95% Neonatal mortality, 0-28 days ( 08): 3.8/1,000 live-birth

5 Objectives Primary objective of this presentation To estimate impact of the national PMTCT program implementing the 2010 WHO PMTCT recommendations on perinatal MTCT of HIV To track progress of the national PMTCT program toward the 2015 elimination of MTCT goal

6 HIV-exposed infant Case Definitions An infant whose Dried Blood Spot (DBS) sample is positive with an HIV antibody test HIV-infected infant An infant whose DBS sample is positive with An HIV antibody test AND An HIV DNA PCR test

7 Methods Design: national facility-based survey Sampling: Multi stage sampling methods national and provincial estimates 580 facilities in all 9 provinces 12,200 infant-dbss eligible caregiver-infant pairs enrolled Interview data collection: Using cell-phone technology real time data collection Duration: Data collection: August 2011 to March 2012

8 Sample size distribution by province N=1800 N=1400 N=1200 N=1600 N=700 N=1300 N=1400 N=1400 N=1400

9 Methods: Laboratory Testing strategy: Serial Screening for HIV exposure status using an HIV ELISA test Confirming for HIV-infection status using an HIV DNA PCR test Test kits ELISA test (Genscreen HIV antibody assay) for Infant HIV Exposure HIV DNA PCR (Automated Ampliprep/Taqman v2.0 technology (Roche) All HIV tests were done at a central laboratory (National Health Laboratory System)

10 Preliminary Findings Adjusted for non-response rates Weighted for population live-birth in 2010 Survey analysis using SAS 9.2

11 2011 SAPMTCTE: Survey Profile Total of caregiver-infant approached at the sites (11,377) Enrolled eligible caregiver-infants wk old infant attending 1 st DPT (10,475; 92.4%) Not eligible (614) Refused to participate (289) Consent incomplete (158) Refused to infant-dbs (330) Insufficient infant-dbs (39) Caregiver-infants interviewed & infant-dbs* (N=10106; 96.5%) Infant-HIV antibody positive (N=3024) Infant-HIV antibody negative (n=7182) Inclusion: 4-8wk old attending clinic for 6wk immunization Exclusion: Severely ill infants needing emergency care

12 Caregiver s characteristics by HIV-exposure status (weighted %) Characteristics HIV exposed infant (n=3024) HIV unexposed infant (n=7182) % 95% CI % 95% CI Mother-infant pairs Marital status of mother Single Feeding practice (last 8 days) non-mixed breast-feeding Mixed breast-feeding Planned pregnancy Yes Delivery mode C-section

13 Weighted HIV exposure prevalence and transmission rate measured at 4-8wks postpartum by year 1. Infant HIV-exposure prevalence 2010: 31.4% (95% CI 30.1% %) 2011: 32.2% (95% CI 30.7% %) 2. National perinatal transmission rate 2010: 3.5% (95% CI 2.9% - 4.1%) 2011: 2.7% (95% CI 2.1% - 3.2%)

14 PMTCT cascade by year 100,0% 80,0% 60,0% 40,0% 20,0% 0,0% 100,0% 80,0% 60,0% 40,0% 20,0% 0,0% Antenatal (ANC) HIV test Received CD4 test resuls Received ANC HIV test result HIV infected mothers 58.7 Mother&infant received ARV therapy Mother on ART Mothers reported being HIV-positive 85.1 Infant received 4wks of NVP

15 Strengths Strengths and Limitations mothers with HIV infection known, unknown, & acquisition mother-infants with or without PMTCT exposure Limitations Facility based (1 st DPT coverage >95%; 0.05% not eligible) Infant mortality (0-28 days): 3.8/1,000 live-birth Excluded: 6% of eligible infants refused HIV testing Mobile clinics, hospitals, private facilities and small clinics with <130 DTP1/year Recall/social desirability bias but recall period short and selfreported maternal HIV consistent with 2010 ANC survey

16 CONCLUSIONS After one year of implementing the 2010 PMTCT guidelines, South Africa reduced perinatal MTCT measured at 4-8 weeks postpartum from 3.5% in 2010 to 2.7% in 2011 On track to reach target of <2% perinatal HIV transmission by 2015 Extended postnatal MTCT (beyond 8 wks) being measured and investigated Mixed breast-feeding (44%) may reduce impact of the overall PMTCT program

17 Acknowledgements Caregiver-infant pairs Provincial Departments of Health Nurse Data collectors Routine health workers Medical Research Council Carl Lombard (Statistician) Selamawit Woldesenbet Wesley Solomon Vundli Ramokolo Tanya Doherty Charles Hongoro Fred Koopman National Department of Health Yogan Pillay, Nonhlanhla Dlamini Thabang Mosala University of the Western Cape Wondwossen Lerebo UNICEF (SA) Siobhan Crowley CDC Katherine Robinson/Lorena Espinoza Jeff Klausner/Thurma Goldman Mary Mogashoa/Lerato Lesole CDC South Africa and Atlanta teams Infant Diagnosis Gayle Sherman Adrian Puren Technical Advisors Mickey Chopra (UNICEF) Nathan Shaffer (WHO) The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the centers for Disease control and Prevention

18 More findings to be presented Identifying Gaps Along the PMTCT Cascade to Achieve the MTCT Elimination Goals: Results From the South African PMTCT Effectiveness Survey (SAPMTCTE), 2011 Presented by Selam Woldesenbet - Poster P_71 (July 21 4 th International Paediatric HIV workshop) Impact of the South Africa s PMTCT Programs on Perinatal HIV Transmission, : Using data to improve program implementations, and policy Presented by Dr. Yogan Pillay; Deputy Director General of Health - MOH Satellite session Measuring Effectiveness of the National PMTCT Programme and Validating EMTCT: Towards Elimination of EMTCT Venue: Mini Room 2; Time: Sunday 22 July :45-17:45