PMTCT decentralization does not assure optimal service delivery :
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Washington D.C., USA, 22-27 July 2012www.aids2012.org
PMTCT decentralization does not assure optimal service delivery:
revelations from successful individual-level tracking of HIV-infected mothers and their infants
Andrew EdmondsDeidre ThompsonVitus OkitolondaLydia FeinsteinBienvenu KawendeFrieda Behets
for the PMTE team
Washington D.C., USA, 22-27 July 2012www.aids2012.org
Background• Essential services for the prevention mother-to-child
HIV transmission (PMTCT) are being increasingly decentralized to antenatal care (ANC) sites
• However, the consequences of shifting services from dedicated HIV care and treatment (C&T) clinics remain incompletely explored– Rwanda: differences between stand-alone and full package
sites (Tsague et al. BMC Public Health 2010, 10:753)– HIV-exposed infants are often not DNA PCR tested at ANC or
immunization sites (Ciaranello et al. BMC Medicine 2011, 9:59)
Washington D.C., USA, 22-27 July 2012www.aids2012.org
Context• The University of North Carolina at Chapel Hill (UNC)
has assisted with implementation of HIV prevention, care, and treatment the Democratic Republic of Congo (DRC) since 2003
• PMTCT activities– HIV testing ~63,000 women/year
(49 sites)– Scaling up to ~100,000 women/year
(105 sites)– HIV prevalence ~1.3%
Washington D.C., USA, 22-27 July 2012www.aids2012.org
Locations and characteristics of 44 maternities providing vertical HIV prevention services and 2 comprehensive care and treatment sites
Washington D.C., USA, 22-27 July 2012www.aids2012.org
PMTCT Ya Sika• In October 2010, an enhanced standard of care was
introduced at the UNC-supported ANC sites– Personnel were retrained to implement co-located post-
delivery care and the 2010 World Health Organization PMTCT guidelines including Option A
– They were also provided with new individual-level tracking tools and supportive supervision
– HIV-infected “mother-mentor” clinic volunteers
• The ANC sites became decentralized in waves– Sites that had not yet been fully decentralized continued to
refer all HIV-infected women to the care and treatment sites
Washington D.C., USA, 22-27 July 2012www.aids2012.org
Purpose
• We compared service delivery at ANC and HIV C&T clinics in Kinshasa, DRC, a low HIV prevalence, resource-deprived setting
Washington D.C., USA, 22-27 July 2012www.aids2012.org
Mother Infant Register
Tracking of individual-level data for the mother-infant pair across the PMTCT spectrum
Washington D.C., USA, 22-27 July 2012www.aids2012.org
Washington D.C., USA, 22-27 July 2012www.aids2012.org
Epi Info database for Mother Infant Register (mother data)
Washington D.C., USA, 22-27 July 2012www.aids2012.org
Epi Info database for Mother Infant Register (infant data)
Washington D.C., USA, 22-27 July 2012www.aids2012.org
New or previous HIV diagnosis
Pregnancy stage at arrival
CD4 test during pregnancy
ARVs before delivery
Referred to C&T
Accepted C&T referral
Referral location
Arrival at KLL/Bomoi
Projected Delivered
Complete maternal regimen
Infant delivery outcome
Infant NVP at delivery
Infant ≥ 1 month of age
Visit ≥ 1 month of age
Infant extended NVP
PCR test
Infant cotrimoxazole
0 200 400 600 800 1000 1200 1400 1600
1151
1030
530
557
1468
1311
768
489
1386
93
666
906
922
526
510
523
473
422
206
491
522
86
133
588
285
93
281
24
130
54
391
93
244
61
110
314
232
1573 HIV+ women (and their infants) individually tracked at 49 maternities in Kinshasa, DRC, 10/2010-4/2012 (includes follow-up data from 2 care and treatment centers)
New Previous1573
1573
1329
1311
768
1573
1386
1386
≤ 28 weeks >28 weeks, before L&D L&D Other before L&D
Yes
Yes
Yes
Yes
Projected delivered
Facility, paid deliveryFacility, free delivery
Yes
Yes
Yes
Yes
Yes
Yes
Projected not deliv-ered
No information
Non-facility
None AZT ART
KLL/Bo-moi
Other Unknown
LTF Under tracking At maternity
None NVP only ARTAZT
LTF Under tracking
(some women are still preg-nant)
88 of 1047 infants died, 8% of the total
28 of 523 infants positive (5%). 5 in-fants had mothers who received AZT+NVP; 17 infants had mothers who received NVP only; 3 infants had mothers who receievd ART.
(212 ≤ 350; 254 > 350; 64 no re-sult)
40% of women who presented while pregnant
93% of women
89% of referred women
87% of infants
57% of infants ≥ 1 month of age
55% of infants ≥ 1 month of age
57% of infants ≥ 1 month of age
51% of infants ≥ 1 month of age
Washington D.C., USA, 22-27 July 2012www.aids2012.org
New or previous HIV diagnosis
Pregnancy stage at arrival
CD4 test during pregnancy
ARVs before delivery
Referred to C&T
Accepted C&T referral
Referral location
Arrival at KLL/Bomoi
Projected Delivered
Complete maternal regimen
Infant delivery outcome
Infant NVP at delivery
Infant ≥ 1 month of age
Visit ≥ 1 month of age
Infant extended NVP
PCR test
Infant cotrimoxazole
0 200 400 600 800 1000 1200 1400 1600
1151
1030
530
557
1468
1311
768
489
1386
93
666
906
922
526
510
523
473
422
206
491
522
86
133
588
285
93
281
24
130
54
391
93
244
61
110
314
232
1573 HIV+ women (and their infants) individually tracked at 49 maternities in Kinshasa, DRC, 10/2010-4/2012 (includes follow-up data from 2 care and treatment centers)
New Previous1573
1573
1329
1311
768
1573
1386
1386
≤ 28 weeks >28 weeks, before L&D L&D Other before L&D
Yes
Yes
Yes
Yes
Projected delivered
Facility, paid deliveryFacility, free delivery
Yes
Yes
Yes
Yes
Yes
Yes
Projected not deliv-ered
No information
Non-facility
None AZT ART
KLL/Bo-moi
Other Unknown
LTF Under tracking At maternity
None NVP only ARTAZT
LTF Under tracking
(some women are still preg-nant)
88 of 1047 infants died, 8% of the total
28 of 523 infants positive (5%). 5 in-fants had mothers who received AZT+NVP; 17 infants had mothers who received NVP only; 3 infants had mothers who receievd ART.
(212 ≤ 350; 254 > 350; 64 no re-sult)
40% of women who presented while pregnant
93% of women
89% of referred women
87% of infants
57% of infants ≥ 1 month of age
55% of infants ≥ 1 month of age
57% of infants ≥ 1 month of age
51% of infants ≥ 1 month of age
Washington D.C., USA, 22-27 July 2012www.aids2012.org
New or previous HIV diagnosis
Pregnancy stage at arrival
CD4 test during pregnancy
ARVs before delivery
Referred to C&T
Accepted C&T referral
Referral location
Arrival at KLL/Bomoi
Projected Delivered
Complete maternal regimen
Infant delivery outcome
Infant NVP at delivery
Infant ≥ 1 month of age
Visit ≥ 1 month of age
Infant extended NVP
PCR test
Infant cotrimoxazole
0 200 400 600 800 1000 1200 1400 1600
1151
1030
530
557
1468
1311
768
489
1386
93
666
906
922
526
510
523
473
422
206
491
522
86
133
588
285
93
281
24
130
54
391
93
244
61
110
314
232
1573 HIV+ women (and their infants) individually tracked at 49 maternities in Kinshasa, DRC, 10/2010-4/2012 (includes follow-up data from 2 care and treatment centers)
New Previous1573
1573
1329
1311
768
1573
1386
1386
≤ 28 weeks >28 weeks, before L&D L&D Other before L&D
Yes
Yes
Yes
Yes
Projected delivered
Facility, paid deliveryFacility, free delivery
Yes
Yes
Yes
Yes
Yes
Yes
Projected not deliv-ered
No information
Non-facility
None AZT ART
KLL/Bo-moi
Other Unknown
LTF Under tracking At maternity
None NVP only ARTAZT
LTF Under tracking
(some women are still preg-nant)
88 of 1047 infants died, 8% of the total
28 of 523 infants positive (5%). 5 in-fants had mothers who received AZT+NVP; 17 infants had mothers who received NVP only; 3 infants had mothers who receievd ART.
(212 ≤ 350; 254 > 350; 64 no re-sult)
40% of women who presented while pregnant
93% of women
89% of referred women
87% of infants
57% of infants ≥ 1 month of age
55% of infants ≥ 1 month of age
57% of infants ≥ 1 month of age
51% of infants ≥ 1 month of age
Washington D.C., USA, 22-27 July 2012www.aids2012.org
New or previous HIV diagnosis
Pregnancy stage at arrival
CD4 test during pregnancy
ARVs before delivery
Referred to C&T
Accepted C&T referral
Referral location
Arrival at KLL/Bomoi
Projected Delivered
Complete maternal regimen
Infant delivery outcome
Infant NVP at delivery
Infant ≥ 1 month of age
Visit ≥ 1 month of age
Infant extended NVP
PCR test
Infant cotrimoxazole
0 200 400 600 800 1000 1200 1400 1600
1151
1030
530
557
1468
1311
768
489
1386
93
666
906
922
526
510
523
473
422
206
491
522
86
133
588
285
93
281
24
130
54
391
93
244
61
110
314
232
1573 HIV+ women (and their infants) individually tracked at 49 maternities in Kinshasa, DRC, 10/2010-4/2012 (includes follow-up data from 2 care and treatment centers)
New Previous1573
1573
1329
1311
768
1573
1386
1386
≤ 28 weeks >28 weeks, before L&D L&D Other before L&D
Yes
Yes
Yes
Yes
Projected delivered
Facility, paid deliveryFacility, free delivery
Yes
Yes
Yes
Yes
Yes
Yes
Projected not deliv-ered
No information
Non-facility
None AZT ART
KLL/Bo-moi
Other Unknown
LTF Under tracking At maternity
None NVP only ARTAZT
LTF Under tracking
(some women are still preg-nant)
88 of 1047 infants died, 8% of the total
28 of 523 infants positive (5%). 5 in-fants had mothers who received AZT+NVP; 17 infants had mothers who received NVP only; 3 infants had mothers who receievd ART.
(212 ≤ 350; 254 > 350; 64 no re-sult)
40% of women who presented while pregnant
93% of women
89% of referred women
87% of infants
57% of infants ≥ 1 month of age
55% of infants ≥ 1 month of age
57% of infants ≥ 1 month of age
51% of infants ≥ 1 month of age
Washington D.C., USA, 22-27 July 2012www.aids2012.org
Washington D.C., USA, 22-27 July 2012www.aids2012.org
• No evident improvement over time in CD4 test provision• Decentralization did provide a new point of access
– Several hundred women and infants received services at the level of the maternity
Washington D.C., USA, 22-27 July 2012www.aids2012.org
Conclusions• Detailed individual-level tracking of mothers and infants
was feasible in Kinshasa • It revealed that PMTCT services were delivered less
effectively at sites historically focused on ANC rather than HIV C&T
• Logistical barriers pose a significant challenge but can be overcome
• While decentralization increased access to services, its potential to further reduce vertical transmission cannot be fully realized without sustained training, supervisory support, and site-specific real-time data quality monitoring
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