PMTCT program in Arua Uganda Lessons learned after 5 years of

experience

Experts Roundtable 23-24 June 2008

Geneva

Arua PMTCT program (1)• Started in January 2000

• 1st ante-natal visit : HIV voluntary counselling & testing

• HIV+ enrolled in PMTCT program

Arua PMTCT program (2)

• National PMTCT protocol (2000 to 2005)

– Mother : NVP at labour onset

– Infant : AZT (1 wk) or NVP (<72 h)

• Follow-up

– Cotri prophylaxis + feeding education

– Infant formula (up to June 2004)

Arua PMTCT program (2)

• National PMTCT protocol

(2000 to 2005)

– Mother : AZT from 36 wk or NVP at

labour onset or ART

– Infant : AZT (1 wk) or NVP (<72 h)

• Follow-up

– Cotri prophylaxis + feeding

education

– Infant formula (up to June 2004)

Pregnant women in ANCn=30 536

Pre-test counselingn=22 105 (72%)

HIV-test refused Routine ANCn=3 088 (14%)

HIV-testedn=19 017 (62%)

HIV– n=17 980

(95%)

HIV +n=1 037 (5%)

PMTCT n=517

(49.8%)

Routine ANCn=520

(50.2%)

Objectives

• Describing characteristics of mothers & infants

• Quantifying and describing reasons for loss to

follow-up (LTFU)

• Estimating HIV transmission

Evaluate the performance of the PMTCT program of Arua by:

Methods (1)

• Retrospective cohort analysis

– Inclusion: Women enrolled in PMTCT between July 2000-July 2005

• Description of infant outcomes

• Active tracing of LTFU

• Cross-sectional survey

– Interview of caregivers (reasons for LFU)

– Clinical examination and HIV testing for infants

Methods (2)

• Survival Analyses (Kaplan-Meier)

• HIV transmission

– HIV testing for children alive

– HIV-related deaths*:

• severe infection or persistent diarrhoea AND

• > 1 HIV-related symptom at last MCH visit

• Risk factors for HIV-transmission (multiple logistic

regression)

* Ghent Int. Working Group on MTCT of HIV

Lost to follow-up

53%

Actively followed

16%

Died 17%

Follow-up completed

14%

Results: PMTCT Program (July 2000 – July 2005)

• Enrolled:

– Mothers (N=517)

– Infants (N=567)

Infant outcomes (n=567)

Lost to follow-up

untraceable30%

Lost to follow-up & traced

23%

Actively followed

16%

Died 17%

Follow-up completed

14%

Results: PMTCT Program (July 2000 – July 2005)

• Enrolled:

– Mothers (N=517)

– Infants (N=567)

• Cross-sectional survey

– Mothers (N= 327, 63%)

– Infants (N= 368, 65%)

Infant outcomes (n=567)

Maternal characteristics at PMTCT enrolment (N=327)

32 (10)On ART368 [200 -535]Median CD4+ cells/ml; n=201 [IQR]

5 (2) 164 (50) 144 (44)

13 (4)

WHO stage (%) Asymptomatic Stage I/II Stage III Stage IV

4 (1) 72 (22)

233 (71) 18 (6)

Trimester of pregnancy (%) First Second Third At/after birth

28 [25-32] Median age (yr) [IQR]

Newborn characteristics (N=368)

Place of delivery (%) Arua Regional Hospital Home/on the way Health centre/other hospital

280 (76)70 (19)

17 (5)

Female (%) 182 (50)

Median weight, kg [IQR] (n=334) 3 [2.7 - 3.4]

Timing of ARV start for mother ART ≥ 3 months before birth ART < 3 months before birth NVP prophylaxis at birth AZT prophylaxis at birth None

44 (12) 21 (6)

253 (69)19 (5) 24 (7)

ARV post-partum prophylaxis (%) NVP single dose AZT one week None

288 (78) 12 (3)

65 (18)

Follow-up characteristics of infants (N=368)

Median nb of post-natal consultation visits [IQR] 4 [0 -9]

Type of feeding received (%)

Exclusive breastfeeding

Exclusive infant milk formula

Mixed feeding

103 (29)

96 (27)

154 (44)

Median age at weaning start [IQR] (n=353) 6 [4 - 6]

HIV transmission

• 8.3% (24 / 288) of children were HIV+

• Overall transmission = 15.5% (57 / 367)

Risk factors for MTC HIV transmission*

CharacteristicsHIV+

(%)

Multivariate analysis

OR (95% CI) p-value

Age (yr) >=25 vs. <25 9 (9) 0.4 (0.1- 1.2) 0.09

WHO stage 3/4 vs 1/2 7 (9) 0.7 (.22 - 1.9) 0.45

CD4+ (cells/mm3) >=350 vs. < 350 11 (14) 1.7 (0.5 - 5.2) 0.38

Home delivery/on the way 7 (26) 3.7 (1.2 - 11.3) 0.03

Females 4 (6) 0.4 (0.1 - 1.4) 0.15

ARV prophylaxis vs. none 13 (10) 3.6 (0.6 - 23.1) 0.17

Type of feeding

Infant formula vs. breast feeding

Mixed feeding vs. breast feeding

2 (6)

10 (15)

1.14 (0.2 - 7.5)

2.6 (0.7 - 10.3)

0.30

Weaning at <6months vs. >6 months 7 (14) 1.5 (0.5 - 4.7) 0.46

*Among children tested for HIV (n=288)

Moth

er

Child

Infant survival

• 33 / 72 deaths were HIV-related

• Most frequent causes of death – Acute or chronic diarrhoea (34.7%)– Respiratory tract infections (20.8%)

0.0

00.2

50.5

00.7

51.0

0P

rob

ab

ilitie

s

0 10 20 30 40Follow-up (months)

Kaplan-Meier survival estimate

0.81 (95% 0.77 – 0.85)

Mother/baby pair LTFU

• Median time at LTFU was 1 month (IQR : 0 – 5)

• Reasons for LFU (n=197)

– 30% mothers' ignorance of the importance of FU

– 27 % infant death

– 13 % discouraged by the partner

– 12 % address change

Discussion (1)

Mothers

• 40% women refused to be tested

• Among the HIV +, 50% refused to be enrolled in the PMTCT

• Among the enrolled women , 50% drop out

• First visit in third trimester of pregnancy

• 50% accessed ANC in earlier HIV disease

• 21% home delivery

Discussion (2)Infants

• 18% did not receive PMTCT prophylaxis

• HIV transmission rate reduced from 35% to 15.5%

Mother/baby pairs LTFU

• 53% LTFU before tracing

• Main reasons for LTFU = mother’s ignorance of importance of FU & infant death

BUT 30% of pairs untraced

Recommendations

• Improve the message delivered to mothers

at enrolment

• Increase resources for PMTCT (HR, logistics…)

• Reconsider Feeding strategy

• Early diagnosis and treatment for children

Acknowledgments

• Ugandan Ministry of Health in Arua and

Kampala

• MSF team in Arua and Kampala

• Epicentre in Kampala and Paris

• CDC laboratory in Entebbe (Ugandan Virus

Institute)

ARUA REFFERAL REGIONAL HOSPITAL

PMTCT From May 2007 to end of February 2008

Organigram

Flow of patient

PMTCTAN +HIV f/up

Mother and child f/up until 1 year

ANCVCT

HIV clinicWomen became pregnant

Maternity wardLabour suite

Homedelivery

Mother 1year after deliveryChild+ after 1 year

Treatment protocol

Antepartum

treatment

Labour

treatment

Postpartum

treatment

Child

treatment

Pregnant

women

Cd4<350

HAART HAART HAART AZT 1ml bd

7 days

( *4 weeks if the mother begins treatment less than 1 month before delivery)

Pregnant women Cd4>350

AZT 300mg bd

>28 WA

Sd NVP 200mg

+

(AZT-3TC)

(600/300) stat

Tail

AZT-3TC (300/150) bd

7 days

Sd NVP 0.6ml

+

AZT 1ml bd

7 days ( or *)

Data from ANCfrom May 2007 to end of February

2008

• 63% women accept to be tested

• 75% of mother tested HIV+ are enrolled in PMTCT

• HIV prevalence at ANC is 4 % during the period

Total first ANC 9923

Total pregnant women tested 6252

Total tested HIV + 256

Total enrolled in PMTCT 191

Mothers enrolled in PMTCT May 2007 to End of February 2008 (1)

Weeks in pregnancy Total (%)

< 28 weeks 273 (54%)

> 28 weeks and < 36 weeks 83 (16%)

> 36 weeks 48 (9%)

With baby 99 (20%)

Total 503 (100%)

Mothers enrolled in PMTCT May 2007 to End of February 2008 (2)

• Median CD4 : 448 /mm3

WHO staging (from ANC only ) Total (%)

Stage 1 125 (64%)

Stage 2 38 (20%)

Stage 3 19 (10%)

Stage 4 9 (5%)

Total 191 (100%)

85%

Mothers enrolled in PMTCT May 2007 to End of February 2008 (3)

• 8% are lost to follow-up • 40% are on ARVs (10% in 2000-2005) • 62% of the mothers enrolled in PMTCT are coming from HIV

clinic

Total (%)

Total enrolled 503 (100%)

death 1 (0%)

Lost of follow-up 41 (8%)

Transfered 4 (1%)

Followed with no ttt 252 (50%)

Followed on ARV 203 (40%)

Unspecified 2 (0%)

Prophylaxis and treatment (1)Ante partum drugs %HAART 40%

AZT (> 28 weeks) 33%

None 25%

Unknown 1.5%

Intra partum drugs

HAART 40%

NVP+ (AZT/3TC) 13%

AZT+NVP 4%

Stat NVP 10%

AZT 13%

None 17%

73%

57%

Prophylaxis and treatment (2)Post partum prophylaxis

HAART 43%

Tail AZT/3TC 19%

None 20%

Baby prophylaxis

Stat NVP+ AZT 37%

Stat NVP 17%

None 26%

Location of delivery May 2007 to End of February 2008

85%

15%

In Maternity/Hospit

Other

Feeding Option PMTCT May 2007 to End of February 2008

85%

10%

4% 1%

0%

Breast FeedingInfant formulaMixedOtherUnspecified

Outcome of children

• Will need to wait 2009 regional meeting….

Thanks

WHO stage & CD4 at PMTCT enrolment

<350 CD4 cells/ml

>=350 CD4 cells/ml

No CD4 Total

Stage 1&2 37 (21.9)

61(36.1)

71 (42.0)

169

Stage3 54 (37.5)

44(30.5)

46 (32.0)

144

Stage4 2 (15.4)

3 (23.1)

8 (61.5)

13

No staging 0 (0)

0 (0)

1 (100)

1

Total 93 (28.4)

108 (33.0)

126 (38.6)

327

Maternal characteristics at follow-up (N=327)

• Partner/family aware of HIV status : 297 (90.8%)

• Partner aware of PMTCT enrolment : 242 (74.0%)

• Participation in PMTCT

No problems : 279 (85.3%)

Separation/divorce : 22 (6.7%)

No male involvement/conflict : 15 (4.6%)

Family stigma/conflict : 9 (2.8%)

Other : 2 (0.6%)