Population-level impact of the National PMTCT …anovahealth.co.za/uploads/documents/Documenting_progress...Antenatal (ANC) HIV test Received ANC HIV test result Mothers reported being

Population-level impact of the National PMTCT programme: 2010 and 2011

Ameena Goga, HSRU/MRC

Thu-Ha Dinh, US CDC/GAP, Debra Jackson, UWC, MRC/HSRU

on behalf of the SAPMTCTE Team

PMTCT Symposium, Johannesburg, 23-24

October, 2012

2008-2010:

– HIV-infected pregnant women

CD4 > 200 AZT from 28 wks + sd NVP in labour

CD4< 200 / WHO stage 4 lifelong ART (d4t+3TC+NVP/EFV)

– HIV-exposed infants: sd NVP + AZT (7 - 28 days)

2010-present ≈ WHO Option A:

– HIV-infected pregnant women

CD4 > 350 AZT from 14 wks + sd NVP + TDF/FTC in labour

CD4< 350/stage 3/4 ART (TDF+3TC/FTC+NVP or AZT+3TC+NVP)

– HIV-exposed infants

Mother on ART or non-breastfed infants: 6 wks NVP

Breastfed infant: NVP through out breastfeeding

Background: PMTCT guidelines

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)

– 1st immunization (DPT, 6 wks) coverage (‘10): >95%

– Neonatal mortality, 0-28 days (‘08): 18/1,000 live-birth

Improved national regimens between 2001 and 2010:

SAPMTCTE Aims and Objectives

To periodically conduct facility-based surveys to monitor the effectiveness of the South African National PMTCT

programme until 18 months postpartum

Primary Objectives: To measure rates of • Early MTCT at 6- weeks postpartum* • MTCT at 6, 9, 12 and 18 months postpartum • Infant HIV free survival at 6, 9, 12 and 18 months postpartum

Secondary Objectives: • To estimate coverage of key PMTCT services* • To estimate the association between MTCT rate and other key indicators / characteristics * (!) • To measure uptake of HIV care-and-treatment referral services

Case Definitions

• HIV-exposed infant

– 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

Methods

• Design: national facility-based survey

• Sample size: 12,200 infant-DBS national and

provincial estimates

• Sampling: Multi stage sampling methods

– 580 facilities in all 9 provinces

– Infant’s consecutively or

systematically sampled

• Interview data collection: Using cell-phone

technology real time data collection

• Duration: Data collection: Round 1: June-Dec 2010

Round 2: August 2011 to March 2012

• EC - 78 • FS - 72 • GP - 59 • KZN - 64 • LP - 74

• MP - 79 • NC - 34 • NW - 67 • WC - 58

Sample size distribution by province

N=1300 N=1400

N=1800

N=1400

N=1600

N=1400

N=1200

N=700

N=1400

• 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 centrally - NICD, NHLS

Methods: Laboratory

Findings

• Adjusted for sample attainment and

• Non-response rates / population live-birth using 2010 estimates

• Survey analysis using SAS 9.2

2011 Preliminary Survey Profile

Enrolled eligible caregiver-infants - 4-8 wk old infant attending 1st DPT

(10,475; 92.4%) 10735 enrolled in 2010

Caregiver-infants interviewed & infant-DBS*

(N=10106; 96.5%) 10154 in 2010

• Refused to infant-DBS (330 – 3.2%) • Insufficient infant-DBS (39 – 0.4%)

Infant-HIV antibody positive (N=3024) 3107 in 2010

• Not eligible (614)– 5%) • Refused to participate (289 – 2.7%

of eligible) • Consent incomplete (158)– 1.5%)

Total of caregiver-infant approached at the sites

(11,377) 10820 eligible in 2010

Infant-HIV antibody negative

(n=7182) 7071 in 2010

Inclusion: 4-8wk old attending clinic for 6wk immunization

Exclusion: Severely ill infants needing emergency care

Desired & Actual Sample Size by Province

PROVINCE DESIRED SS ACTUAL 2010

(%)

ACTUAL 2011

(%)

EC 1400 776 (55) 1194 (85)

FS 1300 1143 (88) 1056 (81)

GP 1800 1735 (96) 1607 (89)

KZN 1400 1224 (87) 1052 (75)

LP 1400 1022 (73) 1070 (76)

MP 1600 1286 (80) 1210 (76)

NC 700 444 (63) 506 (72)

NW 1200 1171 (98) 1037(86)

WC 1400 1381 (99) 1374 (98)

Total - ZA 12 200 10182 (83) 10106 (83)

Characteristics

HIV exposed infant

(n=3024)

HIV unexposed infant

(n=7182)

% 95% CI % 95% CI

Mother-infant pairs 97.5 96.9 – 98.1 96.6 96.2 – 97.1

Marital status of mother

Single 77.7 75.8 – 79.6 72.7 71.1 – 74.3

Feeding practice (last 8 days)

non-mixed breast-feeding 56.3 52.5 – 60.0 43.6 40.8 – 46.4

Mixed breast-feeding 43.7 41.3 – 46.0 56.3 54.4 – 58.3

Planned pregnancy

Yes 34.1 32.0 – 36.2 39.9 38.3 – 41.5

Delivery mode

C-section 23.5 21.6 – 25.3 21.0 19.9 – 22.0

Caregiver’s characteristics by HIV-exposure status (weighted %) 2011

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% - 32.6%)

– 2011: 32.2% (95% CI 30.7% - 33.6%)

2. National perinatal transmission rate

– 2010: 3.5% (95% CI 2.9% - 4.1%)

– 2011: 2.7% (95% CI 2.1% - 3.2%)

Weighted Infant HIV Exposure & MTCT

2010 2011

PROVINCE Infant HIV-

Exposed

MTCT % (95%CI) Infant HIV-

Exposed

MTCT % (95%CI)

Eastern Cape 30.0 (26.3-33.7) 4.7 (2.4-7.0)* 32.0 (29.6-35.5) 3.8 (2.1-5.5)

Free State 31.1 (28.9-33.3) 5.9 (3.8-8.0) 30.9 (28.6-33.3) 3.8 (2.3-5.3)

Gauteng 30.2 (27.7-32.8) 2.5 (1.5-3.6) 33.1 (29.8-36.4) 2.1 (0.9-3.4)

KwaZulu Natal 43.9 (39.7-48.0) 2.9 (1.7-4.0) 44.4 (39.8-48.9) 2.1 (0.9-3.3)

Limpopo 22.6 (20.4-24.8) 3.6 (1.4-5.8) 23.0 (19.9-26.2) 3.1 (1.2-4.9)

Mpumalanga 36.2 (33.6-38.9) 5.7 (4.1-7.3) 35.6 (33.3-37.8) 3.3 (2.2-4.5)

Northern Cape 15.6 (13.0-18.3) 1.4 (0.1-3.4)* 15.1 (12.7-17.5) 6.1 (2.5-9.6)*

Northwest 30.9 (28.6-33.1) 4.4 (2.9-5.9) 30.8 (28.5-33.1) 2.6 (1.1-4.0)

Western Cape 20.8 (16.8-24.9) 3.9 (1.9-5.8) 17.8 (14.8-20.8) 1.98 (0.6-3.3)

National 31.4 (30.1-32.6) 3.5 (2.9-4.1) 32.2 (30.7-33.6) 2.7 (2.1-3.2)

PMTCT cascade by year

98.8 98.6

29.4

96.7 99.3

29.5 0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

Antenatal (ANC) HIV test Received ANC HIV testresult

Mothers reported beingHIV-positive

2010 2011

HIV infected mothers

78.3 58.7

33.1

77.7 42.6 46.2

85.1

0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

Received CD4 testresuls

Mother&infantreceived ARV therapy

Mother on ART Infant received≥4wks of NVP

Factors Associated with Early MTCT – Prelim Analysis 2011

Adj OR 95% CI

ARV/ART

Maternal ART (HAART) Ref. --

Either maternal ARV OR

infant ARV

5.2** 2.7-10.0

≤10 week maternal

AZT*+infant ARV

2.4** 1.2-5.1

11-30 week maternal

AZT*+infant ARV

1.7* 0.9-3.5

C-Section

Yes Ref. --

No 1.1 0.4-2.9

Feeding practices

(last 8 days)

EBF or no breastmilk Ref. --

Mixed breastfeeding 1.6* 1.0-2.5

Planned pregnancy Yes Ref.

No 1.4* 0.8-2.3

Birth attendant Non-doctor Ref. --

Doctor 1.2 0.5-2.9

Strengths and Limitations

Strengths

– mothers with HIV infection known, unknown, & acquisition

– mother-infants with or without PMTCT exposure

Limitations

– Facility based (1st 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 self-reported maternal HIV consistent with 2010 ANC survey

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 PMTCT program

Acknowledgements

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

Provincial Departments of Health 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)

Caregiver-infant pairs

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