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