Evaluation of PMTCT coverage in four African countries:The PEARL Study

D Coetzee, EM Stringer, BH Chi, N Chintu, TL Creek, DK Efouevi, K Stinson, P Thi, T Welty, F Dabis, N Shaffer, CM Wilfert, JSA Stringer

University of Alabama – Center for Infectious Disease Research Zambia University of Bordeaux (France) – PAC-CI (Cote d’Ivoire)

Elizabeth Glazer Pediatric AIDS Foundation and Cameroon Baptist Health Convention University of Cape Town – Infectious Disease Epidemiology Unit (South Africa)

PEARL study

Methodology developed with CDC in “die Paarl” over a bottle or two of red wine

Hence PEARL study

PEARL Study

4-country effectiveness evaluation Facilities and their catchment populations randomly

identified in each country Facility-based evaluations

Cord Blood Surveillance Facility Survey – exit and informant interviews

Community-based evaluations Community Survey to identify HIV-free survival

Cost-effectiveness evaluation________________________________________ Funding: CDC-GAP (ZM, CI, RSA)

EGPAF (Cam)

PEARL Study

An effectiveness evaluation Facilities and their catchment populations randomly

identified in each country Facility-based evaluations

Cord Blood Surveillance – preliminary data Facility Survey

Community-based evaluations Community Survey

Cost-effectiveness evaluation________________________________________ Funding: CDC-GAP (ZM, CI, RSA)

EGPAF (Cam)

PMTCT interventions

All sites used at least single-dose nevirapine (SD-NVP) for PMTCT;

Some also used short course zidovudine SC-ZDV+SD-NVP and/or HAART.

Cord Blood Surveillance Methodology

Anonymous consecutive cord blood specimens from all live-births – (except Cameroon)

April 2007 and October 200843 randomly selected sites in 4 countries

Zambia Cote d’Ivoire South Africa Cameroon

Methodology (2)

Cord blood collected anonymously from every delivery

Tested for HIV If cord blood (mother) was HIV-infected, then cord

blood tested for NVP by high-performance liquid chromatography

And ZDV + 3TC (where applicable)

Methodology (3)

Key PMTCT information (from folder) collected anonymously

age of mother parity acceptance of HIV testing result received mother documented as having received

NVP infant documented as having received NVP

Definitions

Coverage = maternal & infant ingestion of NVP

Maternal ingestion = NVP present in cord blood if HIV-infected

Infant ingestion = documentation of the infant having received NVP

28, 955 Live births

(100%)

28,060 Specimens Obtained

(96.9%)

27,996Specimens Tested

(96.7%)

3,250 Cord blood HIV Positive

(12.2%)

Specimen collection rate

HIV prevalence

HIV prevalence was typical of that observed in each area in the particular country

Coverage Cascade

0 1000 2000 3000 4000

Positive cord bloods (100%)

I nformation in folder (92%)

HI V test offered (84%)

HI V tested (81%)

Result in folder (74%)

Mother received NVP (71%)

NVP in cord blood (57%)

Coverage (50%)

Maternal coverage by site

Factors associated with failed coverage

Adjusted OR

Mother’s Age

> 30 1.0

26-30 1.22 (1.04 - 1.44)

20-25 1.33 (1.08 - 1.64)

<= 20 1.58 (1.23 - 2.02)

Gravidity

1 1.0

2-3 1.08 (0.88 - 1.33)

4+ 1.14 (0.89 - 1.45)

Number of ANC Visits

6+ 1.0

4 or 5 1.47 (1.27 - 1.70)

2 or 3 1.68 (1.38 - 2.05)

0 or 1 2.92 (2.22 - 3.84)

Maternal adherence across sites

Factors associated with maternal non-adherenceAdjusted OR

Mother’s Age > 30 1.0 26-30 1.42 (1.04 - 1.93) 20-25 1.28 (0.92 - 1.78) <= 20 1.30 (0.90 – 1.90)Gravidity 1 1.0 2-3 1.33 (0.95 - 1.85) 4 1.62 (1.12 - 2.34)Number of ANC Visits 6+ 1.0 4 or 5 1.71 (1.33 - 2.20) 2 or 3 2.04 (1.48 - 2.83) 0 or 1 2.98 (2.07 - 4.28)Delivery Method Cesarean 1.0 Vaginal 1.51 (1.11 - 2.05)Prophylaxis Type NVP only 1.0 NVP and AZT 1.42 (1.04 - 1.93) HAART 1.28 (0.92 - 1.78)

Western Cape PMTCT guidelines

Guidelines 2007/08SC-ZDV+SD-NVP for women with CD4

> 200HAART for women with CD4 <200

No data collected on CD4+ cell count in this study

Maternal adherence – Western Cape

HAART 12% ZDV and NVP 47%

Standard of care 59%

NVP only 6%

At least NVP 65%

ZDV only 8%

Nothing 27%

Conclusions

PMTCT involves a cascade of interventions All sites: only 50% coverageFailures occur along each step of the

cascade Interventions are required at each point Even in settings with dual therapy and

HAART to target high risk women, more than 25% of women are not covered with PMTCT prophylaxis

AcknowledgementsCameroon Pius Tih Tom Welty

Cote d’Ivoire Francois Dabis Didier Ekouevi Serge Kahon

South Africa Andrew Boulle David Coetzee Kathryn Stinson

Zambia Max Bweupe Ben Chi Namwinga Chintu Mark Giganti Jeffrey Stringer Wendy Mazimba

Centers for Disease Control Mark Bulterys Tracy Creek Nathan Shaffer

EGPAF Allison Spensley Christophe Grundmann Cathy Wilfert

Others Cameroon Baptist Health Convention Elliott Marseille Mary Louise Newell MOH Cote d’Ivoire Zambian MOH