What happens to the babies? Factors associated with PMTCT outcomes among a community sample of HIV-exposed infants

from Zimbabwe

Frances M Cowan, Raluca Buzdugan, Sandra I McCoy, Tyler E Martz, Constancia Watadzaushe, Jeffrey Dirawo, Angela Mushavi, Agnes Mahomva, Nancy S Padian

PMTCT in Zimbabwe• Overall Goal: Virtual

elimination of paediatric HIV

• Follow-up and care of HIV-exposed infants is critical to– prevent new HIV

infection (HIV-free survival)

– decrease mortality and morbidity in HIV-exposed infants

IAS Poster MOPE113

Simulation of cumulative LTFU of exposed infants - SSA

HIV positive women at ANC registration

Infants delivered at facility

Infants tested for HIV (EID)

Infants remaining in follow-up after HIV

testing

10

20

30

40

50

60

70

80

90

100

Impact Evaluation

• Impact evaluation of Zimbabwe MoHCW’s accelerated PMTCT program (WHO Option A)

• External evaluators: University of California Berkeley, CeSHHAR Zimbabwe and University College London

• Funding: Children’s Investment Fund Foundation

Impact Evaluation Design

• Serial cross-sectional community-based surveys in 157 health facilities

• Pre-post design with the facility catchment area as unit of analysis –Baseline – 2012; endline – 2014/5

• Primary outcomes: MTCT rate & HIV-free infant survival at 9-18 months

Methods I

• Cross-sectional data from baseline survey of the impact evaluation of Zimbabwe’s accelerated implementation of the 2010 WHO PMTCT guidelines

• The accelerated program was initiated in 2011 by the Zimbabwe Ministry of Health and Child Welfare (MOHCW) with the Elizabeth Glaser Pediatric AIDS Foundation (EGPAF).

1 2

3

4

5

Survey SampleRandom sample of women living in catchment areas of 157 randomly selected health facilities offering PMTCT services in:

1. Mashonaland West2. Mashonaland Central3. Harare4. Matabeleland South5. Manicaland

Methods II

• Eligible women were ≥16 years old and biological mothers of infants (alive or deceased) born 9-18 months prior.

• Participants were interviewed about health service utilization during pregnancy and HIV status and had DBs taken for HIV testing.

• Here we use self-reported HIV status and service uptake.

• Factors associated with reported infant ARV prophylaxis and infant HIV testing respectively were examined.

IAS Poster TUPE424

Baseline Enrolment

• 9087 mother-infant pairs (98.9% of those eligible) from 157 facility catchment areas

• 9019 alive infants (99.3%)

• 997 (11.5%) mothers reported positive HIV status before or during delivery

• 16 HIV-exposed babies (1.6%) were deceased

• Average infant age:– All infants: 412 days – HIV-exposed infants: 407 days

[IAS Poster TUPE425]

Results: Maternal PMTCT Cascade:

0

1000

2000

3000

4000

5000

6000

7000

8000

9000

10000

0

200

400

600

800

1000

1200100% 94% 92% 92%

77%

100%

All women (n=8662)HIV-positive women (n=997)

Step in the PMTCT Cascade

No.

wom

en

No.

HIV

pos

itive

wom

en

12%

67%

Results: Uptake of postnatal services

Attended postnatal visit Immunization visit0

102030405060708090

100

66

80

94 9896 98

Not testedNegativePositive

Results: Uptake of Infant PMTCT Services (997 biological mothers who self-reported HIV positive status)

683 [66%]

[62%]*610

[58%]516

[52% (85%)]

33[3.3% (6.4%)]

28[2.8%(86%)]

* Among mothers who delivered at health facilities

Which infants received ARV prophylaxis?

Note: Poisson regression (n=981), outcome: infant ARV prophylaxis; controlling for education and marital status; PR=prevalence ratio

Maternal characteristics

PR 95% CI p value

Mother found out she is HIV+…

Before pregnancy 1.00 During pregnancy 1.16 1.07 1.26 <0.001

Mother received ARV prophylaxis 4.29 2.99 6.15 <0.001Infant delivered at home 0.52 0.42 0.64 <0.001Mother visited health facility for herself (last year) 1.17 1.06 1.30 0.003

Which infants were HIV tested?Maternal & infant characteristics PR 95% CI p

value

Mother/ infant on ARV prophylaxis

No ARVs 1.00 <0.001Maternal ARVs only 5.86 3.80 9.02 Infant ARVs only 6.29 3.93 10.06 Both maternal & infant ARVs 7.11 4.54 11.14

Mother visited health facility for herself (last year) 1.17 1.05 1.30 0.006Infant was hospitalized 1.13 1.02 1.26 0.024

Note: Poisson regression (n=995), outcome: infant HIV testing; controlling for age and whether living with mother in law; PR=prevalence ratio

Limitations

• Data are cross-sectional• Uptake of health services is based on self

reports• HIV status during ANC and at delivery was

based on self-report• Data are not representative of all regions

in Zimbabwe.

Conclusions

• High rates of attrition at key stages along the cascade of services for HIV-exposed infants

• Strong association between maternal & infant ARV prophylaxis

• Strong association between ARV prophylaxis & infant HIV testing

• Cost effective interventions to reduce LTFU required

Other IAS Posters/ Presentations based on this study

• Food insecurity – barrier to PMTCT service uptake– Presentation MOAD0204

• Feasibility of population-based cross-sectional surveys for estimating vertical HIV transmission: data from Zimbabwe – Poster -TUPE424

• Uptake of Prevention of Mother-to-Child HIV Transmission (PMTCT) Services Among Women With a Recent Birth in Zimbabwe – Poster TUPE425

• Role of fees in the demand for PMTCT services - Poster WEPE631

Acknowledgements

Ministry of Health and Child Welfare

EGPAF Zimbabwe• Reuben Musarandega

The Children’s Investment Fund Foundation (CIFF) funded the baseline impact evaluation survey.

UC Berkeley• Maya Petersen

CeSHHAR Zimbabwe• Survey team