Monitoring of HIV positive mothers Ministry of Health and ... · Outline of the presentation...

Ministry of Health

NASCOP

Monitoring of HIV positive mothers and HIV exposed infants in context

of Option B+ implementationMinistry of Health Kenya

Ministry of HealthNASCOP

Outline of the presentation

• Background: Kenya in Context

• PMTCT Program progress 2012-2015

• Option B+ uptake in the country 2013-2015

• Retention on Option B+: PMTCT Cohort analysis

• PMTCT Outcome determination: HEI Cohort Analysis

• Recommendations and Conclusions

• Acknowledgements


� Total population ~ 42 million �HIV prevalence adults : 6.0% (HIV

Estimates 2013)� ~ 1.59 million estimated PLHIV

o 190,000 are children < 14 years (HIV estimates 2013)

� Estimated 1.5 million pregnancies/yr�HIV +ve pregnant women 79,036

(HIV Estimates 2013)�HIV exposed infants 79,036

Kenya Background


PMTCT Program Progress, 2012-2015

61%

70%66%

72%

36%

57%

63%

68%

0%

10%

20%

30%

40%

50%

60%

70%

80%

0

200000

400000

600000

800000

1000000

1200000

1400000

2012 2013 2014 Jan-June 2015

1st ANC Known Status HIV+ Pregnant women identified

Maternal Prophylaxis issued % maternal prophylaxis coverage % infant prophylaxis coverage

July 2014: Start of B+


37%

74%98%

49%

21%

1%

0%10%20%30%40%50%60%70%80%90%

100%

2013 2014 Jun, 2015

Interrupted ARTNVP only(AZT + SdNVP)ART

ART Use in PMTCT (2013-2015)

Use of ART (Option B-plus) in PMTCT

Patient Category <1000 cps/ml Total Viral Suppression Rate*Adults 108,706 128,220 85%

Pregnant women 306 362 84%

Viral Load Suppression Rate (Nov 2013-June 2015)


Maternal B+ Cohort Analysis Pilot project in KenyaBackground

• Aim to determine retention of mother on HAART from 35 pilot facilities (L2 - 3; L3 - 14; L4 - 17; L5 - 1)

• NPs( New positives) and KPs (Known Positives) put in the same cohort month when started ART for NPs and month first seen at clinic for KPs

• Outcomes determined at 3, 6 and 12 months

• Data presented for quarterly cohorts reported from Jan-March 2015

• Data source: ANC Registers and ART Registers at MCH

• NB: Option B+ (the only option) rolled out from Jun 2014

Definition of terms• KP: Known positives at 1st ANC contact at facility• NP: Newly diagnosed positive at ANC, L&D or PNC• Enrolled into cohort: PMTCT Women entered into

a particular monthly cohort in MCH ART register, including KPs and NPs

• Defaulters: Any person missing appointment and not returned to the clinic by reporting time

• LFU: Any defaulter not returned 3 months (90days) from date of missed appointment

• Stopped: A person who has stopped taking medication for whatever reason

• Virally suppressed: Person with viral load reported as undetectable (LDL) or <1,000copies/ml


Maternal B+ Cohort Analysis - pilot project Results: Summary

Key: KP = Known Positive ; NP = Newly Diagnosed Positive

Indicator KP NP Total KP NP Total KP NP TotalEnrolled into Cohort 236 263 499 199 218 417 150 114 264Transfers in (T.I) 23 2 25 12 3 15 7 1 8Transfer Out (T.O) 9 9 18 12 11 23 6 4 10Net Cohort (A+B-C 250 256 506 199 210 409 151 111 262Defaulters 47 68 115 10 22 32 6 9 15

Lost To Follow Up (LTFU) 0 0 0 14 17 31 7 7 14Reported Dead 3 1 4 1 2 3 2 0 2Stopped 0 0 0 0 1 1 0 0 0Alive and Active on Treatment 200 187 387 174 168 342 136 95 231Viral Load Collected 25 8 33 45 26 71 39 21 60Virally Suppressed (VL<1000) 20 8 28 17 12 29 20 15 35% Retained (I/D*100) 80% 73% 76% 87% 80% 84% 90% 86% 88%VL uptake 13% 4% 9% 26% 15% 21% 29% 22% 26%VL Suppression 80% 100% 85% 38% 46% 41% 51% 71% 58%

Jan,Feb,Mar 20143 Months Cohort 6 months Cohort 12 Months CohortOct,Nov,Dec2014 Jul,Aug,Sept 2014

Reporting Month:____JAN,FEB,MAR 2015_________

Not applicable


Observations / Challenges

• Decreasing number defaulters as cohort gets older• All cohorts: Higher retention among KP; Low in NPs (47 % are KPs)• Low uptake of VL among PMTCT clients: ?Documentation challenges• Low VL suppression for clients: 58% @3/12; 41% @ 6/12; 85% @1 yr

(small numbers due to missing data)• Difficult to do data abstraction from data in source documents in

context of transition period to MCH model of ART provision• Incompleteness of some ART registers in MCH• There is no standard national approach to B+ cohort analysis


HEI Card

• Each clinic visit information

HEI Register

• Cohorts by birth month

• Summarizes clinical information by month, up to 18 months

HEI Cohort Analysis (HCA)

Tool

• 9 and 18 month outcomes

Piloted: Mar-Sep 2012Implemented: July 2013 to date

HIV Exposed Infant (HEI) Cohort Analysis


12 mo 24 mo18 mo0 6 weeks 9 mo

HEI Follow-Up

2nd Review0 - 18 months

1st Review0 - 9 months

1st Review: Cohort birth month + 12 months1.0 % mothers who received PMTCT ARVs 2.0 % Infants who received ARVs at 0-6 weeks3.0 % HEI tested with PCR at age 6-8 weeks and results available4.0 % HEI tested positive by first PCR at age 6-8 weeks

5.0 % HEI tested with PCR and results available between 0 and 9 months

6.0 % eligible HEI tested with 1st AB test and results available

7.0 % HEI who tested AB positive with confirmatory PCR and results available

8.0 % HEI who were Exclusively Breastfed at 6 months among HEI assessed

9.0 % HIV positive infants identified between 0 and 9 months linked to CCC

10.0 Outcomes for birth cohort at 9 months10.1 % Continuing in HEI follow-up10.2 % Identified as positive between 0 and 9 months 10.3 % Transferred out between 0 and 9 months 10.4 % Missing 9 month follow-up visit 10.5 % Died between 0 and 9 months

2nd Review: Cohort birth month + 24 months

11.0 % HEI tested by AB test at >= 18 months and results are available

12.0 % HIV positive infants linked to CCC among those testing positive

13.0 Outcomes for birth cohort at 18 months

13.1 % Attending 18 month visit and AB negative

13.2 % Attending 18 month visit and no AB test done

13.3 % Identified as positive between 0 and 18 months

13.4 % Transferred out between 0 and 18 months

13.5 % Lost to Follow-Up between 0 and 18 months

13.6 % Died between 0 and 18 months

HCA Flow Diagram


89 8979

9180

48

76

93 9487

95 91 87 88

0

20

40

60

80

100

% mothers whoreceived PMTCT

ARVs

% Infants whoreceived ARVsat 0-6 weeks

% HEI testedwith PCR at age6-8 weeks and

results available

% HEI testedwith PCR and

results availablebetween 0 and

9 months

% eligible HEItested with 1st

AB test andresults available

% HEI whotested AB

positive withconfirmatory

PCR and resultsavailable

% HEI who wereExclusively

Breastfed at 6months among

HEI assessed

HEI Services Uptake: Nine-month review, July 2012-March 2014 Birth Cohorts by Year

2012 (n=11,770) 2013 (n=25,411) 2014 (n=7286)

EBF(*p value <0.001)

Antibody/Conf. PCR(*p value <0.001)

1st PCR(*p value <0.001)

ARVs(*p value <0.001)

*Chi square trend test

1,094 sites (reporting HCA between July 2012 and March 2014)

Results: Service Coverage


2012 2013 2014

% HIV positive linked to care

(p value <0.001)

83%(n=544)

86% (n=1063)

92%(n=254)

5

4

3

0 20 40 60 80 100

2012 (n=11,770)

2013 (n=25,411)

2014 (n=7286)

HEI Outcomes: 12-month review, July 2013 to March 2014 Birth Cohort by Year

% Active in follow-up (pvalue <0.001)

% Identified as positivebetween 0 and 9 months (pvalue <0.001)% Transferred out between0 and 9 months (p value0.8)% Missing 9 month follow-up visit (p value <0.001)

% Died between 0 and 9months (p value 0.9)

Linkage to HIV Care

Results: 9-month Infant Outcomes

P value- Chi square trend test


7

6

5

0 20 40 60 80 100

2011 (n=11,238)

2012 (n=25,928)

2013 (n=7436)

HEI Outcomes: 24-month review, July 2013 to March 2014 Birth Cohort by Year % AB negative at 18 months (p

value <0.001)

% Active at 18 months but no ABtest done (p value <0.001)

% Identified as positive between0 and 18 months (p value <0.001)

% Transferred out between 0 and18 months (p value 0.013)

% Lost to Follow-Up between 0and 18 months (p value <0.001)

% Died between 0 and 18 months(p value 0.9)

2012 2013 2014¥% HIV positive linked to care

(p value 0.002)

83%(n=740)

91% (n=1435)

93%(n=390)

Linkage to HIV Care

Results: 18-month Infant Outcomes

P value- Chi square trend test


Conduct 1st Review for Jan 2013 Cohort

Conduct 2nd Review for Jan 2012 Cohort

Transfer 1st and 2nd

review results to the HCA Monthly Report Form

Track/plot progress on HCA Facility Progress Chart for each cohort year reviewed.

Summarize HEI Cohort Analysis findings and plan to improve performance using HCA Routine Review Summary.

1

Birth cohort Year: 2013

Birth cohort Year: 2012

2

3

4

5

HCA Monthly Tool Use: Example of Jan 2014 HCA


Recommendations –Maternal Option B+9 There is need to address challenges in the documentation of PMTCT

services so as to improve monitoring in context of option B+9 Pilot different approaches to cohort analysis to fit facility B+

implementation approaches and provide standardized cohort analysis system and tools as part of PMTCT cascade

9Need to strengthen strategies for retention of MCH clients such as tailored psychosocial support package for PMTCT mothers

9Need to focus on LTFU and defaulters identified during cohort analysis as a standard next step in cohort analysis

9 Accelerated initiative to increase viral load testing among pregnant women -guidance for VL testing among pregnant women(baseline, preconception )


Conclusion and Recommendations- HEI cohort � Pilot of HEI Cohort analysis successfully done, and scale up ongoing

with good progress� Use of HCA has shown statistically significant improvement in

uptake of HEI services and outcomes for infants in the last 3 years and is as such an important facility level quality of care improvement for HEI

� Routine, facility-based HEI cohort analysis is feasible and useful in evaluating and improving program performance

� Next steps: o Integration of HCA within national reporting tools and health

information system: o Current tools review to adopt specific few indicators that are

critical for upward reporting with adoption of others as QI facility level indicators


�Ministry of Health Kenyao National AIDS & STI Control Programme o County, Sub-County and Facility Health Teams

�The UN in Kenyao WHOo UNICEFo UNFPA

�President’s Emergency Plan for AIDS Relief (PEPFAR) - Kenya o U.S. Centers for Disease Control and Prevention o United States Agency for International Developmento Department of Defense o Implementing Partners o EGPAFo APHIA+WESTERN KENYA

Acknowledgments

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